Every finding on record at Medway Country Manor Skilled Nursing & Rehabilitat

Based on interview and record review, the facility failed to provide adequate pain management for one Resident (#7), out of a total sample of 24 residents, when the facility was unable to reach the Resident's primary care physician for a prescription to order Resident's Oxycodone (short-acting opioid medication used to treat moderate to severe pain), resulting in the Resident suffering with severe pain of 7 on a scale of 1-10 with 10 being the worst pain for 19 hours post-admission. Findings include:Review of the facility's policy titled Pain Assessment and Management, last revised 10/2022, included but was not limited to:-The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and address the underlying causes of pain. Monitoring and Modifying Approaches:-Re-assess the resident's pain and consequences of pain at least every shift for acute pain or significant changes in levels of chronic pain-Monitor the following factors to determine if the resident's pain is being adequately controlled: -The resident's response to interventions and level of comfort over time-Monitor the resident by performing basic assessment with enough detail and, as needed, with standardized assessment tools and relevant criteria for measuring pain management-If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Reporting:Report the following information to the physician or practitioner:-Significant changes to the level of the resident's pain.-Prolonged, unrelieved pain despite care plan interventions. Review of the facility's policy titled Pain Assessment and Use of Standardized Scales, undated, included but was not limited to:-To ensure a systematic and consistent approach to identifying, assessing, and managing pain for all residents.-Quantify: Ask the resident to rate the pain using the Numeric Rating Scale-1-3: Mild pain-4-6: Moderate pain-7-10: Severe painResident #7 was admitted to the facility in February 2026 and had diagnoses including displaced supracondylar fracture without intracondylar extension of lower end of right femur (a fracture of the right thighbone just above the knee joint) and periprosthetic fracture around internal prosthetic right knee joint (a fracture occurring adjacent to an existing knee replacement implant), status post-surgical intervention requiring incisional sites to lateral right thigh and lateral right knee.Review of the Minimum Data Set (MDS) assessment, dated 2/15/26, indicated Resident #7 had intact cognition as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated the Resident's pain intensity had been severe.Review of the Hospital Discharge summary, dated [DATE], indicated Resident #7 was ordered to receive the following medication for pain management:-Oxycodone IR 5 mg (milligram) tablet- take 1-2 tablets (5-10 mg total) by mouth every 4 hours as needed for breakthrough pain for up to 7 days. Maximum daily amount: 60 mgReview of the Physician's Orders for pain management indicated:-Oxycodone HCL oral tablet 5 mg give one tablet by mouth every four hours as needed for breakthrough pain for 7 days maximum dose 60 mg-Acetaminophen Oral Tablet 325 mg- give 2 tablets by mouth every 6 hours as needed for pain/fever not to exceed 3 grams in 24 hours During an interview on 3/13/26 at 8:38 A.M., Resident #7 said when he/she had arrived, he/she did not get his/her pain medication for three days. Resident #7 said he/she was in severe pain; it was horrible.Review of the admission pain assessment, dated 2/11/26 at 5:59 P.M., indicated:Pain issue: #001 Location right posterior thigh. Pain score: 7. Aching, Sharp, StabbingPain issue: #002 Location right popliteal (knee) region. Pain score: 7, Aching, Sharp, StabbingPain Note: Resident complained of severe pain on his/her right leg that requires pain medicationReview of a Nurse's note, dated 2/12/26 at 12:52 A.M., indicated Resident reported severe pain and was restless.Review of a Nurse's note, dated 2/12/26 at 6:42 A.M., indicated Resident reported severe pain and was restless overnight. Resident was asking for his/her Oxycodone, but the medication did not come on the overnight run. Resident #7 had received acetaminophen at 10:00 P.M. and 4:00 A.M.Review of the narcotic log indicated Resident #7 did not receive his/her prescribed dose of Oxycodone until 2/12/26 at 12:00 P.M. (19 hours post-admission).During an interview on 3/13/26 at 2:21 P.M., the Physician said that the facility's medical video conferencing partner would reconcile admissions after hours. The medical video conferencing partner does not provide prescriptions for narcotics. The physician said he would provide the prescription if needed. The physician said staff should be calling the on-call phone number after hours.During a telephonic interview on 3/18/26 at 3:18 P.M., Pharmacist #4 said the facility's pharmacy provider received a prescription for Resident #7's Oxycodone on 2/12/26 at 10:30 A.M., seventeen and one half hours after admission. Pharmacist #4 said the prescription was given by Nurse Practitioner (NP) #1. Pharmacist #4 said the pull information (prescription verification and pharmacy entered code into the Pyxis MedBank authorizing the release of Oxycodone for Resident #7) was cleared by the pharmacy at 11:20 A.M. During an interview on 3/18/26 at 4:26 P.M., the Assistant Director of Nurses (ADON) said she had placed a text message to the physician to obtain a prescription for Residents #7's Oxycodone on 2/11/26 at 7:57 P.M. The ADON said she did not receive a return call. During an interview on 3/19/26 at 7:05 A.M., Nurse #6 said she was the nurse providing care for Resident #7 the day of admission overnight. Nurse #6 said Resident #7's Oxycodone had not arrived from the pharmacy. Nurse #6 said she only had an order for Tylenol to give him/her. Nurse #6 said Resident #7 was saying he/she was in severe pain despite having Tylenol at 10:00 P.M. Nurse #6 said she had given Resident #7 Tylenol at 6:00 A.M. with no relief. Nurse #6 said she did not reach out to the physician to update him on Resident #7's pain status.During an interview on 3/19/26 at 11:00 A.M., Nurse #7 said he was the admitting nurse for Resident #7. Nurse #7 said Resident #7 was stating he/she had severe pain. Nurse #7 said he had given Resident #7 his/her ordered acetaminophen at 10:00 P.M. with no relief. Nurse #7 said he was waiting for authorization to obtain Resident #7's Oxycodone from the Pyxis MedBank (an automated medication dispensing system). Nurse #7 said by the end of his shift he had not received authorization. Nurse #7 said he did not reach out to the physician to update him on Resident #7's pain status.During an interview on 3/19/26 at 11:20 A.M., NP #1 said she had arrived at the facility on 2/12/26 at approximately 10:15 A.M. NP #1 said Unit Manager #1 (UM) said she needed a prescription for Resident #7's Oxycodone. UM #1 said the pharmacy never received a prescription. NP #1 said she had not received a call requesting a prescription for Resident #7's Oxycodone day of admission. NP #1 said she had faxed a prescription and called the pharmacy at approximately 10:30 A.M. to get an authorization code (an authorized number that needs to be entered into the Pyxis MedBank to release a narcotic medication). NP #1 said staff should have used the after-hours phone number that would go directly to the personal cell phone for each provider. NP #1 said Resident #7 should not have gone 19 hours before receiving his/her dose of narcotic pain medication given Resident #7's recent acute pain from right leg fractures.During a telephonic interview on 3/19/26 at 2:31 P.M., the Physician said he did not receive a message on 2/11/26 for Resident #7's needed prescription. The physician said if he had received a message, he would have sent the prescription into the pharmacy and let the facility know.During an interview on 3/19/26 at 3:45 P.M., the Director of Nurses (DON) said she had learned that the facility did not receive a prescription for Resident #7's Oxycodone during the morning meeting on 2/12/26. The DON said staff should have utilized the on-call system to follow up on the status of the prescription and update on Resident #7's pain status. The DON said Resident #7 should not have gone 19 hours without appropriate pain medication.

Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, the facility failed to ensure their grievance policy included the right to file grievances anonymously and failed to ensure residents were aware of and had access to formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).Findings include:Review of the facility's policy titled Grievances Policy and Procedures, revised 8/30/24, failed to indicate residents and/or their representatives had the right to file grievances anonymously.On 3/16/26 at 10:00 A.M., the surveyor held a resident group meeting with ten residents in attendance. All ten residents said that they were not aware of their right to file a grievance anonymously. They said if they have an issue, they must tell a staff member about it or write their name on the grievance form to include their room number, and hand the form into a staff member. The residents said there is nowhere to file them in a way to remain anonymous.On 3/18/26 at 10:56 A.M., the surveyor toured all three units in the facility and observed a document titled Resident Grievances/Complaints Procedures posted on a bulletin board on each unit. The document indicated but was not limited to:-Any person has the right to file a grievance anonymously.-Give the completed form to Charge Nurse, Social Services, Administrator, or Director of Nurses.-It is the policy of this facility to assist you in filing a grievance or complaint.The posting failed to indicate availability and location of grievance forms as well as instructions on where or how to submit the forms to file anonymously.During an interview on 3/18/26 at 12:12 P.M., the Administrator identified herself as the Grievance Officer with social services playing a role in handling the resolution and maintaining the grievance log binders. She said residents can complete a grievance form and turn the form in to the nurses, staff, or reception. She said there is no process to file anonymously. However, if a resident wants to file anonymously, they could slide it under a staff member's door on the ground level but if the resident is not mobile or unable to leave the unit they would have to hand the grievance to a staff member. She said there is no location on any unit or on the ground floor to place a grievance form to maintain anonymity.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure a nebulizer machine (used to treat airway obstruction and bronchospasm by nebulizing aerosol medications) mouthpiece and reservoir (chamber that hold the liquid medication) were maintained in a sanitary manner for one Resident (#106), of 24 sampled residents. Findings include:Review of the facility's policy titled Respiratory Treatment Administration Policy, undated, indicated but was not limited to the following:-Respiratory treatments (including nebulizer treatments, oxygen therapy, and inhalation therapies) will be administered as ordered by the provider, following proper technique and infection control practices.-Equipment Care:-equipment must be changed weekly and as needed if soiled, contaminated, or malfunctioning-equipment must be stored in a clean, single-use designated bag at bedside-storage bags must be changed weekly and as needed if soiled or damaged Resident #106 was admitted to the facility in June 2025 with diagnoses including acute respiratory failure (sudden onset when lungs cannot adequately supply oxygen to the blood or remove carbon dioxide) with hypoxia (body tissues are deprived of adequate oxygen).Review of Resident #106's Minimum Data Set (MDS) assessment indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Furthermore, the MDS assessment indicated he/she was moderately to completely dependent on staff for activities of daily living.Review of Resident #106's Physician's Orders indicated but were not limited to the following:- Change tubing, mouthpiece and bag weekly - on Sundays Note: Date and Initial tubing and bag (3/15/26).-DuoNeb Inhalation Solution (use to open lung airways) 0.5-2.5 (3) milligrams (mg)/3milliliters (mL), give 3mg inhale orally three times a day, 6:00 A.M., 12:00 P.M., and 8:00 P.M. (3/12/26).-DuoNeb Inhalation Solution 0.5-2.5 (3) MG/3ML, give 3mL inhale orally every 6 hours as needed (PRN) (8/21/25). On the following dates/times, the surveyor observed Resident #106's Nebulizer mouthpiece and the chamber holding clear liquid residual medication resting directly on his/her bedside nightstand and open to air, with a undated clear plastic bag folded up on the bedside nightstand behind the nebulizer machine:-3/17/26 at 3:50 P.M.,-3/18/26 9:44 A.M.During an interview on 3/18/26 at 10:30 A.M., the surveyor, with Nurse #2 present, observed Resident #106's nebulizer equipment resting directly on the Resident's bedside table. Nurse #2 said the equipment should have been cleaned out to remove residual medication and stored in a dated plastic bag when it is not in use.During an interview on 3/18/26 at 11:17 A.M., Unit Manager (UM) #1 said the nebulizer equipment should have been cleaned after each treatment, then stored in a clean bag and the bag should be dated.During an interview on 3/19/26 at 12:01 P.M., the Director of Nursing (DON) said the nebulizer equipment should have been cleaned and stored properly.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment on two out of three units. Specifically, the facility failed to ensure: 1. For the [NAME] unit, the residents' environment was free of a pervasive pungent odor of feces and urine; and 2. For one room on the second floor, the footboard was in place. Findings include:Review of the facility's policy titled Homelike Environment, undated, indicated residents are to be provided with a safe, clean, comfortable, and homelike environment and encouraged to use personal belongings to the extent possible. The policy stated staff and management are to maximize characteristics that reflect a personalized, homelike setting, including: -A clean, sanitary, and orderly environment -Clean bed and bath linens in good condition -Pleasant, neutral scents The policy also indicated staff and management are to minimize characteristics of an institutional setting, including institutional odors. 1. On 03/12/26 at 08:20 A.M., the surveyor smelled a pervasive and unbearable odor of feces and urine upon entering the [NAME] Unit. On 03/17/26 at 08:10 A.M., the surveyor smelled a pervasive and unbearable smell of feces and urine upon entering the [NAME] Unit. On 03/18/26 at 8:05 A.M., the surveyor smelled a persistent odor of feces and urine upon entering the [NAME] Unit. The surveyor identified the following rooms as having the strongest, most noticeable odor: Rooms 178, 177, 176, 165, 159, 163, and 158. During an interview on 03/18/26 at 8:20 A.M., Certified Nursing Assistant (CNA) #6 said he always wears a mask because of the pervasive and overwhelming smell. During an interview on 03/18/26 at 10:48 A.M., CNA #5 said he usually wears a mask to avoid the unbearable smell. During an interview on 03/18/26 at 11:15 A.M., the Housekeeping Supervisor acknowledged the pervasive and overwhelming odor and stated it was present because many residents are incontinent with bowel and bladder. The Housekeeping Supervisor said if she was told that the smell was pervasive and overwhelming, she would have sent her staff to do a deeper cleaning. During an interview on 3/18/26 at 1:46 P.M., the Unit Manager stated the odor was pervasive and unbearable and attributed it to the number of incontinent residents on the [NAME] Unit. 2. On the following days and times, the surveyor observed the footboard of Resident #106's bed to be missing from the end of the bed and instead tucked under the Resident's mattress on top of the bedframe. The surveyor observed part of the metal bed frame to be extending off the end of the bed where the wood footboard should have been attached. -3/12/26 at 11:15 A.M. -3/16/26 at 12:36 P.M. -3/17/26 at 3:40 P.M. -3/18/26 at 9:44 A.M. -3/18/26 at 10:30 A.M. During an interview on 3/18/26 at 10:30 A.M., Nurse #2 said the footboard has been off Resident #106's bed for a few weeks. Nurse #2 said the footboard should have been repaired by Maintenance. During an interview on 3/19/26 at 11:21 A.M., CNA #12 said he was aware the footboard was off the bed and that it was under the mattress. CNA #12 said he has been making the Resident's bed around the footboard under the mattress. During an interview on 3/18/26 at 2:38 P.M., the Maintenance Director said he goes in and out of every resident's room performing environmental rounds daily. The Maintenance Director said he should have seen the missing footboard and repaired it during daily rounds but missed it.

Based on observations, record reviews, and interviews, the facility failed to ensure for three Residents (#105, #106, #29), out of a total sample of 24 residents, that services were provided to maintain their vision or hearing abilities. Specifically, the facility failed:1. For Residents #105 and #106, to ensure they were provided with audiology services after the Residents notified staff that their hearing aid devices were not working properly/broken, to support the Residents' hearing needs; and2. For Resident #29, to arrange for an optometry appointment to address the Resident's vision impairment. Findings include: Review of the facility's policy titled Sensory Impairments-Clinical Protocol, dated March 2018, indicated but was not limited to the following: -Treatment/Management: -For residents with impaired hearing, the staff should check for cerumen, and may (as indicated) help the individual obtain a hearing evaluation, hearing aid, or employ written or other means to communicate with the individual. -The physician will identify and order appropriate consultations to help manage causes, complications, and risks of sensory impairment. As part of the initial assessment, the staff and physician will help identify individuals with sensory impairments, including hearing, taste, vision, smell, and touch.The physician will order appropriate consultations (for example, ophthalmology or podiatry evaluations) to help define causes and complications of sensory impairments.The staff and physician will identify approaches to help the resident improve or compensate for sensory deficits. For example, they may refer visually impaired individuals for vision evaluation and/or corrective lenses.The physician and staff will adjust interventions based on the results of these interventions and on subsequent changes in the resident's condition, prognosis, and function. Review of the facility's policy titled Ancillary Mobile Health Services (Dental, Vision, Podiatry, Audiology), indicated but was not limited to the following: Establish a standardized process for the delivery of specialized clinical services by third-party mobile vendors, ensuring high-quality care, informed resident consent, and regulatory compliance.Residents must be informed that they have the right to choose these vendorsNo services shall be performed without a signed informed consent formThe vendor must provide a written or electronic Encounter Note for every resident seen before leaving the facility. This note must include assessment finding, treatments performed, and follow-up recommendations. 1. During an interview on 3/12/26 at 11:15 A.M., Resident #106 said he/she has been sharing hearing aids with his/her spouse. Resident #106 said they both wear hearing aids and are very hard of hearing. Resident #106 said the hearing aids broke so they have been sharing hearing aids because they have not been able to see the audiologist. Resident #106 said staff informed them both that they are on the list to be seen but it has been since July 2025 and they have not seen anyone. Resident #105 showed the surveyor a broken hearing aid. The hearing aid was observed to be in two pieces. Resident #105 said the hearing aid broke a while ago and said they have been trying to get with the audiologist and did not understand why it is taking so long. A. Resident #106 was admitted to the facility in June 2025 with diagnoses including but not limited to adjustment disorder with mixed anxiety and depressed mood. Review of Resident #106's Minimum Data Set (MDS) assessment indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. MDS indicated Resident wears hearing aids and received therapy services for speech-language pathology and audiology services. Review of Resident #106's care plan indicated but was not limited to the following: -Focus: Resident has a communication problem related to hearing deficit (8/26/25). -Goal: Resident will maintain current level of communication function through the review date (initiated 8/26/25, target date 5/3/26). -Interventions: Ensure hearing aid(s) are in place (8/26/25). Review of Resident #106's Physician's Orders failed to indicate orders for Audiology consult. Review of Resident #106's medical record indicated a consent was signed on 6/27/25 for ancillary mobile health services, requesting services for audiology, dental, eye care, and podiatry. Review of Resident #106's medical record progress notes indicated but was not limited to the following: -7/19/25- Nurses note: indicated decreased hearing. -8/20/25-Nurses note: indicated hearing impairment. B. Resident #105 was admitted to the facility in June 2025, with diagnoses including but not limited to adjustment disorder with mixed anxiety and depressed mood. Review of Resident #105's MDS assessment indicated he/she was cognitively intact as evidenced by a BIMS score of 14 out of 15. The MDS failed to indicate Resident #105's hearing deficit or use of hearing aid(s) (12/19/25). Review of Resident #105's Physician's Orders failed to indicate orders for an Audiology consult. Review of Resident #105's care plan indicated but was not limited to the following: -Focus: Resident has potential for communication problem related to hearing deficit (7/27/25). -Goal: Resident will maintain current level of communication function with use of hearing aids through the review date (initiated 7/27/25, target date 6/7/26). -Interventions: Communication- -Resident requires bilateral hearing aids to communicate. Ensure availability and functioning of adaptive communication equipment (7/27/25). -Ensure bilateral hearing aids are in place and volume is at the highest setting (7/27/25). -Refer to Audiology for hearing consult as ordered (7/27/25). Review of Resident #105's medical record indicated a consent was signed on 7/6/25 for ancillary mobile health services, requesting services for audiology, dental, eye care, and podiatry. Review of Resident #105's medical record progress notes indicated but was not limited to the following: -12/5/25 Nurse Practitioner (NP) progress note: indicated Resident not hearing well. -12/10/25 NP progress note: indicated Resident not hearing well. -1/5/26 NP progress note: indicated Resident not hearing well. During an interview on 3/17/26 at 9:11 A.M., Ancillary Services Consultant (ASC) #3 said Residents #106 and #105 do not have audiology appointments scheduled. ASC #3 said both Residents' enrollment forms were received from the facility on 12/19/25 and would be able to be seen on the next scheduled visit sometime in May 2026. ASC #3 said the audiologist visited the facility on 7/9/25 and 7/17/25. ASC #3 said if a resident needs to be sooner for a concern or device issue they will have a provider working in the area go to the facility and see the resident sooner. During an interview on 3/18/26 at 4:17 P.M., Social Worker (SW) #1 said she was aware both Resident's had concerns with the function of their hearing aid(s), specifically that Resident #106's hearing aid was broken. SW #1 said she sent an email to Ancillary services providers which provided signed consents requesting services, however there was no further follow-up to the ancillary services providers since 12/2025. SW#1 said and they should have done this knowing there was a concern. SW#1 said she does not have a system in place to track residents' ancillary service needs and should have. During an interview on 3/19/26 at 11:47 A.M., Nurse Practitioner (NP) #1 said she would have expected both Residents to have been seen by audiology services for hearing aid concerns and if the nursing staff needed orders for this service, she would have expected them to contact her. During an interview on 3/19/26 at 12:01 P.M., the Director of Nursing (DON) said both Residents should have been seen by the ancillary service providers for audiology services and were not. The DON said her expectations are as residents admit to the facility, they complete a consent for requesting services for the ancillary service needs of choice, then that form is faxed to the ancillary service consulting provider, and the resident is placed on the next visit date for care needs. 2. Resident #29 was admitted to the facility in April 2025 with diagnoses which included diabetes mellitus and optic neuritis. Review of the MDS assessment, dated 12/18/25, indicated Resident #29 scored 15 out of 15 on the BIMS indicating the Resident was cognitively intact. Review of Physician's Orders, dated 3/19/2026, include Optometry consult 4/3/25. Review of the medical record indicated Resident #29 signed a Request for Service, including eye care, on 4/16/25. Review of physician and nurse practitioner progress notes indicated Resident #29 would be referred to optometry on 7/7/25, 7/15/25, 8/20/25 and 10/8/2025. Review of the facility's consultant eye care group schedules failed to indicate Resident #29 was scheduled to be seen between April 2025 and February 2026. Review of the Care Plan failed to indicate vision as a focus area. On the following dates and times, the surveyor observed Resident #29 not wearing glasses: 3/12/26 at 9:27 A.M.3/16/26 at 8:14 A.M.3/17/26 at 4:30 P.M.3/18/26 at 9:11 A.M. During an interview on 3/12/26 at 9:27 A.M., Resident #29 said his/her glasses are no good and would like to get that resolved. During an interview on 3/16/26 at 12:57 P.M., Unit Manager #3 said Resident #29 occasionally wears glasses and his/her preference is not to wear them. Unit Manager #3 did not know when Resident #29 was seen by Optometry. During an interview on 3/17/26 at 9:20 A.M., consultant eye care group Regional Account Manager #3 said Resident #29 was not enrolled with the facility's consultant eye care group. During an interview on 3/18/26 at 9:11 A.M., Resident #29 said if he/she got a new pair of glasses, he/she might be able to see more clearly. Resident #29 also said he/she wears glasses for distance. During an interview on 3/18/26 at 11:15 A.M., Social Worker #1 said that consultant eye care group consents are reviewed during quarterly care plan meetings and if any new services are requested, the consent is updated and sent to the consultant eye care group to initiate service.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with professional standards of practice. Specifically, the facility failed to ensure the medications were administered under direct supervision of a licensed nurse and not left at the bedside for one Resident (#126), out of a total sample of 24 residents.Findings include:Review of the facility's policy titled Self-Administration of Medications, dated February 2021, indicated but was not limited to the following:-Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them.-Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.Resident #126 was admitted to the facility in March 2026 with diagnoses which includes chronic obstructive pulmonary disease (COPD) (restriction of airflow causing chronic breathing difficulties, cough, and fatigue) and panlobular emphysema (severe form of COPD where there is destruction of alveoli throughout the lung).Review of the medical record indicated Resident #126 was advised of their right to self-administer medications on 3/4/26 and indicated he/she wished to have the medication nurse administer their medications.During an interview with observation on 3/12/26 at 4:12 P.M., the surveyor observed Resident #126 sitting on his/her rollator walker seat and on the seat next to the Resident's bed was an Albuterol inhaler. Resident #126 said nurses are always late, especially at night providing medications and he/she kept the inhaler provided by the nurses to use when he/she feels the medication is needed. On 03/19/26 at 10:29 A.M., the surveyor observed Resident #126's Albuterol inhaler on the Resident's bedside table which was at the foot of the bed close to the window. Resident #126 was sitting in a chair next to his/her bed and said he/she has been using the inhaler frequently and needs a replacement because the inhaler is almost empty.During an interview on 3/19/26 at 10:40 A.M., Nurse #7 said the Resident should not have this medication at the bedside.During an interview on 3/19/26 at 11:29 A.M., Unit Manager (UM) #1 said the medication should have been locked up.During an interview on 3/19/26 at 11:47 A.M., Nurse Practitioner (NP) #1 said Resident #126 should not have medications at the bedside.During an interview on 3/19/26 at 12:01 P.M., the Director of Nursing (DON) said Resident #126 should not have had an Albuterol inhaler at the bedside and the medication should have been locked up in the nurse's medication cart.

Based on observation, record review and interview, the facility failed to ensure nutritional status was maintained for two Residents (#83 and #3), out of a total sample of 24 residents. Specifically, the facility failed:1. For Resident #83, to ensure a strict fluid restriction was provided and accurately documented.2. For Resident #3, to ensure a strict fluid restriction was provided and accurately documented. Findings include:Review of the facility's policy titled Encouraging and Restricting Fluids, dated as revised October 2010, indicated but was not limited to:The purpose of this policy is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids.General Guidelines1. Follow specific instructions concerning fluid intake or restrictions.2. Be accurate when recording fluid intake3. Record fluid intake in mLs. (milliliters)1. Resident #83 was admitted to the facility in January 2024 with diagnoses that included Type 2 diabetes mellitus with diabetic chronic kidney disease, end stage renal disease and dependence on renal dialysis (a medical procedure that filters products, toxins, and excess water from the blood when the kidneys fail). Review of the Minimum Data Set (MDS) Assessment, completed on 2/17/26, indicated Resident #83 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of March 2026 Physician's Orders indicated but was not limited to:1000 cubic centimeter (cc) fluid restriction: 840 cc dietary (360 cc-B (Breakfast), 240 cc-L (Lunch), 240cc-D (Dinner)) 160 cc Nursing (60 cc 7-3, 60 cc 3 - 11, 60 cc 11 - 7) every day for fluid restriction. On 3/16/26 at 12:50 P.M., the surveyor observed Resident #83 eating lunch in the main dining room. He/She received 480 cc cranberry juice and drank the entire glass. Review of Resident #83's Lunch meal ticket, dated 3/16/26, indicated 8 oz (240 cc) diet ginger ale with each meal. Further review of the meal ticket failed to indicate the Resident was on a fluid restriction. During an interview on 3/16/26 at 12:50 P.M., Certified Nursing Assistant (CNA) #11 said he did not know that the Resident had restricted fluids because there was nothing on the ticket. He said he checks the meal ticket for any instructions. During an interview on 3/16/26 at 2:01 P.M., Nurse #5 said Resident #83 is on a fluid restriction and the fluid intake is recorded in the Treatment Administration Record (TAR). She said she documents only the fluid that she administers and does not document what is given by CNAs or with meals in the dining room. She said she does not know where that gets documented. Review of the TAR for the day shift on 3/16/26 with Nurse #5 indicated Resident #83's fluid intake for the day shift was 160 (cc). Nurse #5 said that was the amount of fluid she gave Resident #83 on the day shift. She said the physician's order for fluid was 60 cc for nursing to give on days and she gave too much. She said she did not know how much fluid Resident #83 drank with lunch. On 3/17/26 at 8:30 A.M., the surveyor observed Resident #83 in the main dining room eating breakfast. Resident #83 was observed drinking 480 cc cranberry juice, 240 cc coffee and water in a large styrofoam glass. He/She finished all of the drinks. Review of Resident #83's meal ticket, dated 3/17/26, indicated 12 oz (360 cc) fluid restriction for breakfast. During an interview on 3/17/26 at 8:40 A.M., CNA #10 said he did not know that Resident #83 was on a fluid restriction, no one told him. During an interview on 3/17/26 at 1:00 P.M., Resident #83 said he/she knows that his/her fluid intake is restricted because of kidney failure. He/she said his/her biggest hope is to get a kidney transplant someday. He/she said that the staff provide reminders about the fluid restriction, but sometimes it's hard to follow because he/she likes to drink. 2. Resident #3 was admitted to the facility in December 2025 with diagnoses that included end stage renal disease and dependence on renal dialysis and stage five chronic kidney disease. Review of the MDS Assessment, completed on 1/27/26, indicated Resident #3 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of Resident #3's Physician's Orders for March 2026 indicated but was not limited to: Fluid restriction. (1000mL) Dietary: 120ml per meal Nursing 7-3 130mL, 3-11 150mL, 11-7 120mL, and 240ml Nepro QD Further review of the Physician's Order indicated Miralax oral powder 17GM (gram)/scoop. Give one scoop by mouth two times a day for constipation. Mix 17 g in 4 - 6 oz of fluids. On 3/16/26 at 8:49 A.M., the surveyor observed Resident #3's breakfast tray that was delivered to his/her room and left on the overbed table. Drinks on the tray included 240 cc of tea and 120 cc of milk. Review of Resident #3's breakfast meal ticket, dated 3/16/26, indicated 8 oz (240cc) tea at every meal. Further review of the ticket failed to indicate any fluid restriction. During an interview on 3/16/26 at 8:49 A.M., Unit Manager #3 said the Resident was at dialysis and the tray was for Resident #3 and they would get another tray from the kitchen when he/she returned. On 3/16/26 at 12:45 P.M., the surveyor observed Resident #3 sitting in his/her room with a lunch tray on the overbed table. On the tray from the kitchen was 240 cc of tea and a 120 cc carton of milk, which the Resident had finished. On the table there was a one-liter bottle of ginger ale approximately half full and four unopened juice containers (120cc). The Resident also had a personal pink water bottle in a holder on his/her wheelchair containing approximately 240 cc of water. During an interview on 3/16/26 at 12:45 P.M., Resident #3 said he/she drank the tea and milk with lunch. The Resident said he/she knows that fluids are restricted, but he/she likes to drink. The Resident said the staff bring drinks to him/her when he/she asks. Review of the TAR for day shift on 3/16/26 with Nurse #5 indicated Resident #3's fluid intake for the day shift was 120 (cc). During an interview on 03/16/26 at 2:01 P.M., Nurse #3 said that Resident #3 is on a fluid restriction. She said she gives the Resident two cups of water with meds, one for meds (150cc) and another (150cc) for Miralax. She said she was supposed to give 130cc on her shift, but she was giving the Resident more every day, approximately 300 cc with the morning med pass. She said she documents only the fluid that she administers on the TAR and does not document what is given by CNAs or with meals. She said that she documented an intake of 120 cc on the TAR and that was incorrect. On 3/17/26 at 12:45 P.M., the surveyor observed Resident #3 sitting in his/her room eating breakfast. There was an empty mug. The Resident said that it had tea in it and he/she finished it. Review of Resident #3's breakfast meal ticket, dated 3/17/26, indicated 8 oz (240cc) tea at every meal. Further review of the ticket failed to indicate any fluid restriction. During an interview on 03/16/26 at 3:09 P.M., the Registered Dietitian (RD) said that when a resident requires a fluid restriction, she divides the liquid amounts between nursing and dietary and notifies them. She said for Resident #3, she was unaware of the addition of the 240cc of tea to each tray (three times per day day) along with 120 cc that she allotted. She also said she was unaware that nursing is administering MiraLAX twice a day in 4 - 6 oz of water that she did not include in her calculation. She said that amount is more than the 1,000 cc fluid restriction and she didn't think that he/she should be getting that much extra. The RD further said that both Resident #3 and Resident #83 are on strict fluid restrictions because the nephrologist at dialysis ordered it. She said she meets with the dialysis team once a month about both residents and the nephrologist is firm about the restrictions. She said both residents have been educated by her and the dialysis staff about the restriction and importance of compliance. During an interview on 03/17/26 at 10:13 A.M., the Food Service Director said fluid restrictions for residents are not on meal tickets. He said dietary staff use the tickets to see what fluids to put on the meal trays. He said he updates the tickets but he's not always aware of what the restrictions are and what the dietary portion of the fluid is allowed. He said that if a resident requests extra fluids they will add that to tickets because it's the resident's right, but they don't have a process to let the RD know it has been added. During an interview on 03/18/26 2:57 P.M., Nurse Practitioner (NP) #3 said that when a resident goes to dialysis and the nephrologist orders a fluid restriction, the provider at the facility will review the recommendation and put the order in place at the facility if in agreement. She said she expects that the RD will determine how the fluid amounts are divided up between nursing and dietary. She said the kitchen should know how much fluid to provide with meals and nursing should be documenting the total intake. She said it's important to make sure residents adhere to the restriction because there is a risk of fluid overload or other complications. They need to avoid getting more than ordered. During an interview on 03/18/26 at 4:23 P.M., the Director of Nursing (DON) said when a fluid restriction is ordered for a resident, the RD divides the ordered volume of fluid between nursing and dietary. She said her expectation is that the nursing staff will offer those amounts to the residents. If they ask for more, the staff should educate the residents about the restrictions but if the residents persist, the staff should give the residents what they want because it's their right, then the physician and RD should be notified. She said the volume should be documented in the TAR and totaled by the night shift. Nursing should document all fluids given on the shift including during meals and with medications. During the interview, the surveyor and DON reviewed the fluid intake documentation on the March TAR. The DON said that the nurses were not consistently documenting the intakes and it would need to be corrected.

Based on record review and interviews, the facility failed to develop and implement a person-centered plan of care which included care and management for one Resident (#15) who had been determined by the staff to be at risk of elopement (an incident when a resident leaves the premises or a safe area without authorization or the necessary supervision to do so safely), out of a total sample of 24 residents. Findings include:Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised 3/2022, included but was not limited to:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.-care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.-assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.Review of the facility's policy titled Wandering and Elopements, last revised 3/2019, included but was not limited to: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.-If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.Review of the facility's policy titled Wander Guard Policy, undated, included but was not limited to:-The facility will use the Wander Guard system (or equivalent) as part of its elopement prevention program.-The system will be implemented only after a comprehensive assessment determines that a resident is at risk for unsafe wandering.-Nursing staff will complete an Elopement Risk assessment upon admission and as needed thereafter.-The decision to use a Wander Guard device must be documented in the resident's care plan and approved by the interdisciplinary team.Resident #15 was admitted to the facility in October 2023 with diagnoses including: bipolar disorder, alcohol abuse, alcoholic cirrhosis of the liver with ascites (advanced liver disease where scarring causes high pressure in the liver's blood vessels leading to abdominal fluid accumulation), and cancer of the liver. Review of the Minimum Data Set (MDS) assessment, dated 1/23/26, indicated Resident #15 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. During an interview on 3/12/26 at 4:48 P.M., Family Member (FM) #2 said they were called by the facility and were told Resident #15 was found in the parking lot early in the morning. FM #2 said Resident #15's health care proxy had been invoked. FM #2 said the date they had received the call was around 1/22/26. During an interview on 3/13/26 at 9:11 A.M., Resident #15 said he/she had this thing on their left leg (referring to the wander guard). Resident #15 said he/she wanted it removed. Resident #15 said, They told me I was sleepwalking and slapped this thing on. Resident #15 could not recall who had placed the wander guard on him/her. Review of the medical record indicated but was not limited to the following: - The Healthcare proxy was activated on 1/22/26 secondary to cognitive decline.- Nursing admission assessment indicated the Resident was not at risk for wandering.- Social Service Progress Notes failed to indicate the Resident demonstrated a behavior of wandering or was a risk for elopement.- Nurse Practitioner and Physician Notes failed to indicate the Resident demonstrated a behavior of wandering or was at risk for elopement.- Nursing Progress Notes from January 2026 to March 13, 2026, failed to indicate the Resident demonstrated a behavior of wandering or was a risk for elopement. - Current March 2026 Physician's Orders did not indicate use of a wander guard.- On 3/13/26, current care plans for Resident #15 failed to indicate the Resident was at risk for elopement and required a wander guard device. During an interview on 3/13/26 at 10:14 A.M., Certified Nursing Assistant (CNA) #1 said she was not sure why Resident #15 had a wander guard placed. CNA #1 said she believed he/she was trying to go out unsupervised.During an interview on 3/13/26 at 10:41 A.M., CNA #2 said Resident #15 had a wander guard place because he/she was going outside to smoke unsupervised. CNA #2 said she did not know when the wander guard was placed. CNA #2 said Resident #15 needed to be supervised for his/her cigarette scheduled times. During an interview on 3/18/26 at 12:14 P.M., Unit Manager (UM) #1 said she was not sure who placed a wander guard on Resident #15. UM #1 said she heard Resident #15 was found outside by staff around 5:00 A.M. but she could not recall the date. UM #1 reviewed the medical record and could not locate a progress note indicating Resident #15 had exited the facility. In addition, UM #1 did not locate an elopement risk assessment or updated care plan for risk of elopement and wander guard use. UM #1 said whoever put the wander guard on Resident #15 should have completed the elopement assessment and updated the care plan.During an interview on 3/19/26 at 11:05 A.M., Nurse Practitioner (NP) #1 said she was asked to look at invoking Resident #15's health care proxy on 1/22/26. NP #1 said the decision was made to invoke the HCP secondary to Resident #15's cognitive decline and poor decision making. NP #1 said she was made aware that Resident #15 was found outside around 5:00 A.M. on 1/21/26.During an interview on 3/18/26 at 4:08 P.M., the Director of Nurses (DON) said she was made aware during morning meeting on 1/21/26 that Resident #15 was found outside at approximately 5:30 A.M. just outside the main lobby door. The DON said she did not know who had found the resident outside. The DON reviewed the medical record and said there were no progress notes indicating Resident #15 was outside unsupervised. The DON said whoever put the wander guard on Resident #15 should have written a progress note, completed the elopement assessment, and updated the care plan.

Based on record review and interview, the facility failed to accurately complete an assessment with the Preadmission Screening and Resident Review Level I (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for one Resident (#6), out of a total sample of 24 residents. Specifically, the facility failed to document the resident's diagnosis of Post-traumatic stress disorder (PTSD) in Question 4A, history of substance use disorder (SUD) in Question 4B and Department of Mental Health (DMH) Involvement/case management in Question 5A resulting in an incorrect negative serious mental illness (SMI) screen.Findings include:Review of the facility's policy titled PASARR, established and revised 8/2025, indicated but was not limited to: The facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with mental disorders (MD), intellectual disability (ID), or a related condition receive care and services in the most integrated setting appropriate to their needs.1. Applicants to the facility will be screened for serious MD or ID and related conditions in accordance with the State's Medicaid rules for screening.a. PASARR Level I - initial pre-screening that is completed prior to admissioni. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious MD or ID or intellectual disability arises later.ii. Positive Level I Screen - necessitates and PASARR Level II evaluation prior to admission.a. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services that the individual needs.1. The facility will only admit individuals with a MD or ID who the State mental health or ID authority has determined as appropriate for admission2. Recommendations such as any specialized services, from a PASARR Level II determination and/or PASSAR evaluation report will be incorporated into the resident's assessment, care planning and transitions of care. Resident #6 was admitted to the facility in July 2025 with diagnoses that included but were not limited to schizoaffective disorder, PTSD, bipolar disorder, anxiety disorder, and major depressive disorder.Review of the Minimum Data Set (MDS) Assessment, completed on 1/27/26, indicated Resident #6 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 3/17/26 at 3:33 P.M., Resident #6 said that he/she has lived in the facility for a few months. The Resident said he/she has had some mental health issues and hard times in life. The Resident said he/she lived in a group home prior to coming to the facility and does not want to be in the facility for long-term. The Resident said he/she is looking for an apartment or place to live as he/she doesn't want to live in a nursing home for the rest of his/her life.Review of Social Service Assessment 1, dated 7/22/25, indicated but was not limited to:G1. Substance Use Disorder - Yes, Hx (History) of drug/alcohol abuse. Currently clean and soberReview of Hospital History and Physical Reports, dated 7/18/25, indicated but was not limited to:Department of Mental Health (DMH)Review of PASRR Level I Screening, dated 7/22/25, failed to indicate the following in Section B: Screening for SMI: diagnosis of PTSD; history of SUD; and DMH involvement/case management. Further review of the PASRR Level I Screening, dated 7/22/25, indicated in the section titled SMI: Screening Results: Negative SMI screen (Level II PASRR Evaluation is not indicated)During an interview on 3/17/26 at 3:53 P.M., the Administrator said she reviewed the PASARR Level I form she completed when the Resident was admitted in July of 2025. She said she missed checking off the diagnosis of PTSD and history of SUD and the fact that the Resident was being followed by DMH. She said at the time of the admission, she thinks she talked with the resident's stepfather, but she should have talked with his/her DMH case worker or the Resident at the time, but she did not. She said that if she had filled out the PASARR Level I correctly on admission, Resident #6 would have had a positive SMI screen.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had moderate cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that on 01/20/25, after Facility Administration was made aware of an allegation of verbal abuse of a resident (Resident #1)by a staff member (Certified Nurse Aide #1), that they reported the allegation to the Department of Public Health (DPH) within two hours as required, when it was not reported to DPH until 01/23/25, (three days later). Findings include: Review of the Facility's Abuse Policy, untitled and undated, indicated the following: -verbal abuse includes, but is not limited to, threats of harm and/or making statements to frighten a resident, and -the Facility must report an allegation of abuse to the Department of Public Health within two hours of becoming aware of the allegation. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 01/23/25, indicated that on 1/18/25 at approximately 11:30 A.M., Activity Assistant (AA) #1 was pushing her activity cart down the hallway when Resident #1 moved in front of the activity cart. The Report indicated that a CNA (later identified as CNA #1) was beside Activity Assistant #1 and told her (AA #1) to run Resident #1 over with the activity cart and kill him/her because she (CNA #1) hated him/her (Resident #1). Review of the Facility's Internal Investigation Summary Report, undated, indicated that on 01/18/25 at approximately 11:30 A.M., Activity Assistant #1 had stopped the activity cart she was pushing because Resident #1 had moved in front of it with his/her wheelchair. The Report indicated that CNA #1 was standing next to Activity Assistant #1 when she (CNA #1) told her to run Resident #1 over with the activity cart and kill him/her because she (CNA #1) hated him/her (Resident #1). During an interview on 02/05/25 at 10:21 A.M., the Activity's Director said that Activity Assistant #1 called her on 01/18/25 to report that while she had been waiting for Resident #1 to move out of her way, CNA #1 told her to get him/her (Resident #1) out of there, kill him/her, and get rid of him/her because she (CNA #1) did not like him/her (Resident #1). The Activity's Director said she did not report the allegation of verbal abuse to Administration until 01/20/25, but said she should have reported it immediately. During an interview on 02/13/25 at 1:23 P.M., the Administrator said that sometime in the morning, on 01/20/25, she was notified of an allegation of verbal abuse by a staff member (CNA #1) that occurred on 01/18/25 and involved Resident #1. The Administrator said she thought the allegation had been reported timely, but said she had misunderstood the timing and the process of reporting to DPH via the HCFRS. The Administrator said after being made aware of an allegation of abuse, it should be reported to DPH within two hours, but for alleged incident it had not been.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had moderate cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 01/18/25, after being notified of an allegation of verbal abuse by staff, the Activity's Director did not immediately report the allegation of verbal abuse to Administration, and did not do so until two days later. Findings include: Review of the Facility's Abuse Policy, untitled and undated, indicated the following: - verbal abuse includes, but is not limited to, threats of harm and/or making statements to frighten a resident, and - upon receiving an allegation of abuse, covered individuals will take necessary steps to protect all residents and then immediately notify the Administrator. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/23/25, indicated that on 1/18/25 at approximately 11:30 A.M., Activity Assistant (AA) #1 was pushing her activity cart down the hallway when Resident #1 moved in front of the activity cart. The Report indicated that a CNA (later identified as CNA #1) was beside Activity Assistant #1 and told her (AA #1) to run Resident #1 over with the activity cart and kill him/her because she (CNA #1) hated him/her (Resident #1). Review of the Facility's Internal Investigation Summary Report, undated, indicated that on 01/18/25 at approximately 11:30 A.M., Activity Assistant #1 had stopped the activity cart she was pushing because Resident #1 had moved in front of it with his/her wheelchair. The Report indicated that CNA #1 was standing next to Activity Assistant #1 when she (CNA #1) told her to run Resident #1 over with the activity cart and kill him/her because she (CNA #1) hated him/her (Resident #1). During an interview on 02/05/25 at 10:01 A.M., Activity Assistant #1 said that on 01/18/25 at approximately 11:20 A.M., she was wheeling her cart down the hall and stopped because Resident #1 had moved his/her wheelchair in front of the cart. Activity Assistant #1 said that when she stopped and waited for Resident #1 to move, CNA #1 told her to just run Resident #1 over with the cart, murder him/her, and [NAME] him/her somewhere because she (CNA #1) could not stand him/her. Activity Assistant #1 said she immediately called the Activity Director and reported the incident. During an interview on 02/05/25 at 10:21 A.M., the Activity's Director said that Activity Assistant #1 called her on 01/18/25 to report that while she had been waiting for Resident #1 to move out of her way, CNA #1 told her to get him/her (Resident #1) out of there, kill him/her, and get rid of him/her because she (CNA #1) did not like him/her (Resident #1). The Activity's Director said she did not report the allegation of verbal abuse to Administration until 01/20/25 (two days later), but said she should have reported it immediately. During an interview on 02/05/25 at 2:17 P.M., the Director of Nurses (DON) said she was not notified of the allegation of verbal abuse by staff that occurred on 01/18/25 involving Resident #1, until 01/20/25. The DON said that the allegation should have been reported to her immediately, but it was not. During an interview on 02/05/25 at 2:40 P.M., the Administrator said she was not notified of the allegation of verbal abuse by staff that occurred on 01/18/24 involving Resident #1 until 01/20/25. The Administrator said the Activity's Director should have reported the allegation of verbal abuse to her immediately, but she had not.

Based on observations, records reviewed and interviews, for three of seven sampled residents (Resident #3, Resident #5, Resident #6), who required transmission based precautions to be utilized by nursing staff during the provision of care, the Facility failed to ensure, 1) that nursing staff were competent and had the necessary skill set to appropriately care for residents by donning the correct Personal Protective Equipment (PPE) when a resident was on Contact Precautions (CP) or Enhanced Barrier Precautions (EBP), when nursing staff members were observed not following precautions while caring for these residents and 2) that after a nursing staff member responsible for providing direct care to residents tested positive for Group A streptococcal Infection, (GAS, a bacterium that can cause many different infections, including strep throat and also cause severe, life-threatening invasive disease, and spread person to person through respiratory droplets or direct contact with an infected person's skin sores, nose, throat or wound secretions) that the staff member was removed from the schedule and not allowed to return to work until after being on an antibiotic for 24 hours, which increased the risk for the spread of an infectious disease to other residents in the facility. Findings include: Review of the Facility Policy, titled Isolation - Categories of Transmission-Based Precautions, dated as revised September 2022, indicated that transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection or has a laboratory confirmed infections and is at risk of transmitting the infection to other residents. The Policy indicated the following: -standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status; -transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected; -these measures are determined by the specific pathogen and how it is spread from person to person; -transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures; -when a resident is placed on transmission based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need and type of precaution; -the signage informs the staff of the type of CDC precaution, instructions for use of PPE, and/or instructions to see a nurse before entering the room; -Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment; -Contact Precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified; -Contact Precautions are used for residents infected or colonized with Multi Drug Resistant Organisms (MDRO) when a resident has wounds, secretions, or excretions that are unable to be covered or contained and on units where, despite attempts to control the spread of MDRO, ongoing transmission is occurring; -Enhanced Barrier Precautions (EBP) additional usage of PPE may be used for residents who do not meet criteria for contact precautions but are infected or colonized with MDRO's; -staff wear gloves, when entering the room, while caring for a resident, staff will change gloves after having contact with infective material, gloves are removed and hand hygiene performed before leaving room, staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed; -staff wear a disposable gown upon entering the room and remove gown before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed; Review of the CDC Recommendations for GAS, Transmission Based Precautions, dated 04/03/24 indicated to use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. During an in-person interview on 1/22/25 at 3:20 P.M. with Surveyor #1 and Surveyor #2 and subsequent telephone interview on 1/23/25 at 8:39 A.M. with Surveyor #1, the Director of Nurses (DON) said that the Facility does not have a separate policy for staff competencies. The DON said that each staff member has a Job Description which includes a competency evaluation column that is used for competencies. The DON said that the competencies are completed with each newly hired employee within 90 days of employment and then annually with their review. Review of the Facility's Nurse Supervisor Job Description, indicated it included but was not limited to the following: -ensure that personnel follow established procedures for the use and disposal of PPE; -participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel; -ensure that nursing service personnel follow established infection control procedures when isolations precautions become necessary; Review of the Facility's Unit Manager (Registered Nurse) Job Descriptions, indicated it included but was not limited to the following: -is responsible for overseeing direct nursing care to assigned residents and assumes responsibility and accountability for the nursing care and services provided on the assigned unit; -is responsible for and adheres to the standards of care for assigned residents; -makes daily rounds on unit to ensure resident care needs and environmental standards are met; -makes frequent rounds to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards; Review of the Unit Manager's personnel file, indicated that she had received and reviewed a copy of the Unit Manager Job Description which was a five page packet of information specific to the Unit Manager, and that she signed and dated the Job Descriptions on 12/11/24. Review of the Facility's Charge Nurse (Registered Nurse RN/Licensed Practical Nurse LPN) Job Description, indicated it included but was not limited to the following: -ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility; -primary purpose of your job description is to provide direct nursing care to residents; -to supervise the day-to-day nursing activities performed by nursing assistants; -participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel; -follow established infection control procedures when isolation precautions become necessary. Review of Nurse #1's personnel file, indicated he had received and reviewed a copy of the Charge Nurse RN/LPN Job Description which was a sixteen page packet of information specific to nurses, including a Competency Evaluation Section and that he signed and dated the Job Description on 12/26/24. Review of the Facility's Certified Nursing Assistant Job Description, indicated it included but was not limited to the following: -perform all assigned tasks in accordance with our established policies and procedures; -follow established isolation precautions and procedures; -wash hands before entering and after leaving an isolation room; -follow established procedures in the use and disposal of personal protective equipment; Review of Certified Nurse Aide (CNA) #2's and CNA #3's personnel files, indicated they had received and reviewed a copy of the Certified Nursing Assistant Job Description which was a nine page packet of information specific to certified nursing assistants, and included Competency Evaluation Sections and that CNA #2 signed and dated the Job Description on 12/27/24 as having been completed, and CNA #3 signed and dated the Job Description on 12/19/24 as having been completed. 1. On 1/22/25, Surveyor #1 observed an EBP sign posted on the door outside the room occupied by Resident #3 and Resident #7 and there was a bin with Personal Protective Equipment (PPE) outside the room by the door. The EBP sign indicated that Resident #3 was on EBP and everyone must clean their hands, including before entering and when leaving the room. The EBP sign indicated that staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of urinary catheter. Resident #3 was admitted to the Facility in November 2024, medical diagnoses included, urinary tract infection, sepsis, Chronic Obstructive Pulmonary Disease (COPD) , Extended Spectrum Beta Lactamase (ESBL) Resistance, bacteremia, and Diabetes Mellitus. Review of Resident #3's Physician Orders, dated 11/24/24, indicated he/she required Enhanced Barrier Precautions (EBP) related to an indwelling Foley catheter and wound care treatment. Review of the Residents on Precautions List, updated 01/17/25, indicated that Resident #3 was on EBP related to use of a Foley catheter. Review of Resident #3's most current Care Plan related to Enhanced Barrier Precautions for the care of Foley catheter, indicated to wear gloves and gown for the following high-contact resident care: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, for device care or use of urinary catheter and wound care, and any skin opening requiring a dressing. Resident #7 was admitted to the Facility in August 2024, medical diagnoses included chest pain, cirrhosis of liver, malignant neoplasm of prostate, dementia, traumatic brain injury and urinary tract infection. Review of Resident #7's Current Care Plans and Current Physician Orders indicated that he/she was not on any Infection Control Precautions. On 1/22/25 at 8:52 A.M., Surveyor #1 observed Certified Nurse Aide (CNA) #3 enter Resident #3's room wearing gloves, a mask, but not a gown. CNA #3 assisted Resident #3 with dressing, touched the bed linens and then set-up his/her meal tray. CNA #3 then removed her gloves, performed hand hygiene, donned on a new pair of gloves and proceeded to reposition Resident #7's upper body and legs in bed. During an interview on 1/22/25 at 9:00 A.M. with Surveyor #1, CNA #3 said that Resident #7 was on precautions and that she did not believe Resident #3 was on any precautions. CNA #3 said that she put on gloves and not a gown when she entered Resident #3 and Resident #7's room, because she was only delivering breakfast trays. CNA #3 said that she dressed Resident #3, touched his/her bed linens without wearing a gown and said she was unaware that she was supposed to wear a gown when performing those activities for residents on EBP. CNA #3 said that she had seen the EBP sign at the door and said that she believed that Resident #7 was the one on EBP. CNA #3 said that if she was unsure if a resident was on precautions, she would ask the nurse. On 1/22/25 at 9:00 A.M., Surveyor #1 observed CNA #2 enter Resident #7's room wearing gloves, a mask and set up his/her breakfast tray. CNA #2 then removed her gloves, performed hand hygiene and exited the room. During an interview on 1/22/25 at 9:05 A.M. with Surveyor #1, CNA #2 said that she had seen the EBP sign at the door (to Resident #3 and #7's room) but said she did not know which resident in the room was on EBP. CNA #2 said that sometimes the signs are not accurate as to which resident in the room is on precautions or if any of the residents in the room are on precautions at all. CNA #2 said that sometimes the precaution signs posted outside a residents door belonged to a previous resident who was discharged but the sign was not taken down. CNA #2 said that if she was unsure if a resident was on precautions, she would ask the nurse. Although CNA #2 and CNA #3 received education, training and were required to complete competencies in the areas of isolation precautions and the use of PPE, they were unable to apply their training into practice when they were both observed entering resident rooms without putting on gowns and then caring for a resident on EBP, which required the use of full PPE. CNA #3 was unaware of Resident #3's specific clinical condition which necessitated the need for EBP, and CNA #2 had no idea which resident (#3 or #7) required EBP, yet both proceeded into the room to provided care without checking with nursing. Resident #5 was admitted to the Facility in November 2024, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, bipolar disorder, chronic myeloid leukemia in remission, malignant neoplasm of cervix, and type 2 diabetes mellitus. Review of Resident #5's Care Plan related to chemotherapy due to cancer, dated 11/15/24, indicated he/she required contact isolation precautions due to chemotherapy, to dedicate equipment to resident, no sharing, wear gown/gloves during care if risk of exposure to body fluids. Review of Resident #5's Physician Orders, dated 12/31/24, indicated he/she required Contact Precautions for chemotherapy drug treatments. Review of Resident #5's Treatment Administration Record (TAR), dated 01/01/25 through 1/22/25, indicated he/she required Contact Precautions due to Chemotherapy drug administration and to see directions posted outside of room. Review of the Residents on Precautions List, updated 01/17/25, indicated that Resident #5 was on Contact Precautions related to chemotherapy. Review of the Contact Precaution sign posted outside Resident #5's room indicated staff to put on gloves before room entry and discard gloves before room exit, put on gown before room entry and discard gown before room exit, and there was a bin with Personal Protective Equipment (PPE) just outside the room by the door. On 1/22/25 at 8:40 A.M., Surveyor #2 observed Certified Nurse Aide (CNA) #2 enter Resident #5's room without putting on and using a gown or gloves and assist Resident #5 with the set-up of a meal tray. CNA #2 then exited the room and performed hand hygiene. On 1/22/25 at 8:42 A.M., Surveyor #2 observed Nurse #1 enter Resident #5's room without putting on a gown or gloves. Nurse #1 asked Resident #5 about his/her medications, performed hand hygiene and exited the room. During an interview on 1/22/25 at 8:43 A.M., with Surveyor #2, CNA #2 said that she delivered Resident #5's breakfast tray and did not wear any PPE as indicated on the Contact Precaution sign outside his/her room. CNA #2 said that she asked the nurse (exact name unknown) about the Contact Precautions for Resident #5 and was told by the nurse that Resident #5 was no longer on Contact Precautions. Although Nurse #1 and CNA #2 had received education, training and had been required to complete competencies related to isolation precautions and the use of PPE, they were unable to apply their training into practice when they were observed entering Resident #5's room, which had a Contact Precaution sign clearly posted outside of it with instructions for PPE, yet both of them were observed going into the room without putting on gowns or gloves. Resident #6 was admitted to the Facility in June 2020, diagnoses included vascular dementia with behavioral disturbance, dysphagia, aphasia, cerebral infarction, atrial flutter, cardiac pacemaker, benign prostatic hyperplasia and anxiety disorder. Review of Resident #6's Physician Orders, dated 12/26/24, indicated that he/she was on Contact Precautions for a rash. Review of Resident #6's Treatment Administration Record (TAR), dated 12/26/24 through 12/31/24 indicated that he/she was on Contact Precautions for a rash. Review of Resident #6's Weekly Skin Assessment, dated 12/26/24, indicated that he/she had a rash to his/her left front thigh. Review of December 2024 Infection Control Line Listing, indicated that on 12/27/24 Resident #6 developed itch and redness to his/her bilateral lower extremities, had a rash to his/her skin and was started on an antibiotic. Review of Resident #6's Care Plan related to suspected scabies, dated 12/26/24, indicated to educate caregivers that anyone in close contact with an infected person should seek medical treatment, that infestation may occur by direct skin to skin contact with an infected person and to wash all clothing, bedding and towels in hot water and dry in a hot dryer. The Care Plan indicated that Scabies is spread by sharing towels, clothing and bedding. Review of the Residents on Precautions List, updated 01/17/25, indicated that Resident #6 was not on any Infection Control Precautions. During the Survey, the Surveyors observed that Resident #6 had a Contact Precaution sign posted outside his/her room. The Sign indicated staff to put on gloves before room entry and discard gloves before room exit, put on gown before room entry and discard gown before room exit. There was also a bin with Personal Protective Equipment (PPE) outside the room by the door. On 1/22/25 at 8:47 A.M., Surveyor #2 observed Certified Nurse Aide (CNA) #2 enter Resident #6's room without the use of a gown or gloves, assist Resident #6 with the set-up of a meal tray and placed a blanket on his/her shoulders. CNA #2 stood in the room chatting with Resident #6, then rubbed his/her (Resident #6's) arm prior to exiting the room and then then performed hand hygiene. During an interview on 1/22/25 at 8:55 A.M. with Surveyor #2, CNA #2 said that she did not know why Resident #6 was on Contact Precautions and said she would have to ask the nurse. CNA #2 said she was not wearing any PPE when she entered Resident #6's room as the sign indicated. On 1/22/25 at 9:12 A.M., Surveyor #2 observed Nurse #1 enter Resident #6's room without the use of a gown or gloves. Nurse #1 repositioned Resident #6 from a sitting position on the side of the bed to a lying position. Nurse #1 was observed adjusting Resident #6's blankets, handing Resident #6 the call light and then performed hand hygiene and exited the room. During an interview on 1/22/25 at 9:15 A.M. with Surveyor #2, Nurse #1 said that Resident #6 was previously on Contact Precautions because he/she had a urinary catheter and said he did not believe Resident #6 was still on Contact Precautions. Nurse #1 said that he would have to ask the Unit Manager about the status of Resident #6's precautions and said he could not explain why Resident #6 had a Contact Precaution sign posted outside the door of his/her room. During an interview on 01/22/25 at 9:24 A.M. with Surveyor #2, the Unit Manager said that after reviewing Resident #6's Medical Record, that he/she was no longer on Contact Precautions. The Unit Manager said that Resident #6's urinary catheter was removed and he/she was on comfort measures only. The Unit Manager said that she would speak with the Infection Preventionist (IP) to confirm Resident #6's status related to need for precautions. Although Nurse #1 and CNA #2 received education, training and were required to complete competencies in the areas of isolation precautions and the use of PPE, they were unable to apply their training into practice when they were observed entering Resident #6's room, that had a Contact Precaution sign posted outside of it, which clearly indicated what PPE staff were to use, yet both of them went into the room without using any PPE. As Resident #6's nurse, Nurse #1 was unsure and unaware if the resident was on precautions and CNA #2 did not check with nursing to see if Precautions were necessary. The Unit Manager was unable to demonstrate that she was competent in identifying residents on her assigned unit who required EBP or Contact Precautions and when the surveyors pointed the residents/rooms out to her, the Unit Manager was unable to identify why those residents' required precautions. During an interview on 01/22/25 at 11:15 A.M. and throughout the survey with Surveyor #1 and Surveyor #2, the Infection Preventionist (IP) said staff were trained and required to complete competencies on EBP and Contact Precautions and were aware that there were signs posted outside room doors indicating which resident(s) was on precautions. The IP said that the signs clearly indicate what type of PPE to wear when performing resident care activities. The IP said that staff are supposed to wear gloves and a gown when performing dressing activities, repositioning residents, and touching linens. The IP said it was her expectation that staff follow the directives that are posted on the precaution signs. The IP said she did not know the status of Resident #6's infection control needs and said she would have to look into it. During an in-person interview on 01/22/25 at 3:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 01/23/25 at 8:39 A.M. with Surveyor #1, the Director of Nurses (DON) said that staff were required to complete competencies, have been trained on EBP and Contact Precautions, and were aware that there are signs posted outside the resident room door indicating which resident or residents was on precautions. The DON said that it was her expectation that staff follow the directives that are posted on the precaution signs and wear the appropriate PPE when providing resident care according to the directives on the signs. The DON said that it was her expectation that nursing staff are aware of the residents who are on precautions and why they are on precautions. The DON said that as the DON, she was ultimately responsible for the Facility's Infection Control Program and ensuring that all of the policies and procedures were followed. 2. Review of the Facility Policy, titled Staff Compliance During Group A Streptococcus (GAS) Outbreaks, dated 06/21/2024, indicated that during an outbreak of GAS in the nursing home, staff are encouraged to undergo testing for GAS. The Policy indicated that staff who test positive must follow medical advice for treatment and may not return to work until cleared by a healthcare professional. The Policy further indicated that CDC recommendations are used as a reference. Review of CDC Recommendations for GAS, dated 03/25/2024 indicated that for healthcare personnel with known or suspected Group A Streptococcus infection, obtain a sample from the infected site, and exclude from work until 24 hours after the start of effective antimicrobial therapy. The DON said on 1/18/25, CNA #1 tested positive for GAS. The DON said that the Laboratory reported CNA #1's positive test results for GAS to the facility on [DATE]. The DON said that on 1/18/25, someone from the facility notified her that CNA #1 was positive for GAS and that she called CNA #1 to tell her that her results were positive for GAS, and to go see a doctor to get treatment for herself and her family. The DON said on 1/18/25 when she called and notified CNA #1 that her test results were positive, she assumed that CNA #1 was home and not at work. The DON said that she did not tell CNA #1 to go home because she was not aware that CNA #1 was working at the facility that day. Review of the Daily Schedules, dated 1/18/25 and 1/19/25, indicated that CNA #1 worked on the [NAME] Unit starting at 7:00 A.M. and worked through to 11:00 P.M. (working a double, day and evening shifts). Review of the Daily Schedule, dated 1/20/25, indicated that CNA #1 worked on the Second Unit from 7:00 A.M. through 3:00 P.M. shift and on the [NAME] Unit from 3:00 P.M. through 11:00 P.M. shift. Review of CNA #1's Timecards, indicated that she worked the following: -on 1/18/25 from 7:07 A.M. to 10:53 P.M.; -on 1/19/25 from 7:06 A.M. to 10:53 P.M.; -on 1/20/25 from 7:09 A.M. to 10:53 P.M. West Unit had a total number of 31 residents residing on it. Second Unit had a total number of 35 residents residing on it. Therefore all residents residing on the [NAME] and Second units, as well as other staff member, were put at risk for contracting and spreading GAS. During an in-person interview on 1/22/25 at 2:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 1/23/25 at 8:52 A.M. with Surveyor #1, CNA #1 said that on 1/18/25 the DON called her, (exact time unknown) and informed her that she was positive for GAS. CNA #1 said the DON told her that she needed to go home and see a doctor. CNA #1 said that she was at work when the DON called her and said sometime after supper (exact time unknown) she went home. CNA #1 said that on 1/19/25, she went to see her doctor (exact time unknown) and she was prescribed antibiotics. CNA #1 said that her doctor did not discuss anything with her regarding when she could return to work. CNA #1 said that she took her first dose of antibiotics at 3:00 P.M. on 1/19/25 and said she came into work the 3:00 P.M. through 11:00 P.M. shift that night on the [NAME] Unit. CNA #1 said that on 1/20/25, she worked from 7:00 A.M. through 3:00 P.M. shift on the Second Floor and from 3:00 P.M. through 11:00 P.M. shift on the [NAME] Unit. CNA #1 said that sometime during the day on 1/20/25, (exact time unknown) she went to the DON's office, gave the DON her doctor's note and told the DON she was on antibiotics. CNA #1 said that the DON never asked her if she was working and never told her that she could not work until after she was on antibiotics for 24 hours. CNA #1 said after speaking with the DON on 1/20/25 she went back to work her scheduled shift. The DON said that on 1/20/25 she noticed that the schedule for 1/19/25 indicated that CNA #1 worked the 3:00 P.M. to 11:00 P.M. shift. The DON said that she had not previously informed CNA #1 or the Scheduler that CNA #1 could not return to work prior to being on antibiotics for 24 hours. The DON said she was unsure if CNA #1 had worked on 1/19/25 and was unaware if CNA #1 had worked on 1/20/25. The DON said that on 1/20/25 (exact time unknown) CNA #1 gave her a doctor's note and told her that she took her first dose of antibiotics on the evening of 1/19/25 and took the next dose of antibiotics in the morning of 1/20/25. The DON said that after reviewing the schedules and timecards, that CNA #1 had returned to work prior to being on antibiotics for 24 hours. The DON said facility policy indicates that staff who are positive for GAS cannot return to work prior to being on antibiotics for 24 hours and said her expectation was that they all follow facility policy. The DON said it was her responsibility to let CNA #1 and the Scheduler know that CNA #1 could not return to work prior to being on antibiotics for 24 hours and said it was a miscommunication.

Based on records reviewed and interviews for one of seven sampled residents (Resident #1), who per Laboratory test results reported to the facility on [DATE] indicated he/she tested positive for Group A Streptococcal (GAS, a bacterium that can cause many different infections, including strep throat and also cause severe, life-threatening invasive disease, spread person to person through respiratory droplets or direct contact with an infected person's skin sores, nose, throat or wound secretions), the Facility failed to ensure Nursing promptly notified the physician of the results, who was not informed until four days later (1/22/25), as a result Contact Precautions were not initiated timely, therefore placing other residents and staff at risk for potentially contracting and spreading the infectious disease. Findings include: Review of the Facility Policy, titled Lab and Diagnostic Test Results - Clinical Protocol, dated as revised November 2018, indicated the following: -the physician will identify and order diagnostic and lab testing on the resident's diagnostic and monitoring needs; -staff will process test requisitions and arrange for test; -the lab will report test results to the facility; -a nurse will identify the urgency of communicating with the physician the seriousness of any abnormality and the individuals current condition; -nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab result: -whether the result should be conveyed to the physician regardless of other circumstances that is, the abnormal result is problematic regardless of other factors; -direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the current treatment needs review or clarification; -staff should document information about when, how, and to whom the information was provided and the response in the progress notes; -a physician will respond with an appropriate time frame based on the clinical significance of the information; -a physician should respond within one hour regarding a lab test result requiring immediate notification; -when responding to notification of test results, the physician and staff will discuss the implications of the test results for the resident, as well as subsequent actions; for example, new or modified medication orders, additional monitoring, etc. Review of the CDC Recommendations for GAS, Transmission Based Precautions, dated 04/03/24 indicated to use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Resident #1 was admitted to the Facility in September 2023, medical diagnoses included stage 4 pressure ulcer (full thickness skin and tissue loss) of sacral region, unspecified dementia with agitation, local infection of the skin and subcutaneous tissue, hyperlipidemia and hypertension. Review of the Laboratory Results Report, sent to the facility on [DATE], indicated that Resident #1 tested positive for GAS isolated in his/her left shoulder. Review of Resident #1's Medical Record indicated there was no documentation to support that after the facility was made aware he/she tested positive for GAS in his/her left shoulder on 1/19/25, that Contact Precautions were initiated per CDC recommendations. Review of Resident #1's Medical Record indicated there was no documentation to support that the physician was notified that he/she had a positive GAS culture of his/her left shoulder until 01/22/25, four days after the positive result had been reported to the facility. Review of Resident #1's Physician Orders, dated 01/22/25, indicated administer Penicillin V(antibiotic) Oral Tablet 500 milligrams (mg) by mouth twice daily for ten days for GAS in wound. Review of Resident #1's Care Plan related to GAS in the wound, dated 01/22/25, indicated to administer antibiotics per Physician orders and Resident to be placed on Enhanced Barrier Precautions (EBP) due to wound infection. During an interview on 01/22/25 at 11:15 A.M. and throughout the survey with Surveyor #1 and Surveyor #2, the Infection Preventionist (IP) said that Resident #1 was tested for GAS on 1/17/25 and said that on 01/19/25, the lab sent Resident #1's result to the facility which indicated he/she tested positive for GAS. The IP said that typically the nurses on the Units get the results of the labs, then notify the provider and nursing management of any positive GAS results. The IP said that she was not notified that Resident #1 tested positive for GAS until 1/22/25 (the date of the survey) when the DON notified her that Resident #1 had tested positive for GAS (on 1/19/25). The IP said she could not explain why the nurses had not notified the provider and nursing management of Resident #1's positive GAS result on 01/19/25. The IP said that it was her expectation that nurses notify the provider and nursing management of any positive GAS results so that appropriate precautions and treatments can be implemented. During an in-person interview on 01/22/25 at 3:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 01/23/25 at 8:39 A.M. with Surveyor #1, the Director of Nurses (DON) said that she found out the morning of the survey (01/22/25) that Resident #1 tested positive for GAS (on 1/19/25) in his/her wound, and said the physician was also notified that morning and he/she was started on antibiotics. The DON said she could not explain why the physician was not notified of Resident #1's positive GAS results on 01/19/25 and said it was her expectation that staff notify the physician, IP, and her of any positive GAS results immediately so that appropriate precautions and treatments can be implemented. During a telephone interview on 1/23/25 at 2:23 P.M., the Medical Director said he became the Medical Director for the Facility in December 2024. The Medical Director said that he was aware that the Facility had several cases of GAS and said he has spoken to an Epidemiologist with the DPH regarding the cases. The Medical Director said that he was aware that Resident #1 tested positive for GAS, but could not recall exactly when he was notified. The Medical Director said that he was not aware that the Facility waited four days before reporting Resident #1's positive GAS results and said it was his expectation that the staff immediately report any positive GAS results to the physician so that treatment can be implemented.

Based on records reviewed and interviews, for two of three nursing units (West and Second) after a staff member Certified Nurse Aide (CNA) #1 tested positive for Group A Streptococcal (GAS, a bacterium that can cause many different infections, including strep throat and also cause severe, life-threatening invasive disease, spread person to person through respiratory droplets or direct contact with an infected person's skin sores, nose, throat or wound secretions) on 1/18/25, facility administration failed to ensure it provided appropriate administrative oversight of Infection Control Practices when CNA #1 was not removed from the schedule until being on antibiotic therapy for 24 hours. Facility Administration was aware there were issues with GAS infections and transmission within the facility, however CNA #1 was scheduled and worked on two different resident care units between 1/19/25 and 1/20/25, placing the residents and staff at risk for contracting and/or spreading the infectious disease that could cause adverse harm up to and including death. Findings include: Review of the Facility Policy, titled Staff Compliance During Group A Streptococcus (GAS) Outbreaks, dated 06/21/2024, indicated that during an outbreak of GAS in the nursing home, staff are encouraged to undergo testing for GAS. The Policy indicated that staff who test positive must follow medical advice for treatment and may not return to work until cleared by a healthcare professional. The Policy further indicated that CDC recommendations are used as a reference. Review of CDC Recommendations for GAS, dated 03/25/2024 indicated that for healthcare personnel with known or suspected group A Streptococcus infection, obtain a sample from the infected site, and exclude from work until 24 hours after the start of effective antimicrobial therapy. During the Entrance Conference on 1/22/25 at 10:40 A.M., with Surveyor #1 and Surveyor #2, the Administrator acknowledged that the Facility has had outbreaks of GAS infections amongst residents and staff. The Administrator said that when an outbreak was identified on a particular unit, the residents on the unit and staff who worked on that unit were tested for GAS. The Administrator said that for residents who test positive, isolation precautions were instituted. During an interview on 01/22/25 at 11:15 A.M. and throughout the survey with Surveyor #1 and Surveyor #2, the Infection Preventionist (IP) said that she was new to the Infection Preventionist role and has only been in the role for three months. The IP said that she was the one responsible for the Facility's Infection Control Program, which included tracking, monitoring and surveillance of all infections for the Facility. The IP said that on 01/15/25 an Epidemiologist from the Department of Public Health (DPH) recommended that the Facility test the residents and staff that work on the [NAME] Unit for GAS because one of their residents' that had passed away was positive for GAS. The IP said that on 01/16/25, residents and staff on the [NAME] Unit were tested for GAS and the samples were picked up by the laboratory on 01/17/25. The IP said that on 01/18/25, the lab reported CNA #1's positive GAS result to the Facility. The IP said that she was not notified of CNA #1's positive GAS result and said the Director of Nurses (DON) was the person that had been notified. The IP said that although she was aware that the residents and staff on the [NAME] Unit were tested for GAS on 01/16/25, said that she had not followed up with the results of those tests when she returned to work on 01/20/25, 01/21/25, or 01/22/25, but said she should have followed up. The IP said that the DON was the one who followed up with the staff member (CNA #1) who tested positive for GAS. The IP said that the Facility Policy for a staff member with a positive GAS result was that they needed to be on antibiotics for 24 hours before returning to work. The IP said that she thought that CNA #1 had not returned to work until she had been on antibiotics for 24 hours, but would have to check with the DON. During an in-person interview on 01/22/25 at 3:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 01/23/24 at 8:39 A.M. with Surveyor #1, the Director of Nurses (DON) said that she, as the DON, was the one ultimately responsible for the Facility's Infection Control Program and ensuring that all of the policies and procedures were followed. The DON said on 1/18/25, CNA #1 tested positive for GAS. The DON said that the Laboratory reported CNA #1's positive test results for GAS to the facility on [DATE]. The DON said that on 1/18/25, someone from the facility notified her that CNA #1 was positive for GAS, that she called CNA #1 to tell her her results, told her to go see a doctor to get treatment for herself and her family. The DON said that she was not aware that CNA #1 was working at the facility when she notified her of the test results and that she assumed when she called CNA #1, she was home. The DON said that she had not informed CNA #1 or the Scheduler that CNA #1 could not return to work prior to being on antibiotics for 24 hours, but said she should have told them. Review of the Daily Schedule, dated 1/18/25 and 1/19/25, indicated that CNA #1 worked on the [NAME] Unit starting at 7:00 A.M. through to 11:00 P. M. (double shift). Review of the Daily Schedule, dated 1/20/25, indicated that CNA #1 worked on the Second Unit from 7:00 A.M. through 3:00 P.M. shift and on the [NAME] Unit from 3:00 P.M. through 11:00 P.M. shift. Review of CNA #1's Timecards, indicated that she worked the following: -on 1/18/25 from 7:07 A.M. to 10:53 P.M.; -on 1/19/25 from 7:06 A.M. to 10:53 P.M.; -on 1/20/25 from 7:09 A.M. to 10:53 P.M. West Unit had a total number of 31 residents residing on it. Second Unit had a total number of 35 residents residing on it. During an in-person interview on 1/22/25 at 2:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 1/23/25 at 8:52 A.M. with Surveyor #1, CNA #1 said that on 1/18/25 the DON called her (exact time unknown) and informed her that she was positive for GAS. CNA #1 said that the DON told her she needed to go home and see a doctor. CNA #1 said that she was at work when the DON called and said sometime after supper (exact time unknown) she went home. CNA #1 said that on 1/19/25, she went to see her doctor (exact time unknown) and she was prescribed antibiotics. CNA #1 said the DON never told her she could not work until after being on antibiotics for 24 hours and that her doctor did not discuss anything with her about work. CNA #1 said that she took her first dose of antibiotics at 3:00 P.M. on 1/19/25 and said she came to work that night at the facility for the 3:00 P.M. through 11:00 P.M. shift on the [NAME] Unit. CNA #1 said that on 1/20/25, she worked the 7:00 A.M. through 3:00 P.M. shift on the Second Floor and the 3:00 P.M. through 11:00 P.M. shift on the [NAME] Unit. The DON said that on 1/20/25, CNA #1 gave her a doctor's note and told her that she took her first dose of antibiotics on the evening of 1/19/25 and took another dose of antibiotics in the morning of 1/20/25. The DON said that CNA #1 had returned to work prior to being on antibiotics for 24 hours, which was not consistent with facility policy. During a telephone interview on 1/23/25 at 2:23 P.M., the Medical Director said he became the Medical Director for the Facility in December 2024. The Medical Director said that he was aware that the Facility had several cases of GAS and said he had spoken to one of the DPH Epidemiologists regarding the cases. The Medical Director said that he was going to have a meeting with the Facility on 1/24/25 to discuss the GAS cases, review Infection Control Policies and Procedures for GAS to mitigate the spread of GAS amongst residents and staff. The Medical Director said that it was his expectation that the staff follow the Facility's policies and procedures for Infection Control.

Based on observations, records reviewed and interviews for five of seven sampled residents (Resident #1, Resident #2, Resident #3, Resident #5 and Resident #6), all of which required the need for staff to use Personal Protective Equipment (PPE) during the provision of care due to an active infection, the Facility failed to ensure they implemented and maintained an infection control program that helped prevent the development and spread of infections, including Group A Streptococcal (GAS, a bacterium that can cause many different infections, including strep throat and also cause severe, life-threatening invasive disease, spread person to person through respiratory droplets or direct contact with an infected person's skin sores, nose, throat or wound secretions), that required treatment with antibiotics, when 1) 1/19/25 laboratory results for a resident who tested positive for GAS was not reported to the physician until 1/22/25, resulting in a delay in the implementation of appropriate precautions, 2) Nursing staff were observed going in/out of resident rooms with precaution signs posted outside of them, but were not compliant with the use of PPE, and/or were unaware of why or which residents required precautions, and 3) and a staff member who tested positive for GAS was not removed from the schedule and worked on two different units, all of which increased the potential for additional residents and staff to be exposed and at risk for developing GAS. Findings include: Review of the Facility Policy, titled Isolation - Categories of Transmission-Based Precautions, dated as revised September 2022, indicated that transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection or has a laboratory confirmed infections and is at risk of transmitting the infection to other residents. The Policy indicated the following: -standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status; -transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected; -these measures are determined by the specific pathogen and how it is spread from person to person; -the CDC maintains a list of diseases, modes of transmission and recommended precautions; -transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures; -when a resident is placed on transmission based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need and type of precaution; -the signage informs the staff of the type of CDC precaution, instructions for use of PPE, and/or instructions to see a nurse before entering the room; -Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment; -Contact Precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified; -Contact Precautions are used for residents infected or colonized with Multi Drug Resistant Organisms (MDRO) when a resident has wounds, secretions, or excretions that are unable to be covered or contained and on units where, despite attempts to control the spread of MDRO, ongoing transmission is occurring; -Enhanced Barrier Precautions (EBP) additional usage of PPE may be used for residents who do not meet criteria for contact precautions but are infected or colonized with MDRO's; -the decision on whether contact precautions are necessary are evaluated on a case by case basis; -staff wear gloves, when entering the room, while caring for a resident, staff will change gloves after having contact with infective material, gloves are removed and hand hygiene performed before leaving room, staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed; -staff wear a disposable gown upon entering the room and remove gown before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed; Review of the CDC Recommendations for GAS, Transmission Based Precautions, dated 04/03/24 indicated to use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Review of the Facility Policy, titled Enhanced Barrier Precautions (EBP), dated as revised August 2022, indicated the following: -EBP are used as an infection prevention and control intervention to reduce the spread of Multi Drug Resistant Organisms (MDRO's) to residents; -EBP employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; -gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); -PPE is changed before caring for another resident; -Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheter, feeding tube); -EBP are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with Extended Spectrum Beta Lactamase (ESBL); -EBP are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; -EBP remain in place for the duration of the resident's stay or until the resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; -staff are trained prior to caring for residents on EBP's; -signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required; -PPE is available outside of the resident rooms. Review of the Facility Policy, titled Lab and Diagnostic Test Results - Clinical Protocol, dated as revised November 2018, indicated the following: -the physician will identify and order diagnostic and lab testing on the resident's diagnostic and monitoring needs; -staff will process test requisitions and arrange for test; -the lab will report test results to the facility; -a nurse will identify the urgency of communicating with the physician the seriousness of any abnormality and the individuals current condition; -nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab result: whether the result should be conveyed to the physician regardless of other circumstances that is, the abnormal result is problematic regardless of other factors; -direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the current treatment needs review or clarification; -a physician will respond with an appropriate time frame based on the clinical significance of the information; -a physician should respond within one hour regarding a lab test result requiring immediate notification; 1. Resident #1 was admitted to the Facility in September 2023, diagnoses included stage 4 pressure ulcer (full thickness skin and tissue loss) of sacral region, unspecified dementia with agitation, local infection of the skin and subcutaneous tissue, hyperlipidemia and hypertension. Review of the Residents on Precautions List, updated 01/17/25, indicated that Resident #1 was on EBP for wound care. Review of Resident #1's Laboratory Results Report, reported to facility on 01/19/25, indicated that he/she had GAS infection isolated in his/her left shoulder. Review of Resident #1's Medical Record indicated there was no documentation to support that the physician was notified that he/she had a positive GAS culture of his/her left shoulder or that Contact Precautions were initiated per facility policy and CDC recommendations until 01/22/25, four days after the positive result were reported to the facility. Review of Resident #1's Physician Orders, dated 01/22/25, indicated administer Penicillin V (antibiotic) Oral Tablet 500 milligrams (mg) by mouth twice daily for ten days for GAS in wound. Review of Resident #1's Care Plan related to GAS in the wound, dated 01/22/25, indicated to administer antibiotics per Physician orders and he/she required EBP due to wound infection. During an interview on 01/22/25 at 11:15 A.M. and throughout the survey with Surveyor #1 and Surveyor #2, the Infection Preventionist (IP) said that she was the one responsible for the Facility's Infection Control Program, which included tracking, monitoring and surveillance of all infections for the Facility. The IP said that on 01/15/25 an Epidemiologist from the Department of Public Health (DPH) recommended that the Facility test the residents and staff that work on the [NAME] Unit for GAS because one of their previous residents had passed away and was positive for GAS. The IP said that on 01/16/25, residents and staff on the [NAME] Unit were tested for GAS and the samples were picked up by the laboratory on 01/17/25. The IP said that on 01/19/25, the lab reported Resident #1's positive GAS results to the facility. The IP said that typically the nurses get the results of the labs, then notify the provider and nursing management of any positive GAS results. The IP said she could not explain why the nurses did not notify the provider and nursing management of Resident #1's positive GAS result on 01/19/25, but said they should have so that appropriate precautions could have been implemented. The IP said although she was aware that the residents and staff on the [NAME] Unit were tested for GAS on 01/16/25, said that she had not followed up on the results of those tests when she returned to work on 01/20/25, 01/21/25 or 01/22/25, but said she should have. The IP said that on 01/22/25 (during the survey), the Director of Nurses (DON) notified her that Resident #1 had tested positive for GAS. The IP said that Resident #1 was already on EBP and should be placed on Contact Precautions due to positive GAS in his/her wound. The IP said she was responsible for initiating precautions and ensuring all of the precaution signs were accurate. During an in-person interview on 01/22/25 at 3:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 01/23/25 at 8:39 A.M. with Surveyor #1, the Director of Nurses (DON) said that on 01/16/25, the [NAME] Unit Residents and Staff were tested for GAS. The DON said that the lab picked up the specimens on 01/17/25 and the lab reported the results to the facility on [DATE] and 01/19/25. The DON said that she found out the day of the survey (1/22/25) that Resident #1 tested positive for GAS in his/her wound. The DON said the physician should have been notified of Resident #1's positive GAS results on 01/19/25 and said it was her expectation that staff notify the physician, IP, and her of any positive GAS results immediately. The DON said that Resident #1 was already on precautions, that she was not sure what level of precautions Resident #1 was on, but said that Resident #1 should be on Contact Precautions. 2. Resident #2 was admitted to the Facility in December 2023, medical diagnoses included, urinary tract infection, severe sepsis, cirrhosis, dementia, and rheumatoid arthritis. Review of Resident #2's Hospital Discharge Summary, dated 12/18/24, indicated that he/she had sepsis secondary to UTI with toxic metabolic encephalopathy (condition where brain function is impaired due to accumulation of toxins), had a positive blood culture, and left lower extremity cellulitis. The Summary indicated that on 12/17/24, Resident #2 was on precautions, had GAS bacteremia (presence of bacteria in the bloodstream) and the Massachusetts Department of Public Health (MDPH) was notified. Review of Resident #2's Physician Orders, dated 12/19/24, indicated he/she required Enhanced Barrier Precautions (EBP) for an infection. Review of the December 2024 Infection Control Line Listing, indicated that on 12/18/24, Resident #2 was on Augmentin (antibiotic) for sepsis, however the line listing was incomplete and did not include site of infection, signs, symptoms or culture site. The Line Listing indicated that on 12/19/24, Resident #2 presented with confusion and behaviors, was identified as having a urinary tract infection (UTI) and Levofloxacin (antibiotic) was started. Review of Resident #2's Physician Orders, dated 12/19/24, indicated administer Levofloxacin (antibiotic) oral tablet 500 mg. by mouth once daily for 14 days for sepsis UTI. Review of Resident #2's Care Plan related to Infection Cellulitis/Strep, dated 12/19/24, indicated to administer antibiotics per Physician orders, follow facility policy and procedures for line listing, summarizing and reporting infections and maintain universal precautions (avoiding contact with patients bodily fluids by means of wearing of nonporous articles such as gloves, goggles and face shields) when providing resident care. Review of a Nurse Practitioner (NP) Progress Note, dated 12/21/24, indicated that Resident #2 was admitted to the hospital on 12/15/24 and was found to have bacteremia and cellulitis leading to sepsis and UTI. The Note indicated that Resident #2's lab results came back today (12/19/24) and urine was positive for GAS, E-Coli (type of urinary tract bacterial infection) and Group B strep (GBS - an infection cause by bacteria streptococcus agalactiae which can cause serious illness and death in the elderly) and blood culture was also positive for GAS. The Note indicated that Resident #2 was discharged to the facility on Augmentin however both organisms are resistant to Augmentin. The Note indicated that Augmentin will be discontinued and Levofloxacin will be started as it is susceptible to both organisms. Review of the Residents on Precautions List, updated 01/17/25, indicated that Resident #2 was on EBP for a wound infection Resident #2 had an EBP sign outside his/her room on the day of the survey. During an interview on 01/22/25 at 11:15 A.M. and throughout the survey with Surveyor #1 and Surveyor #2, the Infection Preventionist (IP) said that Resident #2 returned from the hospital on 12/18/24 with sepsis, was on antibiotics and was on EBP. The IP said that she could not find any information in Resident #2's Hospital paperwork about what microorganism caused the sepsis. The IP said she was the person responsible for the Infection Control Line Listing and said she could not explain why the December 2024 documentation related to Resident #2's infection was incomplete. The IP said she was unaware that Resident #2 returned from the hospital with GAS in his/her urine and blood. The IP said that if a resident is positive for GAS in the urine and blood they should be on Contact Precautions. The IP said she was responsible for initiating precautions and ensuring all of the precaution signs posted outside the resident rooms were accurate. During an in-person interview on 01/22/25 at 3:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 01/23/25 at 8:39 A.M. with Surveyor #1, the Director of Nurses (DON) said that Resident #2 was on EBP for wounds. The DON said that when a resident returns from the hospital, the medical record is reviewed, the IP adds all the pertinent infection information into the Infection Control Line Listing, obtains orders for necessary precautions and puts signage at the entrance to the resident's room. The DON said she could not explain why the December 2024 Infection Control Line Listing was incomplete for Resident #2 and said that the hospital does not always send the facility all of the information that they need. The DON said that it was her expectation that when a resident returns from the hospital with GAS in their urine and blood, that Contact Precautions be initiated and that the Infection Control Line Listing include all of the information related to the infection. Resident #3 was admitted to the Facility in November 2024, diagnoses included, urinary tract infection, sepsis, Chronic Obstructive Pulmonary Disease, Extended Spectrum Beta Lactamase (ESBL) Resistance, bacteremia, and Diabetes Mellitus. Review of Resident #3's Physician Orders, dated 11/24/24, indicated he/she required Enhanced Barrier Precautions (EBP) related to Foley Catheter and wound infection. Review of the Residents on Precautions List, updated 01/17/25, indicated that Resident #3 was on EBP for Foley catheter only. Review of Resident #3's current Care Plan related to Enhanced Barrier Precautions for the care of Foley catheter, indicated nursing staff to wear gloves and gown for the following high-contact resident care, dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, for device care or use of urinary catheter and wound care, and any skin opening requiring a dressing. Resident #7 (who shared a room with Resident #3) was admitted to the Facility in August 2024, diagnoses included chest pain, cirrhosis of liver, malignant neoplasm of prostate, dementia, traumatic brain injury and urinary tract infection. Review of Resident #7's Current Care Plans and Current Physician Orders indicated that he/she was not on any Infection Control Precautions. On 1/22/25, Surveyor #1 observed an EBP sign posted on the outside of Resident #3 and Resident #7's door and a bin with Personal Protective Equipment (PPE) just outside the door. The sign indicated that Resident #3 was on EBP and everyone must clean their hands, including before entering and when leaving the room. The EBP sign indicated that staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of urinary catheter. On 1/22/25 at 8:52 A.M., Surveyor #1 observed Certified Nurse Aide (CNA) #3 enter Resident #3's room wearing gloves, without putting on a gown, she assisted Resident #3 with dressing, touched the bed linens and set-up of his/her meal tray. CNA #3 then removed her gloves, performed hand hygiene, donned on a new pair of gloves and proceeded to reposition Resident #7's upper body and legs in bed. During an interview on 1/22/25 at 9:00 A.M. with Surveyor #1, CNA #3 said that Resident #7 was on EBP precautions and said that she did not believe Resident #3 was on any precautions. CNA #3 said that she just put on gloves when she entered Resident #3 and Resident #7's room, because she was only delivering breakfast trays. CNA #3 said that she dressed Resident #3, touched his/her bed linens without wearing a gown and said she was unaware that she was supposed to wear a gown when performing those activities for residents on EBP. CNA #3 said that she did see the EBP sign at the door. CNA #3 said that if she was unsure if a resident was on precautions, she would ask the nurse. On 1/22/25 at 9:00 A.M., Surveyor #1 observed CNA #2 enter Resident #7's room wearing gloves and set up his/her breakfast tray. CNA #2 then removed her gloves, performed hand hygiene and exited the room. During an interview on 1/22/25 at 9:05 A.M. with Surveyor #1, CNA #2 said that she did see the EBP sign at the door, but did not know which resident (#3 or #7) in the room was on EBP. CNA #2 said that sometimes the signs are not accurate as to which resident in the room is on precautions or if any of the residents in the room are on precautions at all. CNA #2 said that if she was unsure if a resident was on precautions, she would ask the nurse. Resident #5 was admitted to the Facility in November 2024, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, bipolar disorder, chronic myeloid leukemia in remission, malignant neoplasm of cervix, and type 2 diabetes mellitus. Review of Resident #5's Care Plan related to chemotherapy due to cancer of the cervix, dated 11/15/24, indicated he/she required contact precautions due to chemotherapy, dedicate equipment to resident, no sharing, wear gown/gloves during care if risk of exposure to body fluids. Review of Resident #5's Physician Orders, dated 12/31/24, indicated he/she required Contact Precautions due to chemotherapy drug treatment. Review of Resident #5's Treatment Administration Record (TAR), dated 01/01/25 through 1/22/25, indicated he/she required Contact Precautions for Chemotherapy drug, and to see directions posted outside of room. Review of the Residents on Precautions List, updated 01/17/25, indicated that Resident #5 was on Contact Precautions for chemotherapy. On 1/22/25, Surveyor #2 observed a Contact Precautions sign posted on the outside of Resident #5's door and a bin with Personal Protective Equipment (PPE) just outside the room by the door. The Sign indicated staff to put on gloves before room entry and discard gloves before room exit, put on gown before room entry and discard gown before room exit. On 1/22/25 at 8:40 A.M., Surveyor #2 observed Certified Nurse Aide (CNA) #2 enter Resident #5's room without the use of a gown or gloves and assist Resident #5 with the set-up of a meal tray. CNA #2 then exited the room and performed hand hygiene. On 1/22/25 at 8:42 A.M., Surveyor #2 observed Nurse #1 enter Resident #5's room without the use of a gown or gloves. Nurse #1 asked Resident #5 about his/her medications, performed hand hygiene and exited the room. During an interview on 1/22/25 at 8:43 A.M., with Surveyor #2, CNA #2 said that she delivered Resident #5 his/her breakfast tray but did not wear any PPE as indicated on the Contact Precaution sign. CNA #2 said that she had asked the nurse (exact name unknown) this morning about the Contact Precautions for Resident #5 and said she was told by the nurse that Resident #5 was no longer on Contact Precautions. Resident #6 was admitted to the Facility in June 2020, diagnoses included vascular dementia with behavioral disturbance, dysphagia, aphasia, cerebral infarction, atrial flutter, cardiac pacemaker, benign prostatic hyperplasia and anxiety disorder. Review of Resident #6's Physician Orders, dated 12/26/24, indicated that he/she was on Contact Precautions for a rash. Review of Resident #6's Weekly Skin Assessment, dated 12/26/24, indicated that he/she had a rash to his/her left front thigh. Review of Resident #6's Treatment Administration Record (TAR), dated 12/26/24 through 12/31/24 indicated that he/she was on Contact Precautions for a rash. Review of December 2024 Infection Control Line Listing, indicated that on 12/27/24, Resident #6 developed itch and redness to his/her bilateral lower extremities, had a rash to his/her skin and was started on an antibiotic. Review of Resident #6's Care Plan related to suspected scabies, dated 12/26/24, indicated to educate caregivers that anyone in close contact with an infected person should seek medical treatment, that infestation may occur by direct skin to skin contact with an infected person and to wash all clothing, bedding and towels in hot water and dry in a hot dryer. The Care Plan indicated Scabies is spread by sharing towels, clothing and bedding. On 1/22/25, Surveyor #2 observed a Contact Precautions sign posted on the outside of Resident #6's door and a bin with Personal Protective Equipment (PPE) just outside the room by the door. The Sign indicated staff to put on gloves before room entry and discard gloves before room exit, put on gown before room entry and discard gown before room exit. Review of the Residents on Precautions List, updated 01/17/25, indicated that Resident #6 was not listed as being on any Infection Control Precautions. On 1/22/25 at 8:47 A.M., Surveyor #2 observed Certified Nurse Aide (CNA) #2 enter Resident #6's room without the use of a gown or gloves and assist Resident #6 with the set-up of a meal tray and place a blanket on the shoulders of the resident. CNA #2 stood in the room chatting with Resident #6 and then rubbed his/her (Resident #6's) arm prior to exiting the room. During an interview on 1/22/25 at 8:55 A.M. with Surveyor #2, CNA #2 said that she did not know why Resident #6 was on Contact Precautions and said she would have to ask the nurse. CNA #2 said she was not wearing any PPE when she entered Resident #6's room, as the sign indicated. On 1/22/25 at 9:12 A.M., Surveyor #2 observed Nurse #1 enter Resident #6's room without the use of a gown or gloves. Nurse #1 repositioned Resident #6 from a sitting position on the side of the bed to a lying position. Nurse #1 was observed adjusting Resident #6's blankets, and handing Resident #6 the call light. During an interview on 1/22/25 at 9:15 A.M. with Surveyor #2, Nurse #1 said that Resident #6 was previously on Contact Precautions because he/she had a urinary catheter and said he did not believe Resident #6 was still on Contact Precautions. Nurse #1 said that he would have to ask the Unit Manager about the status of Resident #6's precautions and said he could not explain why Resident #6 still had a Contact Precaution sign posted outside the door of his/her room. During an interview on 01/22/25 at 9:24 A.M. with Surveyor #2, the Unit Manager said that after reviewing Resident #6's Medical Record, that he/she was no longer on Contact Precautions. The Unit Manager said that Resident #6's urinary catheter had been removed. The Unit Manager said that she would speak with the IP to confirm Resident #6's status related to the need for precautions. During an interview on 01/22/25 at 11:15 A.M. and throughout the survey with Surveyor #1 and Surveyor #2, the Infection Preventionist (IP) said staff are trained on EBP and Contact Precautions and are aware that there are signs posted outside the door indicating which resident or residents in the room are on precautions. The IP said that the signs clearly indicate what type of PPE to wear when performing resident care activities. The IP said that staff are supposed to wear a gown when performing dressing activities, repositioning residents, and touching linens. The IP said it is her expectation that staff follow the directives that are posted on the precaution signs. The IP said she did not know Resident #6's infection control status and said she would look into it. During an in-person interview on 01/22/25 at 3:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 01/23/25 at 8:39 A.M. with Surveyor #1, the Director of Nurses (DON) said that staff have been trained on EBP and Contact Precautions and are aware that there are signs posted outside the resident rooms door indicating which resident or residents are on precautions. The DON said that it is her expectation that staff follow the directives that are posted on the precaution signs and wear the appropriate PPE when providing resident care according to the directives on the signs. The DON said that it was her expectation that staff are aware of the residents who are on precautions and why they are on precautions. 3. Review of the Facility Policy, titled Staff Compliance During Group A Streptococcus (GAS) Outbreaks, dated 06/21/2024, indicated that during an outbreak of GAS in the nursing home, staff are encouraged to undergo testing for GAS. The Policy indicated that staff who test positive must follow medical advice for treatment and may not return to work until cleared by a healthcare professional. The Policy further indicated that CDC recommendations are used as a reference. Review of CDC Recommendations for GAS, dated 03/25/2024 indicated that for healthcare personnel with known or suspected group A Streptococcus infection, obtain a sample from the infected site, and exclude from work until 24 hours after the start of effective antimicrobial therapy. During an in-person interview on 01/22/25 at 3:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 01/23/24 at 8:39 A.M. with Surveyor #1, the Director of Nurses (DON) said that the residents and staff on the [NAME] Unit were tested for GAS on 1/17/25. The DON said that the Laboratory reported CNA #1's positive test results for GAS to the facility on [DATE]. The DON said that on 1/18/25 someone from the facility notified her that CNA #1 was positive for GAS and said she called CNA #1 to tell her results, that she needed to go see a doctor and get treatment for herself and her family. The DON said that she was not aware that CNA #1 was working at the facility at the time she was notified that her test results were positive and assumed that when she called CNA #1 that she was home. The DON said that on 1/18/25 she had not informed CNA #1 or the Scheduler that CNA #1 could not return to work prior to being on antibiotics for 24 hours. The DON said that on 1/20/25, (exact time unknown), CNA #1 gave her the doctor's note and told her that she took her first dose of antibiotics on the evening of 1/19/25 and took another dose of antibiotics in the morning of 1/20/25. The DON said that CNA #1 returned to work prior to being on antibiotics for 24 hours. The DON said facility policy indicates that staff who are positive for GAS cannot return to work prior to being on antibiotics for 24 hours and said her expectation is that they follow the facility policy. Review of the Daily Schedule, dated 1/18/25 and 1/19/25, indicated that CNA #1 worked on the [NAME] Unit starting at 7:00 A.M. through to 11:00 P. M. (double shift). Review of the Daily Schedule, dated 1/20/25, indicated that CNA #1 worked on the Second Unit from 7:00 A.M. through 3:00 P.M. shift and on the [NAME] Unit from 3:00 P.M. through 11:00 P.M. shift. Review of CNA #1's Timecards, indicated that she worked the following: -on 1/18/25 from 7:07 A.M. to 10:53 P.M.; -on 1/19/25 from 7:06 A.M. to 10:53 P.M.; -on 1/20/25 from 7:09 A.M. to 10:53 P.M. West Unit had a total number of 31 residents residing on it. Second Unit had a total number of 35 residents residing on it. During an in-person interview on 1/22/25 at 2:20 P.M. with Surveyor #1 and Surveyor #2 and a subsequent telephone interview on 1/23/25 at 8:52 A.M. with Surveyor #1, CNA #1 said that on 1/18/25 the DON called her (exact time unknown) and informed her that she was positive for GAS, told her that she needed to go home and see a doctor. CNA #1 said that she was at work when the DON called and said sometime after supper (exact time unknown), she went home. CNA #1 said that she took her first dose of antibiotics at 3:00 P.M. on 1/19/25 and said she came into work that night for the 3:00 P.M. through 11:00 P.M. shift on the [NAME] Unit. CNA #1 said that on 1/20/25, she worked from 7:00 A.M. through 3:00 P.M. shift on the Second Floor Unit and from 3:00 P.M. through 11:00 P.M. shift on the [NAME] Unit. CNA #1 said that sometime during the day, (on 1/20/25, exact time unknown), she went to the DON's office, gave the DON her doctor's note and told the DON she was on antibiotics. CNA #1 said that the DON never asked her if she was working and never told her that she could not work until after she was on antibiotics for 24 hours, CNA #1 said she went back and work her scheduled shifts. During a telephone interview on 1/23/25 at 2:23 P.M., the Medical Director said he became the Medical Director for the Facility in December 2024. The Medical Director said that he was aware that the Fac[TRUNCATED]

Based on observation, interview, and documentation review, the facility failed to ensure nursing staff were able to demonstrate the appropriate competencies and skill sets for 4 out of 5 licensed nurses and for 4 out of 5 Certified Nursing Assistants (CNAs). Specifically, the facility failed to ensure: 1. Staff were able to identify and distribute modified diet textures to residents, as ordered; and 2. Licensed nurses (Nurse #4, #6, #9, and Unit Manager #1) and CNAs (#1, #3, #5 and #6) had demonstrated competency in skills necessary to care for residents. Findings include: Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the Facility Assessment, dated 8/1/24, indicated the facility's training program included an orientation process and ongoing training for all new and existing staff including managers, nursing, and other direct care staff. The facility completes an educational needs assessment and develops a curriculum and training plan based on staff need and resident characteristics. The content at a minimum included: -effective communication -resident rights and facility responsibilities -abuse, neglect and exploitation -infection control -culture change/person-centered care -dementia management and abuse prevention -special needs of residents -caring for residents who are cognitively impaired -identification of resident changes in condition -cultural competency/trauma informed care -QAPI -compliance and ethics -emergency preparedness -workplace hazards The Facility Assessment indicated staff were trained on policies and procedures consistent with their role and training and competencies were ongoing throughout the year. 1. Review of the facility's policy titled Tray Identification, revised April 2017, included but was not limited to: Policy Statement: Appropriate identification/coding shall be used to identify various diets. Policy Interpretation and Implementation: -Nursing staff shall check each food tray for the correct diet before serving to residents. Review of the facility's document titled {Facility} Dysphagia Diets, undated, included but was not limited to the following: -Dysphagia Chopped Soft tender meat cut into bite sized pieces Soft diced cooked vegetables Soft diced fruit Moist bread/pie and cake Pancakes/waffles cut at service -Dysphagia Ground Moist ground meat with gravy Soft diced vegetables Soft diced fruit May have soft bread (no rolls, muffins, English muffins, or bagels) Desserts (soft cookie/pudding/ice cream/fruit) On 11/20/24 at 11:32 A.M., the surveyor observed the lunch tray line in the main kitchen. The ground-textured meals were identical to regular-textured meals: one square of eggplant parmesan, whole penne pasta, and steamed broccoli and cauliflower of various shapes and sizes. On 11/20/24 at 11:50 A.M., the surveyor observed Unit Manager #2 checking lunch trays for the East Unit. The Unit Manager reviewed a meal that indicated ground texture and said the square of eggplant parmesan, whole penne pasta, and steamed vegetables of various sizes was appropriate for a ground-textured diet. The surveyor observed staff take the tray into the Resident's room. Resident #353 was admitted to the facility in October 2024 with a diagnosis of dysphagia (swallowing difficulties). Review of the physician's orders indicated as of 10/21/24 Resident #353 was to have a ground texture. The following meals were observed served to Resident #353: -11/20/24 at 8:37 A.M.: egg strata (baked casserole dish made with layers of bread, eggs, cheese), whole and not in ground form. -11/20/24 at 12:20 P.M.: whole penne and an intact piece of eggplant parmesan. -11/21/24 at 8:37 A.M.: a muffin cut into fourths, without any butter (or moistened). Resident #67 was admitted to the facility in September 2022 with a diagnosis of dysphagia. Review of the physician's orders indicated as of 8/30/24 Resident #67 was to have a chopped texture diet. The following meals were observed served to Resident #67: -11/19/24 at 8:45 A.M.: a whole omelet not cut up into pieces. -11/20/24 at 8:35 A.M.: an egg strata whole, not in pieces. -11/20/24 at 12:15 P.M.: whole penne pasta and a square of eggplant parmesan. -11/21/24 at 8:35 A.M.: four halves of French toast which were not cut into pieces. During an interview on 11/21/24 at 9:06 A.M., Nurse #4 (the nurse for Resident #353 and Resident #67) said the nurses on the units check the meal trays prior to providing the meal to the Resident. He said the nurses check the trays for accuracy (allergies, preferences, texture). He said he was unsure of specific diet textures and did not know if there was anything available on the unit for him to reference food textures. He said he noticed chopped diets contained some food items that were in whole form and not chopped. He said he instructed CNAs and other nurses to chop those food items when they delivered the tray to the resident. Resident #39 was admitted to the facility in September 2021 with diagnoses which included dysphagia. Review of Resident #39's physician's order, dated 6/19/24, indicated a chopped diet texture. The following meals were observed served to Resident #39: -11/19/24 at 9:12 A.M.: a cheese omelet, not cut up and a whole banana -11/20/24 8:26 at A.M.: a slice of strata and home fries (in varying sizes) -11/20/24 at 12:17 P.M., whole penne with eggplant and large pieces of broccoli During an interview on 11/20/24 at 12:20 P.M., Unit Manager #2 reviewed Resident #39's meal and said the facility considers whole penne pasta with slices of eggplant and large pieces of broccoli to be adequate for a chopped diet. On 11/21/24 at 8:45 A.M., the surveyor observed facility staff exiting the room. Resident #39 was having French toast and sausage. The French toast was served as whole slices of bread cut once diagonally, and the sausage had been cut into varying sizes. During an interview on 11/21/24 at 8:55 A.M., the Speech Language Pathologist (SLP, a health professional who evaluates, diagnoses, and treats speech, language, and swallowing disorders) and the surveyor reviewed Resident #39's meals. She said if the food was not prepared in a chopped form, the staff should be cutting it at the time of service, prior to leaving the room. She said the penne pieces should have been smaller, the French toast should have been cut into pieces and the sausage and broccoli pieces should have been cut into smaller pieces. Resident #19 was admitted to the facility in December 2023 with diagnoses including dementia and dysphagia. Review of Resident #19's physician's order, dated 9/12/24, indicated a chopped diet texture. The following meals were observed served to Resident #19: -11/20/24 at 8:50 A.M.: cheese omelet, not chopped/cut up -11/20/24 at 12:34 P.M.: a grilled cheese sandwich, cut in half During an interview on 11/20/24 at 12:07 P.M., the SLP said there was a list of diet texture information the facility followed posted on the units (she then grabbed the {Facility} Dysphagia Diets sheet from behind the nurses' station on the [NAME] unit). She said meat in a chopped diet should be cut into pieces before it gets to the resident. She said the ground texture needed to be smaller than the chopped diet texture. She said for modified textures the eggplant should be served in small pieces for chopped texture or ground into small pieces for the ground texture. She said the egg strata and the omelet should be cut into pieces for the chopped texture and she would prefer scrambled eggs for the ground texture. During an interview on 11/20/24 at 12:10 P.M., the Registered Dietitian (RD) said the kitchen was not cutting the food into pieces for residents with a chopped texture. During an interview on 11/22/24 at 9:10 A.M., the SLP said residents who have difficulty swallowing were on modified texture diets. She said these residents were at risk for choking if they were not provided the correct diet texture. She said if a resident was on a ground diet and provided whole penne pasta or unchopped eggplant with a hard cheese on top it was a safety concern. During an interview on 11/24/24 at 12:15 P.M., the SLP said staff were educated on the {Facility} Dysphagia Diets in June 2024. Review of the Diets and Textures in-service documentation, dated 6/19/24, indicated 19 staff signed as being educated. Review of the staff signatures indicated none of the three Unit Managers or Nurse #4 had been educated. The staff attendance sheet indicated the following representations: one housekeeper, seven activity staff, one Social Worker, one Business Office Manager, one Rehabilitation staff, two Dietary staff, one MDS (Minimum Data Set) coordinator, one Medicaid specialist, three nurses and one CNA. 2. Review of the facility's Charge Nurse Competency Evaluations included the following areas: -Administrative Functions -Charting and Documenting -Drug Administration Functions -Personnel Functions -Nursing Care Functions -Staff Development -Safety and Sanitation -Equipment and Supply Functions -Care Plan and Assessment Functions -Resident Rights Functions -Privacy & Security -Miscellaneous -Working Conditions Review of the facility's CNA Competency Evaluations included the following areas: -Administrative Functions -Admission, Transfer, and Discharge Functions -Personnel Functions -Personal Nursing Care Functions -Special Nursing Care Functions -Food Service Functions -Staff Development -Safety and Sanitation -Equipment and Supply Functions -Care Plan Functions -Resident Rights -Privacy & Security -Working Conditions Review of the following staff education files failed to contain any information regarding competencies (charge nurse or CNA): Nurse #6: hired 8/7/24 Nurse #9: hired 2/25/24 Unit Manager #1: hired 11/9/22 CNA #1: hired 4/5/23 CNA #3: hired 9/25/24 CNA #5: hired 10/24/19 There was no education files provided for Nurse #4 (hired 5/15/24) or CNA #6 (hired 11/21/21). During an interview on 11/22/24 at 11:40 A.M., the Human Resource Coordinator said she conducted a general orientation with staff including the Orientation Education Test Packet. She said this was a one-day lecture orientation and did not include any clinical education/training or return demonstration. During an interview on 11/22/24 at 11:45 A.M., the Director of Nurses (DON) said after the one-day orientation, the nurses and CNAs were placed on orientation with a preceptor on the units and a staff member should be signing off on competencies during this time. She said there was not a specific staff member assigned to provide clinical training as part of the new hire process. During an interview on 11/22/24 at 2:37 P.M., the Human Resource Coordinator said she could not locate any employment files including education and competencies for Nurse #4 or CNA #6. During an interview on 11/22/24 at 2:47 P.M., the Administrator said the facility did not have a system in place to assure staff were competent in their roles. She said she did not think competencies had been completed in the two years she had worked at the facility. She said the preceptors should be orienting new hires to facility policy and procedures such as codes and diet textures. Refer to F805

Based on employee record review and interview, the facility failed to complete performance reviews of Certified Nursing Assistants (CNAs) at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 3 out of 3 CNA employee records reviewed. Findings include: Review of the facility's policy titled In-Service Training, Nurse Aide, dated as last revised in August 2022, indicated the following: -all personnel are required to participate in regular in-service education -the facility completes a performance review of nurse aides at least every 12 months -in-service training is based on the outcome of the annual performance reviews On 11/22/24 at 12:35 P.M., the surveyor requested employee files for CNAs #1, #5, and #6. On 11/22/24 at 2:18 P.M., the surveyor was provided education files for two of the three CNAs. During an interview on 11/22/24 at 2:37 P.M., the Human Resources Coordinator said there was no file for CNA #6 who was hired in November 2021, and she was unable to locate any information regarding the staff member's education or performance evaluations. Review of the file for CNA #1 indicated the staff member was hired in April 2023. The file failed to include a performance evaluation. Review of the file for CNA #5 indicated the staff member was hired in October 2019. The file failed to include a performance evaluation. During an interview on 11/22/24 at 2:47 P.M., the Administrator said there was no process in place for annual performance reviews or for in-servicing to be based on the performance review. She said there was no one at the facility assigned to do the performance reviews at this time.

Based on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA) completed the required 12 hours (no less than) of annual training, which at a minimum must include dementia and abuse training for 3 out of 3 CNA education files reviewed. Findings include: Review of the facility's policy titled In-Service Training, Nurse Aide, dated as last revised in August 2022, indicated the following: -all personnel are required to participate in regular in-service education -the facility completes a performance review of nurse aides at least every 12 months -in-service training is based on the outcome of the annual performance reviews -ensures the continuing competency of nurse aides, are no less than 12 hours per employment year, address areas of weakness -nurse aide participation in training is documented by the staff development coordinator or his/her designee and includes: date and time of training, topic of training, method used for training, summary of the competency assessment and hours of training completed On 11/22/24 at 12:35 P.M., the surveyor requested employee files for CNAs #1, #5, and #6. On 11/22/24 at 2:18 P.M., the surveyor was provided education files for two of the three CNAs. During an interview on 11/22/24 at 2:18 P.M., the Human Resources Coordinator said there was no employee or education file for CNA #6 who was hired in November 2021, and she was unable to locate any information regarding the staff member's education including in-servicing, dementia training, abuse prevention training or performance evaluations. Review of the file for CNA #1 indicated the staff member was hired in April 2023. The file included six undated in-service quizzes. During an interview on 11/22/24 at 2:45 P.M., the Administrator said an education fair was held in November/December 2023 and the six undated in-service quizzes for CNA #1 were from this education fair. She said there should have been 12 and she did not know where the rest of them were. Review of the file for CNA #5 indicated the staff member was hired in October 2019. The file contained the following education: enhanced barrier precautions from March 2023 and May 2023 and a post-dialysis quiz from June 2023. There was no subsequent education in the employee file. During an interview on 11/22/24 at 2:40 P.M., the Assistant Director of Nurses said she had started working at the facility in July 2024 and had not been tracking CNA in-service hours since she arrived. During an interview on 11/22/24 at 2:42 P.M., the Director of Nurses said she had started working at the facility in May 2024 and had not been tracking CNA in-service hours since she arrived. During an interview on 11/22/24 at 2:47 P.M., the Administrator said the facility had held an education fair in November/December 2023 and she thought everyone had received their 12 hours of required in-servicing but was not sure if anyone had tracked the hours or where the documentation of education would be. She said there was no process in place for tracking the hours of in-servicing or for the in-servicing to be based on the performance review.

Based on interviews and record reviews, the facility failed to ensure three Residents (#78, #66, and #43), in a sample of 22 residents, had been seen by a physician every every 60 days and that required visits alternated between the Physician and the Nurse Practitioner (NP). Specifically, the facility failed to ensure for: 1. Resident #78, required visits alternating between the Physician and the NP occurred every 60 days; and 2. Resident #66, required visits alternated between the Physician and the NP occurred every 30 days for the first 90 days then every 60 days; and 3. Resident #43, required visits alternated between the Physician and the NP occurred every 30 days for the first 90 days then every 60 days. Findings include: Review of the facility's policy titled Physician Services, dated as revised February 2021, indicated but was not limited to: -Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. 1. Resident #78 was admitted to the facility in October 2023. Review of the Physician's Progress Notes indicated Resident #78 was seen by the MD (Doctor of Medicine) on 6/5/24. The next visit was conducted by the NP on 9/19/24, 106 days since the previous visit. The proceeding visits from the NP occurred on 9/24/24, 10/22/24, 10/29/24, and 10/30/24. The next visit from the MD occurred on 11/3/24, 151 days since the previous MD visit. During an interview on 11/21/24 at 2:14 P.M., the Director of Nurses (DON) said these were all of the physician visits for Resident #78 and the physicians should be alternating visits with the NP to see residents every 60 days. During an interview on 11/22/24 at 10:47 A.M., the Administrator said there were no additional physician visits for the Resident and said there had been an issue with physicians conducting and documenting timely visits. 46562 2. Resident #66 was admitted to the facility in August 2024. Review of the Physician's Progress Notes indicated Resident #66 was seen by the MD on 8/7/24. The next visit was conducted on 8/26/24. There were no further provider visits, as of 11/25/24 the Resident had gone 91 days without a visit. During an interview on 11/20/24 at 3:11 P.M., Resident #66 said he/she was seen by the doctor when he/she was first admitted but had not been seen since. During an interview on 11/25/24 at 12:26 P.M., the DON said Resident #66 should have been seen every 30 days for the first 90 days of his/her admission then every 60 days. The DON said Resident #66 should not have gone 91 days without a visit. As of the end of survey, on 11/25/24, the survey team did not receive any additional documented evidence of provider visits for Resident #66. 3. Resident #43 was admitted to the facility in May 2024. Review of the Physician's Progress Notes indicated Resident #43 was seen by the MD on 5/10/24 and then again on 7/10/24. The next visit was conducted by the NP on 10/22/24, 104 days since the previous visit. Further review of the Provider Progress Notes indicated Resident #43 was seen by the NP on 10/23/24, 10/29/24, 11/5/24, 11/12/24, 11/13/24, 11/14/24, and 11/19/24. There were no additional MD visits. As of 11/25/24, there was 138 days since his/her last MD visit. During an interview on 11/25/24 at 12:26 P.M., the DON said Resident #43 should have been seen every 30 days for the first 90 days of his/her admission then every 60 days. The DON said the MD and NP could alternate visits but at a minimum the MD should see the residents every 120 days. The DON said Resident #43 should have been seen by a provider prior to 10/22/24 and should not have gone 138 days without an MD visit. As of the end of survey, on 11/25/24, the survey team did not receive any additional documented evidence of provider visits for Resident #43.

Based on observation, record review, interviews, and review of the facility assessment, the facility failed to provide sufficient support personnel with appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Specifically, the facility failed to: 1. Ensure support staff with appropriate competencies and skills were available to provide meals that meet the residents' needs; and, 2. Provide documentation that dietary competencies were conducted on all dietary personnel. Findings include: Review of the Facility Assessment, dated 8/7/24, included but was not limited to: -This facility assessment will be used to inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessment and plans of care; -Information about our residents: Skilled acuity (Time Period: Quarter 2 April 1 - June 30), Mechanically Altered Diet or Swallowing Disorder-15.3 residents; -Policies and Procedures: Staff are trained on policies and procedures consistent with their roles. Review of the facility's Diet Order Tally Report, dated 11/20/24, indicated but was not limited to the resident tally for the following diet orders: -Double portions = 2 residents -Small portions = 1 resident -Chopped texture = 20 residents -Ground texture= 19 residents Review of the facility's policy titled Food and Nutrition Services, revised October 2017, included but was not limited to: -Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Review of the facility's policy titled Tray Identification, revised April 2017, included but was not limited to: Policy Statement: Appropriate identification/coding shall be used to identify various diets. Policy Interpretation and Implementation: -The food services manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. Review of the facility's policy titled Kitchen Weights and Measures, revised April 2017, included but was not limited to: Policy Statement: Food service staff will be trained in proper use of cooking and serving measurements to maintain portion control. Policy Interpretation and Implementation: -Cooks and food services staff will be trained in weights and measures, volume and weights, appropriate utensil use, and food can sizes. Review of the facility's document titled {Facility} Dysphagia Diets, undated, included but was not limited to the following: -Regular Texture Diet: Description: Unaltered meals Soft tender meat Soft vegetables Soft fruit Moist soft bread/pie and cakes allowed Rice with sauce, gravy allowed -Dysphagia Chopped Soft tender meat cut into bite sized pieces Soft diced cooked vegetables Soft diced fruit Moist bread/pie and cake Pancakes/waffles cut at service -Dysphagia Ground Moist ground meat with gravy Soft diced vegetables Soft diced fruit May have soft bread (no rolls, muffins, English muffins, or bagels) Desserts (soft cookie/pudding/ice cream/fruit) 1. On 11/20/24 at 11:30 A.M., the surveyor observed a portion of the lunch tray line in the main kitchen. The Food Service Director (FSD) was not present during tray line observation. Dietary Staff #2 was the cook. The following observations were made: -Ground-textured meals, chopped meals, and regular-textured meals contained whole foods such as a square of eggplant parmesan (layers of breaded eggplant, tomato sauce, and mozzarella cheese), whole penne pasta, and steamed broccoli and cauliflower of various sizes, including whole florets and large chunks of stalks. There was no observed distinguishable difference between a regular diet, a chopped diet, or a ground diet; -One meal ticket indicated ground texture, pureed vegetables, dislikes bread. The resident received one scoop of whole penne pasta and one scoop of pureed vegetable; no entree or protein; -One meal ticket indicated double portions. A single scoop of penne pasta, double serving of eggplant parmesan, and one scoop of vegetables was plated. During an interview on 11/20/24 at 11:32 A.M., Dietary Staff #2 said the ground and chopped meals were plated correctly and followed the facility's guidance on food textures. Dietary Staff #2 said breadcrumbs are considered bread; if she is told no bread then she will not plate any food items containing bread such as eggplant parmesan or the meatloaf alternate. During an interview on 11/20/24 at 11:46 A.M., the Dietitian said she expected double portions to be double of each food item. The Dietitian said for anyone with a dislike of bread, they should still be offered food items that are breaded such as eggplant parmesan and meatloaf or a different entree option per their food preferences. On 11/21/24 at 7:40 A.M., the surveyor observed a portion of the breakfast tray line in the main kitchen. The FSD was not present during the beginning of the tray line observation. Dietary Staff #7 was the cook. The following observations were made: -ground-textured meals were given a muffin; -chopped-textured meals were served a slice of French toast sliced once diagonally and chopped sausage links chopped into various sizes; -a double portioned meal was plated as a double portion of scrambled eggs, one sausage, and one muffin. During an interview on 11/21/24 at 12:15 P.M., the Speech Language Pathologist (SLP) said she, the FSD, and the Dietitian have been collaborating on diets and food textures in recent months to better meet the residents' needs. She said the kitchen has been slowly implementing any diet and food texture changes, but the kitchen had not been performing consistently or changes did not last long. During an interview on 11/25/24 at 1:31 P.M., the FSD said he had not been aware of the kitchen's inconsistency in preparing and serving diets and food textures consistent with facility policy, physician's orders, and the Dietitian's and SLP's orders/recommendations. The FSD said the dietary staff needed extensive education to increase competencies and skills in order to provide meals that meet the residents' needs. 2. During an interview on 11/24/24 at 12:15 P.M., the SLP said she had never provided written or verbal diet education for the orientation program and does not believe that therapeutic diets or diet textures are included in orientation. She said diet textures are a part of providing safe care to residents and should be addressed to all employees during orientation and on an ongoing basis. She said staff were educated on the {Facility} Dysphagia Diets in June 2024. Review of the in-service documentation, dated 6/19/24, included signatures of staff who were educated. There were 20 signatures on the Staff Attendance sheet, two of which were Food Service staff: Dietary Staff #4 and Dietary Staff #6. During an interview on 11/25/24 at 1:31 P.M., the FSD said he had no documentation of job-related competencies for dietary staff. The FSD said diets and textures are on the job training and not documented. The FSD said any education or in-service he provided to dietary staff was verbal and he did not maintain documentation. The FSD also said he did not obtain signatures from dietary staff when he educated or provided in-services. During an interview on 11/25/24 at 2:08 P.M., the Administrator said any orientation and competency documentation specific to food and nutrition services would be in the employee files. The surveyor reviewed five random Dietary employee files and did not observe competency documentation in five out of five sampled files. Refer to F805

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted to the Facility with a wound to the small of his/her back (lower back sacral area) and a large reddened, discolored area in the medial (middle) area of his/her back, the Facility failed to ensure that the Physician was notified of Resident #1's wounds upon admission and that orders were obtained for treatment. As of result of not being treated, the wound to the small of Resident #1's back wound deteriorated to an unstageable pressure injury (full-thickness skin and tissue loss that is obscured by eschar - necrotic tissue) within one week of his/her admission, Findings Include: Review of the Facility's Policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated as revised April 2018, indicated that nursing staff will examine the skin of newly admitted residents for evidence of existing pressure injuries or other skin conditions and the physician will order pertinent wound treatments. Review of the Facility's Policy titled, Pressure Injury Risk Assessment, dated as revised March 2020, indicated to notify the attending MD if new skin alteration is noted. Resident #1 was admitted to the Facility in May 2023, diagnoses included: intertrochanteric fracture of left femur, osteoporosis, sciatica, dementia and atrial fibrillation. Review of Resident #1's Hospital Discharge Summary, dated 05/24/23, indicated that Resident #1 had a wound on the small of his/her back (lower back sacral area) and a large reddened, discolored area in medial (middle) area of his/her back with evidence of some skin tearing. Review of a Nurse Progress Note, dated 5/24/23, indicated that Resident #1 was admitted to the facility with two large excoriated (superficial or partial thickness well defined injury) wounds one to his/her lower back and one to his/her mid/upper spine (back) areas. During an interview on 8/22/23 at 1:30 P.M., Nurse #1 said that she was the nurse who completed Resident #1's admission to the facility. Nurse #1 said that Resident #1 was admitted to the facility from the hospital with two excoriated areas, one to his/her mid back area and one to his/her lower back sacral area. Nurse #1 said she could not recall if she notified the Physician or Nurse Practitioner (NP) upon admission that Resident #1 had wounds. Nurse #1 said if Resident #1 did not have any treatment orders upon admission, then she had not notified the Physician or NP and had not obtained any treatment orders. Nurse #1 said that another nurse helped her with Resident #1's admission. Nurse #1 said she could not explain why there had not been any physicians' orders obtained upon admission for Resident #1 for treatment of his/her two wounds. During an interview on 8/24/23 at 10:37 A.M., Nurse #3 said that she helped Nurse #1 with Resident #1's admission. Nurse #3 said that she obtained Resident #1's vital signs and got him/her settled into his/her room. Nurse #3 said that she had not notified the Physician or NP of Resident #1's admission because Resident #1 was not her admission. Review of Resident #1's Medical Record, which included Physicians orders and his/her Treatment Administration Record, indicated there was no documentation to support that Physician's Orders were obtained by nursing for treatment of the wounds to his/her medial (middle) and lower back areas from 5/24/23 through 5/31/23. Review of a Nurse #4's Progress Note, dated 5/28/23, indicated that Resident #1 was noted by the day shift to have areas that were red/pink, a stage one (localized area that does not turn white when pressed, in which further pressure can cause damage to the underlying tissue) on his/her left middle back and also a stage two (partial thickness skin loss with exposed dermis) area on his/her left buttocks (sacral area). The Note indicated that he/she needs the Wound Physician to assess these areas. The Surveyor was unable to interview Nurse #4 as he did not respond to the Department of Public Health telephone request for an interview. Review of Resident #1's Medical Record, indicated there was no documentation to support the Physician was notified on 5/28/23 of the worsening of the wound to the small of his/her back (lower back sacral area) or the wound to his/her mid back area, or that treatment orders had been obtained by nursing. Review of Resident #1's Initial Wound Evaluation & Management Summary, dated 5/31/23, completed by the Wound Physician, indicated that Resident #1 presented with an unstageable deep tissue pressure injury of the left medial sacrum, partial thickness measuring 4 centimeters (cm) by 4 cm by 0.1 cm with light serous exudate (drainage). The Wound Evaluation indicated to apply leptospermum honey, cover with ABD pad and tape once daily for 30 days, off-load wound and reposition per facility policy. The Wound Evaluation also indicated that Resident #1 presented with a non-pressure wound of the upper medial back, full thickness measuring 10 cm by 3 cm by 0.1 cm with light serous exudate. The Wound Evaluation further indicated to apply leptospermum honey, cover with ABD pad and tape once daily for 30 days, off-load wound and reposition per facility policy. Review of Resident #1's Treatment Administration Record, indicated he/she had new physician's orders, dated effective 6/01/23, for treatments to be completed by nursing to his/her wounds, in accordance with recommendations provided by the wound physician. During an interview on 08/22/22 at 4:15 P.M., the Director of Nursing (DON) said that it was her expectation that if a resident is admitted with a pressure injury or any wound, that the Physician is notified, and a treatment order is obtained. The DON said she could not explain why Resident #1 did not have treatments ordered upon admission and said that she could not explain why Resident #1 waited one week for the wound physician to assess his/her wounds and for nursing to implement treatments.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted to the Facility with a wound to the small of his/her back (lower back sacral area) and a large reddened, discolored area in the medial (middle) area of his/her back, and was assessed by nursing as being at risk for skin breakdown, the Facility failed to ensure Resident #1 received adequate care and services related to the promotion of healing or the prevention of worsening of his/her wounds, when treatment orders for his/her wounds were not obtained from the Physician until a week after his/her admission, at which point the wound to the small of Resident #1's back had deteriorated to an unstageable pressure injury (full-thickness skin and tissue loss that is obscured by eschar - necrotic tissue). Findings Include: Review of the Facility's Policy titled, Pressure Injury Risk Assessment, dated as revised March 2020, indicated the following: -conduct a structured pressure injury risk assessment as soon as possible after admission; -once the assessment is conducted and risk factors identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure injuries; -once inspection of skin is completed, document the findings on a facility-approved assessment tool; -if a new skin alteration is noted, initiate a pressure form related to the type of alteration in skin; -develop a resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition; -the interventions must be based on current, recognized standards of care; -the effects of the interventions must be evaluated; -the care plan must be modified as the resident's condition changes or if current interventions are deemed inadequate; -document the condition of the resident's skin, size and location of any red areas; -document in the medical record addressing MD notification if new skin alteration noted with change of plan of care; -notify attending MD if new skin alteration noted. Review of the Facility's Policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated as revised April 2018, indicated the following: -the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers' -the nurse shall describe, document, report the following: full assessment of pressure injury, including location, stage, length, width, depth and presence of exudates or necrotic tissue; -nursing staff will examine the skin of newly admitted residents for evidence of existing pressure injuries or other skin conditions; -the physician will order pertinent wound treatments; -the physician will evaluate and document the progress of wound healing during resident visits; -the physician will guide the care plan. Resident #1 was admitted to the Facility in May 2023, diagnoses included: intertrochanteric fracture of left femur, osteoporosis, sciatica, dementia and atrial fibrillation. Review of Resident #1's Hospital Discharge Summary, dated 05/24/23, indicated that Resident #1 had a wound on the small of his/her back (lower back sacral area) and a large reddened, discolored area in medial (middle) of his/her back with evidence of some skin tearing. Review of a Nurse Progress Note, dated 5/24/23, indicated that Resident #1 was admitted to the facility with two large excoriated (superficial or partial thickness well defined injury) wounds to his/her lower and middle/upper spine (back) areas. Review of the Resident #1's Norton_Scale Assessment, dated 05/25/23, indicated that he/she was assessed by nursing as being at moderate risk for potential development of pressure injuries. Review of Resident #1's Weekly Skin assessment, dated 5/25/23, indicate that it was incomplete and had been left blank. Review of Resident #1's Nutritional Progress Note, dated 05/25/23, indicated that per nursing note, he/she had two large wounds, one on his/her lower back and one on his/her mid/upper spine (back) and his/her buttocks (sacral) area was excoriated. During an interview on 8/22/23 at 1:30 P.M., Nurse #1 said that she was the nurse who completed Resident #1's admission to the facility. Nurse #1 said that Resident #1 was admitted to the facility from the hospital with two excoriated areas, one to his/her mid back and one to his/her lower back sacral area. Nurse #1 said she could not recall if she notified the Physician or Nurse Practitioner (NP) upon admission that Resident #1 had wounds. Nurse #1 said if Resident #1 did not have any treatment orders upon admission, then she did not notify the Physician or NP and did not obtain any treatment orders. Nurse #1 said that she could not recall if she completed an admission nursing assessment on Resident #1. Nurse #1 said she could not explain why there had not been any physicians' orders obtained upon admission for Resident #1 for treatments of his/her two wounds. During an interview on 8/24/23 at 10:37 A.M., Nurse #3 said that she helped Nurse #1 with Resident #1's admission. Nurse #3 said she obtained Resident #1's vital signs and got him/her settled into his/her room. Nurse #3 said that she did not notify the physician or NP of Resident #1's admission and did not complete Resident #1's admission nursing assessment because Resident #1 was not her admission. Review of Resident #1's Medical Record, Physician's Orders and Treatment Administration Record (TAR), dated 5/24/23 through 5/31/23, indicated there was no documentation to support that Physician's Orders were obtained for treatments for the wound at the small of his/her back (lower back sacral area) or for his/her medial (middle) back wounds. Review of a Nurse #4's Progress Note, dated 5/28/23, indicated that Resident #1 was noted by the day shift to have areas that were red, pink, a stage one (localized area that does not turn white when pressed, in which further pressure can cause damage to the underlying tissue) on left mid back and also stage two (partial thickness skin loss with exposed dermis) on the left buttocks (sacral area). The Note indicated that he/she needs the wound physician to assess these areas. The Surveyor was unable to interview Nurse #4 as he did not respond to the Department of Public Health telephone request for an interview. Resident #1 was seen by the Wound Physician on 5/31/23, one week after his/her admission to the Facility for evalution of his/her wounds, at which time the facility obtained orders for treatments to the areas. Review of Resident #1's Initial Wound Evaluation & Management Summary, dated 5/31/23, completed by the Wound Physician, indicated the following Resident #1 presented with an unstageable deep tissue pressure injury of the left medial sacrum, partial thickness measuring 4 centimeters (cm) by 4 cm x 0.1 cm with light serous exudate (drainage). The Wound Evaluation indicated to apply leptospermum honey, cover with ABD pad and tape once daily for 30 days, off-load wound and reposition per facility policy. The Wound Evaluation also indicated that Resident #1 presented with a non-pressure wound of the upper medial back, full thickness measuring 10 cm x 3 cm x 0.1 cm with light serous exudate. The Wound Evaluation further indicated to apply leptospermum honey, cover with ABD pad and tape once daily for 30 days, off-load wound and reposition per facility policy. Review of Resident #1's Treatment Administration Record, indicated he/she had new physician's orders, dated effective 6/01/23, for treatments to be completed by nursing to his/her wounds, in accordance with recommendations provided by the wound physician. Review of Resident #1's Pressure Ulcer Development Care Plans, dated as initiated on 06/08/23, (almost two week after his/her admission) indicated that he/she had the potential for pressure ulcer development related to immobility. The Care Plan indicated to turn and reposition at least every 2 hours, to monitor skin integrity every shift with care, and to follow facility policies/protocols for the prevention/treatment of skin breakdown. However further review of the Care Plan indicated it did not identify or address Resident #1's actual wounds. During an interview on 08/22/22 at 4:15 P.M., the Director of Nursing (DON) said that it was her expectation that if a resident is admitted with a pressure injury or any wound, that the Physician is notified, and a treatment order is obtained. The DON said she could not explain why Resident #1 did not have treatments ordered upon admission and said that she could not explain why Resident #1 waited one week for the Wound Physician to assess his/her wounds and for the facility to implement treatments. The DON said she could not explain why Resident #1's weekly skin assessment on 5/25/23 was blank. The DON said Resident #1 should have had an individualized plan of care developed upon admission related to his/her actual wounds that included interventions and goals.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was receiving Hospice Services due to end of life care needs, the Facility failed to ensure that based on his/her comprehensive assessment and care needs, that services were provided in accordance with acceptable standards of practice related to pain management. On 12/14/22, Resident #1 returned to the Facility after being evaluated at the Hospital Emergency Department for a significant change in condition due to new extensive wound on his/her left leg. Upon Resident #1's return, his/her Health Care Agent (HCA) was assured by nursing that he/she would be kept comfortable and medicated as needed for pain, and new orders were obtain to administer morphine (narcotic to treat moderate to severe pain) to manage his/her pain However, despite Resident #1 exhibiting obvious signs of pain during his/her dressing change at 3:30 P.M., continuing to exhibit signs and symptoms of pain and discomfort related to his/her left leg during the 3:00 P.M. to 11:00 P.M. shift, and his/her HCA repeatedly asking nursing about when Resident #1 would be administered the morphine, his/her morphine was not readily available and therefore not administered until approximately 11:25 P.M., almost eight hours after his/her original wound dressing was changed and he/she began to exhibit verbal and visual signs of pain. Findings include: Review of the Facility Policy titled, Administering Pain Medications, dated as last revised 3/2022, indicated that the pain management program is based on a facility-wide commitment to appropriate assessment and treatment plan, based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management. Review of the Facility Policy titled, Emergency Medications, dated as last revised December 2019, indicated that the Facility may use automated dispensing machines (Pyxis) for the first dose and emergency medications. Resident #1 was admitted to the Facility in March 2022, diagnoses included late effects hemiparesis (weakness to one side of the body), seizure disorder, history of urinary tract infections, congestive heart failure, atrial fibrillation, and anxiety. Review of Resident #1's Physician's Order, dated 4/15/22, indicated he/she was on Hospice Services. Review of Resident #1's Health Care Proxy, dated 3/18/22, indicated his/her Health Care Proxy had been activated, and his/her Health Care Agent (HCA) was making his/her health care decisions. Review of Resident #1's Nursing Progress Note, dated 12/14/22, indicated he/she was found to have edema (swelling) to both lower extremities, third spacing (when fluids shift out of circulation in the blood and into the space between cells and tissue) from his/her thighs to his/her toes, purple in color, and cool to touch, weeping copious amounts of serosanguinous (bloody) drainage. The Note also indicated that the skin on Resident #1's left inner calf was peeled from his/her knee to his/her ankle. The Note indicated Resident #1 complained of pain and was medicated with Tylenol as ordered. The Note indicated Resident #1's HCA was notified, and Resident #1 was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Emergency Department Summary, dated 12/14/22, indicated that there was extensive skin tearing of his/her left lower extremity. The Summary indicated the following; -skin tear is nearly circumferential (circular); -encompasses from the mid shin medially (middle) to the posterior (back of) calf; -serosanguinous (bloody) drainage; and -on the medical aspect of the dorsum (top of) of the left foot there is a second and separate skin tear with full skin removal of the outer layer. During an interview on 12/30/22 at 1:58 P.M., Resident #1's HCA said on 12/14/22 at approximately 7:30 A.M., she received a call from the Director of Nurses (DON) asking her if they could send Resident #1 to the Hospital Emergency Department (ED) for evaluation of a significant skin tear to his/her left lower leg and she agreed to the transfer. The HCA said she did not want Resident #1 to be admitted to the Hospital as long as he/she could be maintained on Hospice, be medicated with morphine, and kept comfortable at the Facility. The HCA said on 12/14/22, Resident #1 returned to the facility from the ED at approximately 2:00 P.M. and said a few hours later, his/her left leg dressing was saturated and needed to be changed. The HCA said Resident #1 received a Tylenol suppository, for pain, at approximately 3:30 P.M. and then nursing changed Resident #1's dressing, which was extensive, to his/her left leg. The HCA said she was holding Resident #1's leg up while the Hospice Nurse and Unit Manager changed the dressing and said the skin on Resident #1's left leg was dripping off his/her leg. The HCA said Resident #1 was fighting them to not touch his/her leg, moaning, and making faces exhibiting pain. The HCA said the Wound Physician was present for his/her dressing change and offered to have Resident #1 transferred back to the Hospital and, that she said no. The HCA said she wanted Resident #1 to remain in the Facility, and asked if he/she could be medicated with morphine and kept comfortable. The HCA said both the Wound Physician and Hospice Nurse said yes to her request. The HCA said on 12/14/22, after Resident #1 returned to the facility, she stayed with his/her the entire time and said she would frequently go out to his/her Nurse and ask where the morphine was. The HCA said the Nurse told her they were first waiting on the Physician, then waiting on an override secondary to his/her codeine allergy and then the Pyxis system malfunctioned. The HCA said nursing offered to administer Oxycodone to Resident #1 once, in lieu of the morphine, at approximately 8:30 P.M. The HCA said at that time she again asked how much longer would it be for the morphine to be delivered from the pharmacy, and said Nurse #1 told her the morphine should be delivered within an hour. The HCA said she was told by nursing that if Resident #1 were to get the Oxycodone at that time, he/she would not be able to receive the morphine once when it arrived from the pharmacy. The HCA said that she declined the offer to administer Resident #1 the Oxycodone, because she believed that morphine would be there soon. During an interview on 1/10/23 at 2:23 P.M., (and review of her Hospice Nursing Progress Note, dated 12/14/22), the Hospice Nurse said she was in the Facility when Resident #1 returned from the Hospital ED. The Hospice Nurse said she began the dressing change to his/her left lower extremity at 3:35 P.M. and completed the dressing change at 4:15 P.M. The Hospice Nurse said as soon as they began touching Resident #1's legs to change his/her dressings, Resident #1 began to grimace, moan, and yelled out in pain. The Hospice Nurse said she needed to remove the skin hanging off the back of Resident #1's left leg. The Hospice Nurse said Resident #1 exhibited long periods of hyperventilation (increased breathing rate), low level speech with negative or disapproving quality, facial grimacing, and tense body language. The Hospice Nurse said Resident #1's pain was assessed by using the Pain Assessment in Advanced Dementia Scale (PAINAD, pain assessment used when the resident is unable to verbally report their degree of pain) and that Resident #1's score indicated moderate pain as evidence by a score of six. The Hospice Nurse said she assessed Resident #1 during the dressing change to have a labored respiratory rate (RR) of 32 breaths per minute (normal rate 12-16 bpm) and a pulse of 78 beats per minute (Resident #1 average pulse noted to be 52 beats per minute) after completing his/her left lower extremity dressing. The Hospice Nurse said as soon as they were finished with his/her dressing change, she went to Nurse # 1 and told her that they needed to get an order for morphine right away. The Hospice Nurse said she told Nurse #1 that she could expedite the order and get it to the Facility quickly and that Nurse #1 said no, that they were already in the process of getting the order to obtain the morphine from the Emergency-Kit (E-Kit). The Hospice Nurse said she stayed with Resident #1 and the HCA for a bit of time and then left the Facility letting Nurse #1 know if she needed anything to call her for assistance. The Hospice Nurse said she attempted to speak to the DON, but she was told that the DON had left the Facility a couple of hours prior and said she did not hear from the Facility at all for the remained of the day. During an interview on 1/03/23 at 2:39 P.M., the Unit Manager said she was helping with the dressing change to Resident #1's left leg and said he/she definitely experienced pain while they were changing his/her left leg dressing. The Unit Manager said at approximately 4:30 P.M. she called Resident #1's Nurse Practitioner to expedite the prescription for his/her morphine. The Unit Manager said she did not know Resident #1 had not received any morphine until 11:24 P.M., and said that it was not right that Resident #1 was in pain all that time. During an interview on 1/09/23 at 12:08 P.M., Nurse #8 said on 12/14/22 the Director of Nursing (DON) happened to come to the facility that evening (around 7:00 P.M.) and told her to offer Resident #1 and his/her HCA a Tylenol suppository, however Resident #1's HCA declined. Nurse #8 said Resident #1 had already received a Tylenol suppository at 4:45 P.M. according to his/her Medication Administration Record (MAR) and it was too early to medicate him/her with Tylenol again at that time. Review of Resident #1's Nursing Progress Note, dated 12/14/22 (written by Nurse #1) indicated he/she appeared to be incoherent and lethargic throughout the shift and said fluid was seeping from his/her left leg. The Note further indicated Resident #1 appeared to be having difficulty breathing with his/her RR ranging from 38 bpm to 45 bpm and his/her oxygenation saturation (level of oxygen in the blood) was 89 percent (normal is 95-100 percent) on 2 liters of oxygen. During an interview on 1/03/23 at 4:40 P.M., the Director of Nurses (DON) said she saw Resident #1 the morning of 12/14/22, right before he/she was sent to the Hospital ED. The DON said she returned to the Facility sometime around 7:30 P.M. that night to assist with two other separate issues and said she overheard Nurse #1 still trying to get Resident #1's morphine, and that she (Nurse #1) was waiting for the on-call Physician to respond to the request. The DON said she attempted to retrieve the morphine from the facility's E-Kit but the Pyxis (automated dispensing machine) malfunctioned and the cubicle that the morphine was in, that access door did not pop open. The DON said she texted the Nurse Practitioner (NP) at 8:09 P.M. and informed her that there was no morphine in the E-Kit. The DON said the NP sent three prescriptions to the Pharmacy (one for morphine, one for ativan, and one for Oxycodone). The DON said that she did not consider the Pyxis malfunction as an emergency situation because Resident #1's HCA was offered Oxycodone, that the HCA declined, and opted to wait for the morphine to be delivered from the pharmacy. During an interview on 1/10/23 at 3:20 P.M., the Pharmacy Manager said the first prescription for morphine for Resident #1 that was received from the Facility came at 5:06 P.M., and it was for the morphine in the E-Kit. The Pharmacy Manager said no one from the Facility called to obtain the code to access the E-Kit at that time. The Pharmacy Manager said the next prescriptions that came into the Pharmacy from the Facility were at 8:24 P.M. and 8:26 P.M., and that a warning was sent back to the Facility identifying a possible drug interaction that required an override before the Pharmacy could fill the prescription for Resident #1's morphine. The Pharmacy Manager said at 9:24 P.M. the Facility called the pharmacy again and asked for Resident #1's morphine to be delivered and the facility called again at 10:05 P.M. or a stat (quickly) delivery. The Pharmacy Manager said on 12/14/22, there was no call placed from the facility to report a malfunction of the Pyxis system and said that there was no medications dispensed from the Pyxis system for Resident #1 that night. During an interview on 1/10/23 at 8:52 A.M., Nurse #2 said she received the morphine from the pharmacy and at 11:23 P.M., immediately medicated Resident #1 as ordered by the Physician. Nurse #2 said Resident #1 was pronounced dead on 12/15/23 at 1:00 A.M.

Based on observation, record review, and interview, the facility failed to ensure that an individualized, comprehensive care plan was developed and consistently implemented for one resident (#14), out of 23 sampled residents. Specifically, the facility failed to implement the Resident's care plan for the use of pillows to elevate the Resident's lower legs when in bed. Findings include: Review of the facility's policy, Care Plans-Comprehensive (undated), indicated the following: Each resident's comprehensive care plan is designed to: -Identify professional services that are responsible for each element of care -Aid in preventing or reducing declines in the resident's functional status and/or functional levels -Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. For Resident #14, the facility failed to ensure that the comprehensive care plan developed to address the Resident's skin integrity, was consistently implemented in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #14 was admitted to the facility in December 2009 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], indicated that Resident #14 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15, exhibited no behaviors, was dependent on staff for all activities of daily living, and was at risk for developing pressure ulcers. Review of March 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan for alteration in skin integrity related to ulceration to bilateral lower lateral legs, last revised on 2/2/21, indicated that Resident #14 was to have pillows under their legs when in bed. On 3/2/21 at 10:20 A.M., 3/3/21 at 12:10 P.M., 3/5/21 at 10:39 A.M., and 3/8/21 at 8:45 A.M., Resident #14 was observed sitting upright in bed with both legs lying directly on the mattress and not elevated with pillows as ordered by the physician and as care planned. During an interview on 3/8/21 at 9:40 A.M., Nurse #6 pulled the bed sheet off of Resident #14's legs and noted that his/her legs were not elevated with pillows. Nurse #6 said that pillows should be in place while the Resident is in bed. Nurse #6 retrieved a pillow and positioned it underneath the Resident's legs. On 3/9/21 at 11:05 A.M., Resident #14 was observed sitting upright in bed with both legs lying directly on the mattress and not elevated with pillows as ordered by the physician and indicated in the comprehensive care plan. During an interview on 3/9/21 at 11:11 A.M., the surveyor and Nurse #5 reviewed Resident #14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #5 confirmed that staff are supposed to ensure that the Resident's legs were elevated with a pillow while he/she is in bed.

Based on observation, interview, policy, and record review, the facility failed to evaluate comprehensive care plans for falls for effectiveness and revise as needed, for three residents (#1, #2, #22) with repeated falls resulting in major injury, out of a total sample of 23 residents. Findings include: Review of undated facility policy titled, Care Plans-Comprehensive, indicated the following: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set-comprehensive, standardized assessment of each resident's functional capabilities and health needs). 3. Each resident's comprehensive care plan is designed to a. Incorporate identified problem areas b. Incorporate risk factors associated with identified problems; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: b. When the desired outcome is not met; c. New issues arise 1. For Resident #1, facility staff failed to evaluate for effectiveness and revise the care plan for fall risk to prevent falls during a three month period, which resulted in this resident sustaining eight falls including three falls with injury. Review of the significant change Minimum Data Set (MDS), with a reference date of 2/28/21, indicated that Resident #1 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15, and was was totally dependent for bed mobility and required extensive assist with transfer and walking in the room and had sustained two or more falls since admission. The 11/19/20 Fall Risk Assessment indicated that Resident #1 was a high fall risk (score greater than 13). Review of the interdisciplinary care plan, initiated on 11/18/20, indicated Resident #1's fall risk was related to gait/balance problems, [CONDITION(S)] (CVA-stroke) with right sided weakness, and impulsiveness. The goal identified was that the Resident would be free of falls, not sustain serious injury, and would be free from minor injury through the review date. Interventions to achieve this goal included: -Anticipate and meet resident's needs, initiated 11/18/20 -Be sure call light is within reach and encourage him/her to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 11/18/20 -Ensure that he/she is wearing appropriate footwear when ambulating or mobilizing in wheelchair, initiated 11/18/20 -Offer toileting every two hours while awake, initiated 12/1/20 -Place items within reach, initiated 2/22/21 -PT evaluate and treat as ordered or prn (as needed), initiated 11/18/20 -Room change to be closer to nurse's station for easier supervision, initiated 11/22/20 -The resident needs to be evaluated for wheelchair positioning and a seating designed to prevent resident from falling forward, initiated 2/16/21, revised 2/22/21 -When OOB (out of bed) to sit near nurse's station in wheelchair, within view of staff, initiated 11/23/20 Resident #1 sustained eight falls in three months as follows: Review of the 11/19/20 fall Event/Incident Report indicated that at 12:13 P.M. Resident #1 was observed lying on the floor and said he/she slipped off the bed. The Nurse Practitioner (NP) was notified. There were no new orders or recommended interventions. Review of the 11/21/20 fall Event/Incident Report indicated that at 03:30 P.M. Resident #1 was found on the floor near the bed lying on his/her left side. No details regarding the fall were found in the nursing progress notes on the day of the fall. Recommended interventions included a room change to be closer to the nurse's station and to have the Resident sit near the nurse's station in a wheelchair in view when out of bed (OOB) (both added to the comprehensive care plan) and continue with PT/OT/SLP services. Review of the 11/24/20 fall Event/Incident Report indicated that at 05:07 P.M. the Resident was observed by staff in a supine (lying facing upward) position on the floor. The wheelchair was located a few feet away. The Resident was placed in the line of sight. The NP was notified and 15 minute checks were ordered while in bed for 24 hours. The Incident Report was not specific as to the location of the fall. Recommended interventions included assist for all mobility (not added to the comprehensive care plan). Nursing progress notes, dated 11/24/20, indicated that Resident #1 had made several attempts to get out of the chair. Review of the 11/27/20 fall Event/Incident Report indicated that at 12:30 A.M. a loud bang was heard from the Resident's room where he/she was found lying on the floor on his/her right side with a pool of blood under the right side of his/her head, complaining pain to his/her head. The On-call physician was notified and Resident #1 was transported to the emergency room (ER) and diagnosed with a 1 centimeter (cm) facial laceration of the right upper eye with one suture placed to close the wound. He/she was admitted to the hospital and returned to the facility on [DATE]. Newly recommended interventions included offering toileting every two hours when awake (not added to the comprehensive care plan). Review of the 12/27/20 fall Event/Incident Report indicated that at 11:36 P.M. a loud noise was heard and Resident #1 was found lying on his/her right side in the hallway outside of his/her door. His/her arms were flexed (bent) and a scant amount of blood was observed on his/her hand. The Resident also had abrasions on his/her bilateral knees, and two bite marks on his/her bottom right lip with a scant amount of bleeding. The on-call NP was notified. there were no new orders or recommended interventions. During an interview on 3/10/20 at 08:22 A.M., PT #1 said Resident #1 was currently on their caseload and was seen the same day prior to the fall. The Resident refused to participate. PT #1 said the Resident fell while trying to take herself to the toilet. He/she was evaluated on 12/28/20 with no new interventions. Review of the 1/14/21 fall Event/Incident Report indicated that at 11:34 A.M. Resident #1 was found on the floor with both of his/her legs folded underneath him/her. The Resident said he/she/ fell forward as he/she was trying to go from the wheelchair to his/her bed. The NP was notified and ordered neurological checks. A PT fall screen/referral form was completed four days later 1/18/21 with no new recommended interventions. During an interview on 3/10/21 at 08:25 A.M., PT #1 said Resident #1 was discharged from his/her rehabilitation services on the 1/11/21. She did not evaluate the Resident until the 18th because she was not made aware of the fall and said there were no new recommendations at that time. Review of the 1/26/21 fall Event/Incident Report indicated that at 10:41 P.M. Resident #1 was found on the floor parallel to the bed on his/her right side, facing the bed. The Resident said he/she was trying to do more than he/she did. The NP was notified and neurological checks ordered. A PT fall screen/referral form was not completed (no new recommended interventions). A Nursing progress note, dated 1/26/21, indicated that prior to the fall Resident #1 was sitting in the wheelchair in his/her room. the Fall risk care plan initiated 11/23/20 included an intervention that the Resident was to sit near the Nurses' station, within view of the staff, when out of bed. During an interview on 3/10/20 at 08:28 A.M., PT #1 said they were not made aware of this fall so the Resident was not evaluated. Review of the 2/14/21 fall Event/Incident Report indicated that at 02:31 P.M. Resident #1 was found lying face down in front of her wheelchair and bleeding from her nose in the hallway opposite her room. The NP was notified and ordered the Resident to be monitored and notify her of any changes. The next morning the Resident was observed with facial bruising and swelling and a portable x-ray was taken which indicated an acute nasal bone fracture. Resident #1 was transported to a local hospital for evaluation and treatment and returned to the facility the same day. A facial Ct Scan indicated minimally displaced bilateral nasal bone fractures and left facial soft tissue swelling. Physical therapy evaluated the Resident on 2/17/21, three days after the fall with fracture. Recommended interventions included to evaluate and assess wheelchair positioning and needs (added to the comprehensive care plan), Occupational Therapy (OT) to conduct a vision assessment and depth perception testing (not added to the comprehensive care plan) and a psych evaluation to review and adjust medications as needed to decrease agitation (added to the comprehensive care plan), and items to be placed within reach of the Resident (not added to the comprehensive care plan until 2/22/21). During an interview on 3/10/21 at 08:29 A.M., PT #1 said all three therapies, Physical, Occupational, and Speech, resumed services for Resident #1 after this fall. She said the wheelchair was changed to a scoop or wedge wheelchair which is at a bit of a slant backwards so it wouldn't be so easy for the Resident to fall face forward. On 3/2/21 at 11:14 A.M., the surveyor observed Resident #1 sitting up in bed with bilateral periorbital, nasal, and bilateral cheek ecchymosis (discoloration of the skin, bruising). On 3/8/21 at 08:26 A.M., Resident #1 was observed sitting up in bed eating breakfast. The call bell was not within reach and was hanging from the wall behind the bed resting on the floor. On 3/9/21 at 09:25 A.M. and 3/10/21 at 10:00 A.M., the surveyor observed the Resident's call bell which was not within reach and was hanging from the wall behind the resident's bed resting on the floor. The Administrator said she would look to see if they had any fall risk meetings regarding Resident #1 and provide prior to survey exit if found (no completed documentation provided). 2. For Resident #2, facility staff failed to evaluate the care plan for fall risk for effectiveness and revise as needed to prevent falls during a three month period which resulted in the Resident sustaining three falls including one with injury. Resident #2 was admitted to the facility in November of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS, with a reference date of 2/25/21, indicated that Resident #2 was unable to complete the BIMS as evidenced by a score of 99, and required limited assist with transfer, extensive assist with walking, was independent with bed mobility, and is rarely/never understood and rarely/never understands others. Review of Resident #2's Admission Fall Morse Scale, dated 11/17/19, indicated a score of 90.0 (high risk of falling) and the MDS Quarterly Fall Risk Assessment, dated 2/11/20, indicated the Resident was a high risk for falls (score greater than 13). Review of Resident #2's Baseline Care Plan, dated 11/18/19, indicated the following: Nursing: Initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the interdisciplinary care plan, initiated 11/9/20, indicated that Resident #2's fall risk was related to an actual fall with fracture to the right femur. The goal identified was that the Resident would resume usual activities without further incident through the review date. Interventions to achieve this goal included: -Continue interventions on the at-risk plan, call light within reach, initiated 11/9/20, revised 11/11/20 -Medications to assist with pain control, initiated 11/17/20, revised 11/18/20 -Nursing to assist with toileting/offer assist every 2 hours while awake, initiated 11/10/20 -Nursing to offer and assist with toileting every two hours while awake. Foley cath every shift, initiated 11/20/20 -Pharmacy consult to evaluate medications, initiated 11/18/19 -Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bed bound, initiated 11/18/20 -PT consult for strength and mobility, initiated 11/9/20, revised 11/11/20 -Side rails in place as ordered to promote bed mobility, initiated 1/23/20 Review of the 11/9/20 fall Event/Incident Report indicated that at 4:02 P.M. Resident #2 was found lying on the floor in the doorway to the bathroom. X-rays of the right hip and lumbar spine were negative. On 11/11/20 licensed staff noted swelling of the right thigh with tenderness. The NP was notified and ordered pain medication and x-rays which showed an acute distal femur fracture. The Resident was transported to the ER for further evaluation and treatment which required surgical intervention including right femur removal of hardware and right femoral retrograde nail. Resident #2 returned to the facility on [DATE]. There were no fall risk interventions implemented on the comprehensive care plan prior to the first fall despite the Resident's baseline care plan on 11/18/19 indicating that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommended interventions included a physical therapy evaluation (added to the comprehensive care plan), and nursing to offer assistance with toileting every two hours if tolerated while awake (added to the comprehensive care plan). The LNA (Licensed Nursing Assistant) Care Card, however, did not include the recommended toileting intervention until 12/16/20, over a month later. Certified Nursing Assistants use the care cards to provide necessary care to the residents. During an interview on 3/9/21 at 02:01 P.M., the Administrator and MDS Coordinator said the 11/10/20 toileting recommendation should have been updated on the LNA Care Card. Review of the 12/11/20 fall Event/Incident Report indicated that at 09:35 P.M. Resident #2 was found sitting on the floor next to her bed. No new recommended interventions. The Nurse progress notes, dated 12/11/20, indicated the Resident was loud and yelling out with an attempt x1 to get out of bed to use the commode. During an interview on 3/9/21 at 11:52 A.M., PT #1 said Resident #2 if she had seen the Resident that day or evaluated the Resident for the fall, it would be in her progress notes though said she did not have them and they were not found in the Resident's chart. She said if they were alerted to the fall, recommendations would have been implemented. During an interview on 3/9/21 at 02:52 P.M., PT #1 said she was unable to locate any progress notes or evaluation after the 12/11/20 fall. During an interview on 3/10/21 at 10:18 A.M., CNA #8 said Resident #2's LNA Care Card and the ADL card she documents on did not include the recommended intervention to offer toileting every two hours while awake. Review of the 1/30/21 fall Event/Incident Report indicated that at 10:48 A.M. Resident #2 was observed sitting on the floor next to his/her bed. A post fall PT Screen/Referral form or evaluation were not located. There were no new recommended interventions. Nursing progress notes, dated 1/30/21, indicated that in the morning prior to the fall Resident #2 was yelling out on and off through the shift. During an interview on 3/9/21 at 12:00 P.M., PT #1 said she was not made aware of the fall and the Resident should have had a PT evaluation, but didn't. She said the Resident was not receiving services at the time and no new recommendations were carried over to the comprehensive care plan. On 3/8/21 at 08:21 A.M., the surveyor observed the Resident lying down in bed. Resident #2's call bell was seen tied to the right side rail and resting on the ground, not within the Resident's reach On 3/9/21 at 09:20 A.M., the surveyor observed the Resident sleeping upright in bed with the call bell located on the floor. On 3/10/21 at 09:56 A.M., the surveyor observed the Resident's call bell on the floor. 3. For Resident #22, facility staff failed to evaluate for effectiveness and revise the care plan for fall risk to prevent falls during a one month period which resulted in this Resident sustaining two falls including one with injury. Resident #22 was admitted to the facility in February of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), with a reference date of 12/31/19, indicated that Resident #22 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15, and was totally dependent for bed mobility, toileting, and bathing. Review of Resident #22's quarterly Fall Risk Assessment form, dated 1/1/21, did not accurately reflect the Resident's risk for falls as the total indicated a moderate risk (6-13 points) whereas the correct total would have indicated a high risk (greater than 13). The form also indicated that the Resident did not have a fall within 6 months of admission, but did per the 2/9/18 admission MDS which would have added 5 points to his/her score. During an interview on 3/9/21 at 07:21 A.M., the Administrator said the score was wrong and indicated a moderate risk of falls, but should have reflected a high risk for falls and the form should have included the Resident's fall from within one month of admission. Review of the interdisciplinary care plan indicated Resident #22's fall risk was related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal identified was that the resident would be free of falls through the next review date. Interventions to achieve this goal included: -Bolsters to bilateral sides of bottom bed to define periphery of bed/mattress, initiated 3/4/21, revised 3/4/21 -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 2/3/18 -Ensure that the resident is wearing appropriate footwear, initiated 2/3/18, revised 10/30/18 -Incontinent care/check and offer bedpan every two hours while awake, initiated 3/3/21 -Med review by NP with a focus on bowel medication plan of care, initiated 3/3/21 -Rehab screen s/p fall, initiated 3/3/21 -The resident needs activities that minimize the potential for falls while providing diversion and distraction such as Bingo, initiated 2/3/18, revised 10/30/18 Review of the 2/16/21 fall Event/Incident Report indicated that at 06:55 A.M., Resident #22 was observed sitting on the floor next to his/her wheelchair in the dayroom after staff stepped out to use the bathroom. Prior to the fall, the Resident was found sitting at the edge of his/her bed and brought out to the dayroom. No newly recommended interventions were added to the comprehensive care plan. During an interview on 3/4/21 at 04:00 P.M., the Administrator said the care plan should be updated after a fall once the rehab assessment is done and the team meets. She said there were no revisions since 2018 including no revisions documented on the care plan after the 2/16/21 fall or a summary with follow up interventions. She said she would expect to see some. Review of the 3/3/21 fall Event/Incident Report indicated that at 09:49 P.M., Resident #22 was observed on the floor lying on her right side, parallel to the bed with his/her head at the foot of the bed resting next to the closet. Injuries observed at the time of the incident included a bruise on the front of the right lower leg and a hematoma on the top of the Resident's scalp. The NP was notified and ordered a cold pack to the hematoma and wound dressing as needed. Nursing reported trying bolsters (a long, thick pillow that is placed for support) (added to comprehensive care plan). During an interview on 3/4/21 at 04:00 P.M., the Administrator said the care plan is part of the process and follow up recommendations are there. On 3/4/21 at 08:17 A.M., the surveyor observed Resident #22 with a large ecchymotic area on the left forehead and a small area underneath his/her left eye. Dried blood was noted on the left upper scalp, and down the left cheek and neck. The Resident asked Am I purple? and I got something that hurts, but was unable to recall the events. He/she said Maybe I fell . On 3/9/21 at 09:32 A.M., the surveyor observed the Resident's call bell hanging from the back wall out of reach and resting on the floor. During an interview on 3/4/21 at 11:06 A.M., UM #2 said there had been no talk of a room change up to that point that he was aware of for behavioral or fall concerns though said since it was his/her second fall in a month that it would probably be a good idea. He said the resident tried to get up and walk and fell .

Based on observation, interview, policy and record review, the Facility staff failed to ensure that residents were provided adequate supervision to prevent accidents for five residents (#1, #2, #22, #14, #40), out of a total sample of 23 residents. Findings include: Review of undated facility policy titled, Unusual Occurrence Incidents/Accidents, indicated the following: - The nurse will then document their investigation as well as recommendations for preventive measures on the investigation sheets (i.e. padded side rails, staff in-service in resident transfer). The Director of Nursing will review all investigations and recommendations. - The incident/accident will be charted in the resident's medical record to include: a. Detailed account of the incident b. Time the physician was notified c. Time the family was notified-name/relationship d. Time the supervisor/DON was notified (if applicable) e. Disposition of the resident (if applicable) g. Other pertinent observations - A summary of the report will be completed and reviewed by the Incident/Accident Committee to follow-up on recommendations and to identify trends. Incident and Accident Follow up Check list: -Complete Incident Report -Notify Family/Responsible party -Notify Physician -Obtain/carry out MD orders -Complete fall assessment -Statements from staff/resident -Follow up investigation -Care plan/L.N.A care (Licensed Nursing Assistant) card/plan of care updated Review of the facility policy titled, Fall Prevention, dated 2/1/19, indicated the following: Policy: -A fall prevention plan will be initiated on all residents who are at high risk for falling. Each resident will be assessed for risk factors and predisposition for falling. In the event that a fall occurs, a post fall evaluation will be conducted to determine the factors contributing to the fall and to develop a plan of action to prevent further falls. Purpose: -To maintain a safe environment in order to prevent falls and injuries related to falls. Procedure: - Interventions will be documented on the residents fall care plan. - When a resident sustains a fall, assessment will include an investigation to determine probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestation, and medical or assistive devices that may be implicated in the fall. The investigation will be initiated at the time of the fall and reviewed by Nursing Management following the next business day and also at the next weekly clinical rounds meeting. The attending physician and family/responsible party are notified of the fall and the resident's status. - Evaluate why the resident may have fallen and complete the Incident/Accident Report. - The licensed nurse completing the Incident report will obtain statements from the staff using the Witness Account Statement Form. - Identify and implement all new interventions following a fall. - All residents at high risk will have an individualized care plan with intervention specific to individual, tailored to their needs. Review of facility document titled, Fall Management, dated 6/1/19, indicated the following: Practice Guidelines: - Resident Assessment: - Interventions will be documented in the Nursing Notes. - Therapy will screen the resident as indicated. - A resident fall is considered an incident and the Incident and Accident procedure will be followed. - Care Planning: - Residents with a Falls Risk Assessment score of 10 or above will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls and will consider the particular elements of the assessment that puts the resident at risk. The care plan for a resident assessed as at risk for falls will be developed at the time the risk is identified with ongoing evaluation and revisions documented. A. Resident #1 was admitted to the facility in November of 2020 with diagnoses including right [CONDITION(S)] (paralysis on one side of the body) due to [CONDITION(S)] Accident (stroke), history of falls, and muscle weakness. Review of the significant change Minimum Data Set (MDS), with a reference date of 2/28/21, indicated that Resident #1 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15, and was totally dependent for bed mobility and extensive assist with transfer and walking in the room. Review of Resident #1's Comprehensive Care Plan related to falls, initiated 11/18/20, indicated the following interventions: -Anticipate and meet resident's needs, initiated 11/18/20, revised 11/18/20 -Be sure call light is within reach and encourage him/her to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 11/18/20, revised 11/18/20 -Ensure that he/she is wearing appropriate footwear when ambulating or mobilizing in wheelchair, initiated 11/18/20, revised 11/18/20 -Offer toileting every two hours while awake, initiated 12/1/20 -Place items within reach, initiated 2/22/21 -PT evaluate and treat as ordered or prn (as needed), initiated 11/18/20 -Room change to be closer to nurse's station for easier supervision, initiated 11/22/20 -The resident needs to be evaluated for wheelchair positioning and a seating designed to prevent resident from falling forward, initiated 2/16/21, revised 2/22/21 -When OOB (out of bed) to sit near nurse's station in wheelchair, within view of staff, initiated 11/23/20 Review of the clinical record indicated the following eight incidents/falls: 1. Review of the 11/19/20 fall Event/Incident Report indicated that at 12:13 P.M. Resident #1 was observed lying on the floor and said he/she slipped off the bed. The Incident Report was incomplete with blanks. There was no documentation found that the supervisor/Director of Nurses (DON) was notified and there were no statements from staff. During an interview on 3/10/21 at 08:09 A.M., Physical Therapist (PT) #1 said the Resident was already on her case load for a history of CVA with right sided weakness and had a lack of awareness due to her deficit. During an interview on 3/10/21 at 09:12 A.M., the Administrator and Minimum Data Set (MDS) Coordinator said the expectation was for the Incident Reports to be completed without blanks. 2. Review of the 11/21/20 fall Event/Incident Report indicated that at 03:30 P.M. Resident #1 was found on the floor near the bed lying on his/her left side. The Incident Report was incomplete with blanks. There was no time documented for when the family and supervisor/DON were notified. Recommended interventions included a room change to be closer to the nurse's station and to have the Resident sit near the nurse's station in a wheelchair in view when out of bed (OOB) (both added to the comprehensive care plan) and continue with rehabilitation services. 3. Review of the 11/24/20 fall Event/Incident Report indicated that at 05:07 P.M. the Resident was observed by staff in a supine (lying facing upward) position on the floor. The wheelchair was located a few feet away. The Resident was placed in the line of sight. The Incident Report was not specific as to the location of the fall. The Incident Report was incomplete with blanks and no documentation was found that the supervisor/DON were notified. Recommended interventions included assist for all mobility (not added to the comprehensive care plan) During an interview on 3/10/20 at 08:14 A.M., PT #1 said she had seen Resident #1 the same day prior to the fall as he/she was on their current caseload. She said the Resident was agitated and wanted to go home. 4. Review of the 11/27/20 fall Event/Incident Report indicated that at 12:30 A.M. a loud bang was heard from the Resident's room where he/she was observed lying on the floor on his/her right side with a pool of blood under the right side of his/her head complaining pain to his/her head. Resident #1 was transported to the emergency room (ER) and diagnosed with a 1 centimeter (cm) facial laceration of the right upper eye with one suture placed and a head injury. He/she was admitted to the hospital and returned to the facility on [DATE]. The Incident Report was incomplete with blanks and stated no injuries were observed at the time of the incident. No documentation was found that the supervisor/DON were notified. Recommended interventions included offering toileting every two hours when awake (not added to the comprehensive care plan) and continue with short-term rehabilitation (already listed as an intervention on the comprehensive care plan). During an interview on 3/10/20 at 08:18 A.M., PT #1 said Resident #1 was receiving ongoing therapy and was bed to wheelchair with limited assist. She said there were no new physical therapy recommendations after this fall. During an interview on 3/10/21 at 09:30 A.M., the Administrator and MDS Coordinator said said there were no injuries listed on the Incident Report, but there should have been and the new toileting intervention was not implemented as recommended until a later date. During an interview on 3/10/21 at 10:10 A.M., CNA #8 said to find fall risk interventions she would ask a nurse or look at the care card. She was unsure of fall risk interventions for the Resident and went to ask UM #2. Upon review of the care card, CNA #8 said the only interventions listed for falls is that the Resident was a fall risk. She was unable to locate offering the Resident toileting every two hours when awake and said she had not been doing this. 5. Review of the 12/27/20 fall Event/Incident Report indicated that at 11:36 P.M. a loud noise was heard and Resident #1 was found lying on his/her right side in the hallway outside of his/her door. His/her arms were flexed (bent) and a scant amount of blood was observed on his/her hand. The Resident also had abrasions on his/her bilateral knees, and two bite marks on his/her bottom right lip with a scant amount of bleeding. No documentation was found that the supervisor/DON were notified of the incident. Recommended interventions included continuing with therapy services (already listed on the comprehensive care plan). No new interventions were added to the care plan. During an interview on 3/10/20 at 08:22 A.M., PT #1 said Resident #1 fell while trying to take herself to the toilet. He/she was evaluated on 12/28/20 and the recommendation was to continue therapy and no new interventions. 6. Review of the 1/14/21 fall Event/Incident Report indicated that at 11:34 A.M. Resident #1 was found on the floor with both of her legs folded underneath her. The Resident said he/she fell forward as he/she was trying to go from the wheelchair to his/her bed. The Incident Report was incomplete and the immediate actions taken section was left blank. A PT fall screen/referral form was completed four days later on 1/18/21 (no new recommended interventions). No new interventions were added to the care plan. 7. Review of the 1/26/21 fall Event/Incident Report indicated that at 10:41 P.M. Resident #1 was found on the floor parallel to the bed on his/her right side, facing the bed. A PT fall screen/referral form was not completed. No new interventions were added to the care plan. During an interview on 3/10/20 at 08:28 A.M., PT #1 said they were not made aware of this fall so the Resident was not evaluated. During an interview on 3/10/21 at 09:41 A.M., the Administrator and MDS Coordinator said they had no idea why physical therapy was not notified of the fall. 8. Review of the 2/14/21 fall Event/Incident Report indicated that at 02:31 P.M. Resident #1 was found lying face down in front of her wheelchair and bleeding from her nose in the hallway opposite her room. The next morning the Resident was observed with facial bruising and swelling and a portable x-ray was taken which indicated an acute nasal bone fracture. Resident #1 was transported to a local hospital for evaluation and treatment and returned to the facility the same day. Facial CT indicated minimally displaced bilateral nasal bone fractures and left facial soft tissue swelling. Physical therapy evaluated the Resident on 2/17/21, three days after. Recommended interventions included to evaluate and assess wheelchair positioning and needs (added to the comprehensive care plan), Occupational Therapy (OT) to conduct a vision assessment and depth perception testing (not added to the comprehensive care plan) and a psych evaluation to review and adjust medications as needed to decrease agitation (added to the comprehensive care plan), and items to be placed within reach (not added to the comprehensive care plan until 2/22/21). During an interview on 3/10/21 at 08:29 A.M., PT #1 said the wheelchair was changed to a scoop or wedge wheelchair which is at a bit of a slant backwards so it wouldn't be so easy for the Resident to fall face forward. During an interview on 3/8/21 at 09:01 A.M., MDS Coordinator said she filled out Resident #1's LNA Care Card last November and that under safety, there is a risk for falls, but no interventions were written because the Resident's interventions were not out of the ordinary. She said nothing was defined for the Resident. She also said the LNA Care Card was not updated in regards to what type of assist was needed for Activities of Daily Living (ADL's) including bathing, grooming, bed mobility, and dressing. During an interview on 3/10/21 at 09:43 A.M., the MDS Coordinator looked at the Resident's Licensed Nursing Assistant (LNA) care card again with the surveyor and said she would expect to see fall risk interventions on the card, but there were none. The Administrator said she would look to see if they had any fall risk meetings documented for the Resident and provide prior to exit if found (no completed documentation provided). The facility staff failed to provide adequate supervision and create an environment free from accident hazards to prevent falls during a three month period which resulted in the resident sustaining eight falls including three with injury. B. Resident #2 was admitted to the facility in November of 2019 with diagnoses including dementia, a history of falls, polymyalgia rheumatica (inflammatory muscle disorder), [CONDITION(S)], [CONDITION(S)] in the right eye category 3, and a left artificial hip joint. Review of the quarterly MDS, with a reference date of 2/25/21, indicated that Resident #2 was unable to complete the BIMS as evidenced by a score of 99, and required limited assist with transfer, extensive assist with walking, was independent with bed mobility, and is rarely/never understood and rarely/never understands others. Review of Resident #2's Admission Fall Morse Scale, dated 11/17/19, and the MDS Quarterly Fall Risk Assessment, dated 2/11/20, indicated the Resident was a high risk for falls. Review of Resident #2's Baseline Care Plan, dated 11/18/19, indicated the following: Nursing: Initial goals based on Admission orders: Safety due to history of falls Resident Primary Diagnosis: Left hip fracture, falls Review of Resident #2's Comprehensive Care Plan, initiated 11/09/20, indicated the following interventions for has had an actual fall with fracture right femur: -Continue interventions on the at-risk plan, call light within reach, initiated 11/9/20, revised 11/11/20 -Medications to assist with pain control, initiated 11/17/20, revised 11/18/20 -Nursing to assist with toileting/offer assist every 2 hours while awake, initiated 11/10/20 -Nursing to offer and assist with toileting every two hours while awake. Foley cath every shift, initiated 11/20/20 -Pharmacy consult to evaluate medications, initiated 11/18/19 -Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bed bound, initiated 11/18/20 -PT consult for strength and mobility, initiated 11/9/20, revised 11/11/20 -Side rails in place as ordered to promote bed mobility, initiated 1/23/20 Review of the clinical record indicated the following three incidents/falls: 1. Review of the 11/9/20 fall Event/Incident Report indicated that at 4:02 P.M. Resident #2 was found lying on the floor in the doorway to the bathroom. X-rays of the right hip and lumbar spine were negative. On 11/11/20 licensed staff noted swelling of the right thigh with tenderness. The MD was notified and x-rays showed an acute distal femur fracture. The Resident was transported to the ER for further evaluation and treatment which required surgical intervention including right femur removal of hardware and right femoral retrograde nail. Resident #2 returned to the facility on [DATE]. The Incident Report was incomplete with blanks. There were no fall risk interventions implemented on the comprehensive care plan prior to the first fall despite the Resident's baseline care plan on 11/18/19 indicating that the Resident had a history of falls and left hip fracture as well as the 11/17/19 Admission Fall Morse Scale and the 2/11/21 Quarterly Fall Risk Assessment which indicated that the Resident was a high risk for falls. Recommended interventions included a physical therapy evaluation (added to the comprehensive care plan), and nursing to offer assistance with toileting every 2 hours if tolerated while awake (added to the comprehensive care plan). The LNA Care Card, however, did not include the recommended toileting intervention until 12/16/20, over a month later. During an interview on 3/9/21 at 02:01 P.M., the Administrator and MDS Coordinator said the 11/10/20 toileting recommendation should have been updated on the LNA Care Card. 2. Review of the 12/11/20 fall Event/Incident Report indicated that at 09:35 P.M. Resident #2 was found sitting on the floor next to her bed. No documentation was found indicating a PT Screen/Referral form was completed or that the Resident was evaluated. During an interview on 3/9/21 at 11:52 A.M., PT #1 said Resident #2 was actively on their caseload and receiving therapy. If she had seen the Resident that day or evaluated the resident for the fall, it would be in her progress notes though said she did not have them and they were not found in the Resident's chart. She said if they were alerted to the fall, recommendations would have been implemented. During an interview on 3/9/21 at 02:52 P.M., PT #1 said she was unable to locate any progress notes or evaluation after the 12/11/20 fall. During an interview on 3/10/21 at 10:18 A.M., CNA #8 said Resident #2's LNA Care Card and the ADL card she documents on did not include the recommendation to offer toileting every two hours while awake. 3. Review of the 1/30/21 fall Event/Incident Report indicated that at 10:48 A.M., Resident #2 was observed sitting on the floor next to his/her bed. There were no written statements by the staff. A PT Screen/Referral form or an evaluation were not located. No new interventions were implemented. During an interview on 3/9/21 at 12:00 P.M., PT #1 said she was not made aware of the fall and the Resident should have had a PT evaluation, but didn't. She said the Resident was not receiving services at the time and no new recommendations were carried over to the comprehensive care plan or LNA Care Card. During an interview on 3/8/21 at 09:11 A.M., the MDS Coordinator reviewed Resident #2's LNA Care Card and said it was not updated to reflect the Resident's current ADL status and the only intervention listed for falls was toileting, which wasn't initiated until 12/16/20. During an interview on 3/9/21 at 02:23 P.M., the Administrator and MDS Coordinator verified there were no written staff statements and no new recommended interventions implemented. On 3/8/21 at 08:21 A.M., the surveyor observed the Resident lying down in bed and the call bell was seen tied to the right side rail and resting on the ground. On 3/9/21 at 09:20 A.M., the surveyor observed the Resident sleeping upright in bed with the call bell located on the floor. On 3/10/21 at 09:56 A.M., the surveyor observed the resident's call bell on the floor. The facility failed to provide adequate supervision and create an environment free from accident hazards to prevent falls during a three month period which resulted in this resident sustaining three falls including one with injury. C. Resident #22 diagnoses include vascular dementia, muscle weakness, and a history of falls. Review of the quarterly Minimum Data Set (MDS), with a reference date of 12/31/20, indicated that Resident #22 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15, and was totally dependent for bed mobility, toileting, and bathing. Review of Resident #22's quarterly Fall Risk Assessment form, dated 1/1/21, did not accurately reflect the Resident's risk for falls as the total indicated a moderate risk (6-13 points) whereas the correct total would have indicated a high risk (greater than 13). The form also indicated that the Resident did not have a fall within 6 months of admission, but did per the 2/9/18 admission MDS which would have added 5 points to his/her score. During an interview on 3/9/21 at 07:21 A.M., the Administrator said the score was wrong and indicated a moderate risk of falls, but should have reflected a high risk for falls and the form should have included the Resident's fall from within one month of admission. Review of Resident #22's Comprehensive Care Plan related to falls, initiated 03/03/18, indicated the following interventions: -Bolsters to bilateral sides of bottom bed to define periphery of bed/mattress, initiated 3/4/21, revised 3/4/21 -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 2/3/18 -Ensure that the resident is wearing appropriate footwear, initiated 2/3/18, revised 10/30/18 -Incontinent care/check and offer bedpan every two hours while awake, initiated 3/3/21 -Med review by NP with a focus on bowel medication plan of care, initiated 3/3/21 -Rehab screen s/p fall, initiated 3/3/21 1. Review of the 2/16/21 fall Event/Incident Report indicated that at 06:55 A.M., Resident #22 was observed sitting on the floor next to his/her wheelchair in the dayroom after staff stepped out to use the bathroom. Immediate action included placing the resident by the nurse's station for closer monitoring. The IR( incident report) was incomplete with blanks and no staff statements were located. A PT Screen/Referral Form was completed on 2/17/21 (no new recommended interventions). During an interview on 3/4/21 at 04:00 P.M., the Administrator said the care plan should be updated after a fall once the rehab assessment is done and the team meets. She said there were no revisions since 2018 including no revisions documented on the care plan after the 2/16/21 fall or a summary with follow up interventions. She said she would expect to see some. She said there weren't any statements from staff. 2. Review of the 3/3/21 fall Event/Incident Report indicated that at 09:49 P.M., Resident #22 was observed on the floor lying on her right side, parallel to the bed with his/her head at the foot of the bed resting next to the closet. Injuries observed at the time of the incident included a bruise on the front of the right lower leg and a hematoma on the top of the Resident's scalp. Injuries reported post incident were documented as none. A PT Screen/Referral Form was completed on 3/4/21 (no new recommended interventions). Nursing reported trying bolsters (a long, thick pillow that is placed for support) (added to comprehensive care plan). During an interview on 3/4/21 at 04:00 P.M., the Administrator said the care plan is part of the process and follow up recommendations are there. She said she wasn't sure why the IR did not document post incident injuries. On 3/4/21 at 08:17 A.M., the surveyor observed Resident #22 with a large ecchymotic area on the left forehead and a small area underneath his/her left eye. Dried blood was noted on the left upper scalp, and down the left cheek and neck. The Resident asked Am I purple? and I got something that hurts, but was unable to recall the events. He/she said Maybe I fell . On 3/9/21 at 09:32 A.M., the surveyor observed the resident's call bell hanging from the back wall out of reach and resting on the floor and not in reach of the Resident. During an interview on 3/4/21 at 11:06 A.M., UM #2 said there had been no talk of a room change that he was aware of for behavioral or fall concerns but said since it was his/her second fall in a month that it would probably be a good idea. He said the Resident tried to get up and walk and fell . The facility failed to provide adequate supervision and create an environment free from accident hazards to prevent falls which resulted in this Resident sustaining two falls including one with injury. D. For Resident #40, the facility staff failed to provide an environment free of accidents and hazards related to a medication left on an unsupervised medication cart. Resident #40 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. On 3/2/21 at 10:55 A.M., the surveyor observed Resident #40 wandering the second-floor unit. He/she stopped at a medication cart and touched cups and other non-medication items. Review of a Nurse's Note dated, 3/4/21, indicated Resident #40 had touched and taken things from the medication cart, and that interventions were attempted with no effect. Review of Nurses' Notes, dated 3/5/21 and 3/7/21, indicated Resident #40 had intrusive behaviors involving the medication cart. On 3/10/21 at 9:22 A.M., the surveyor observed Resident #40 standing next to an unattended medication cart in the second floor hallway. There was a cup of pink, thick liquid with a spoon in it, on top of the medication cart. On 3/10/21 at 9:25 A.M., the surveyor observed the Activities Director direct Resident #40 away from the unattended medication cart. On 3/10/21 at 9:27 A.M., Nurse #7 returned to the medication cart. During an interview on 3/10/21 at 9:27 A.M., Nurse #7 said she left a cup of [MEDICATION(S)] (laxative) out on the unattended medication cart . Nurse #7 said, medications should not be left out on the medication cart, but if you can explain to me how to multitask, I would appreciate it.

Based on record review and interview the Facility staff failed to maintain nutritional status and monitor to avoid unplanned weight loss for 1 Resident (#99) from a total sample of 20 Residents. Findings include: Review of the Facility's Weight Assessment and Intervention policy revision date of 9/2008, indicated that: - any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation - if weight is verified, nursing will immediately notify the dietician -the dietician will review the unit weight record by the 15th of the month to follow individual weight trends over time -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5 is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Resident #99 was admitted to the Facility in 7/2011 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS, with a reference date of 4/4/19, indicated that Resident #99 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 3 out of 15, and was independent with eating with no help or staff oversight at any time. Review of physician's orders [REDACTED]. -weekly weights every Monday (initiated 3/2/18) -[MEDICATION NAME] 15 mg (milligrams) at bedtime for appetite stimulant (initiated 1/28/19) Review of the care plan nutrition (initiated 9/8/18), indicated the following: Focus - Resident had an alteration in nutrition as evidenced by chewing difficulty-prefers not to wear new dentures - Resident with teeth extractions 11/29/18 - weight loss related to decreased intake and refusal of some foods (4/18/19) Goal -Resident would tolerate a least restrictive diet consistency -weights of 107 lbs (pounds) +/- 3 lbs by next review (target date 7/7/19). Interventions -House, ground/mechanically soft with extra gravy - snacks/supplements as desired - medication, weights, labs as ordered - offer snacks - Nurse Practitioner aware, no new interventions, expected decline (initiated 9/8/18, revised 4/18/19) On 4/18/19 at 8:45 A.M., Resident #99 was observed seated in a chair in his/her room with a breakfast tray on an overbed table in front of him/her. The Resident was observed staring at the tray which included 2 cups of coffee, eggs, muffin, hot cereal, juice, and a cup of ice cream. The Resident said that he/she did not want to eat. On 4/19/19 at 8:50 A.M., Resident #99 was observed seated in a chair in his/her room with a breakfast tray on an overbed table in front of him/her. The Resident was observed staring at the tray which included eggs, muffin, ice cream cup, cup of chocolate pudding, 2 cups of coffee, and juice. The Resident said that the staff want him/her to eat more, but he/she doesn't want to because there was too much food and it was overwhelming. The Resident said that he/she had told staff that there was too much food on the tray. On 4/22/19 at 12:05 P.M., Resident #99 was observed seated in a chair in his/her room with a lunch tray on an overbed table in front of him/her. The lunch tray had a plate with meat, gravy, carrots, mashed potatoes, a slice of pie, cup of chocolate pudding, cup of vanilla/chocolate ice cream, small can of ginger ale, and coffee. The Resident said that there was too much food in front of him/her and it was overwhelming. Review of Resident #99's weight record indicated a 7% weight loss in 1 month as follows: 3/25/19=107 4/1/19=107.5 4/8/19=107 4/15/19=103 4/19/19=102.5 4/22/19=99.5 The Resident's weight loss noted on 4/22/19 indicated a significant weight loss of 7% in one month. The medical record failed to indicate that the Dietician was notified of the significant weight loss immediately according to facility policy. On 4/23/19 at 12:02 P.M., Resident #99 was observed seated in a chair in his/her room with a lunch tray on an over bed table in front of him/her. The tray included a plate with a large serving of pasta with ground meat on top ((which covered 3/4 of the plate),a scoop of mashed potatoes, broccoli, pineapple, cup of chocolate pudding, ice cream, cup of soda, apple juice, and coffee. Resident #99 said that he/she loved potatoes and could eat potatoes all day long. The Resident said that he/she wished the portions were smaller because there was too much food in front of him/her, and it was overwhelming. During interview with the Facility's consultant dietician on 4/24/19 at 10:02 A.M., she said that she was not aware of Resident #99's recent weight loss from 103 lbs to 99.5 lbs. She said that she usually prints a weight report on every Resident on Tuesdays, however, she did not know that Resident #99 had weight loss of 3.5 lbs in the past 7 days. The Surveyor shared with the dietician observations and interviews with Resident #99 during the survey period in which the Resident expressed that he/she was overwhelmed with the large amount of food provided at each meal. The dietician said that she was aware that the Resident was overwhelmed with the quantity of food served at each meal and really couldn't eat it, but figured it was better for the Resident to have it on the tray than not to. The facility failed to review and revise the care plan and approaches in order to provide a plan of care that took into consideration the Resident's choice and preferences to meet the Resident's needs and avoid unplanned significant weight loss.

Based on interview, observations and record review, the Facility staff failed to ensure that adequate supervision was provided to prevent avoidable accidents for 1 Resident (#65), in a total sample of 20 Residents. Findings include: 1. For Resident #65, the Facility staff failed to ensure that the Resident's environment was free from accident hazards, and facility staff failed to provide adequate interventions, monitor for effectiveness and modify when necessary to prevent 13 falls in a 7 month period, 2 of which resulted in lacerations to the Resident's scalp and left eye. Resident #65 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 3/14/19, indicated that Resident #65 had long and short term memory problems, had severely impaired skills for daily decision making, required supervision for all ambulation, and had sustained 2 or more falls since admission. Nursing notes dated 9/13/18 indicated that Resident #65 had an unsteady gait, constant pacing around the unit, and wandering in and out of other Residents' rooms. A 9/13/18 Fall Risk Assessment indicated that Resident #65 was a high fall risk with a score of 65.0 (score of 45 or higher indicated a high fall risk). Review of interdisciplinary care plans indicated a care plan for Resident #65's fall risk related to gait imbalance problems, unaware of safety needs, and wandering (initiated 9/14/18). The goal identified for the care plan was that the Resident would be free of minor injury through the review date. Interventions to achieve this goal were as follows: -Anticipate and meet the Resident's needs (initiated 9/14/18) -Be sure the Resident's call light is within reach and encourage the Resident to use it for assistance as needed; the Resident needs prompt response to all requests for assistance -Ensure that the Resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Resident #65 sustained 13 falls in 7 months as follows: 1. A 9/16/18 nursing note indicated that Resident #65 had an unwitnessed fall and was found lying on his/her back next to another Resident's bed at 9:30 A.M., and had sustained a 2 cm (centimeter) in length skin tear to the top of his/her scalp. The area was washed, a topical antibiotic cream, and dry dressing were applied. The physician was notified and ordered neurological assessment according to facility policy. Staff indicated that the Resident was unsteady, and was on 1:1 supervision due to constant attempts to self ambulate. The care plan was updated with the following intervention: Resident assisted to stationary chair and monitored by staff for safety. 2. On 9/17/18, Resident #65 sustained a fall at 7:50 A.M. The Resident was last seen in a wheelchair at the nursing station for close observation. The nurse was down the hallway pouring medication, when she observed the Resident rise out of the wheelchair unassisted and fall to the floor. The nurse was too far away to intervene and prevent the Resident from falling. No apparent injuries were noted. The physician was notified. No updates were made to the care plan to prevent further falls. 3. On 9/19/18, Resident #65 had an unwitnessed fall. The Resident was found sitting on the floor in his/her room at 10:30 A.M. Staff indicated that the Resident had demonstrated poor safety awareness, unsteady gait, and was assisted to a wheelchair, but would constantly get up out of the chair. No apparent injuries were noted. Neurological checks were initiated according to facility policy. No updates were made to the care plan to prevent further falls. A 9/28/18 At Risk Note indicated that Resident #65 sustained falls on 9/16 and 9/19, was unaware of safety risks but able to ambulate independently, and that therapy was working with the Resident. 4. On 9/29/18 at 3:10 P.M., Resident #65 was observed by nursing staff to be walking with an unsteady gait, and leaning. The Resident was observed to fall into the wall near a windowsill and slide to the floor. The Resident was assisted to a wheelchair and positioned at the medication cart for supervision. No apparent injuries were noted. On 10/1/18, the care plan was updated to include: attempt to give Resident activities that allow him/her to sit such as puzzles and magazines. 5. On 10/4/18 at approximately 10:50 A.M., activity staff witnessed Resident #65 trip over a wheelchair in the dayroom, and land face down on his/her left side. The resident sustained [REDACTED]. The Resident was brought to the nurse's station for close observation. No updates were made to the care plan to prevent further falls. A 10/5/18 At Risk Note reviewed the 10/4/18 fall. The note indicated that the Resident presents with an unsteady gait, poor balance, and no safety awareness. Therapy is currently working with the Resident on wheelchair propelling, and possible working with him/her with a merry walker for safety (walker/chair combination ambulation device). 6. On 11/14/18 at 5:15 P.M., Resident #65 sustained an unwitnessed fall. The Resident was found in another Resident's room lying flat on his/her stomach, with arms extended, hands outright. No apparent injuries were noted. No updates were made to the care plan to prevent further falls. 7. On 11/15/18 at 11:15 A.M., Resident #65 sustained an unwitnessed fall. The Resident was found lying on his/her right side in the hallway. No apparent injuries were noted. 8. On 11/15/19 at 4:15 P.M., the Resident was again found on the floor after sliding out of bed. The Resident was noted to be unsteady on his/her feet when fatigued, does not know cognitively when to take a rest. No apparent injuries were noted. No updates were made to the care plan to prevent further falls. 9. On 1/18/19, Resident #65 sustained an unwitnessed fall. The Resident was found by staff in the unit dayroom sitting on the floor with his/her legs flexed. No apparent injuries were noted. On 1/21/19, the care plan was updated to include: Rehab to review. 10. On 1/25/19, Resident #65 sustained another unwitnessed fall. The Resident was found by staff in another Resident's room sitting on the floor with his/her legs extended. No apparent injuries were noted. The care plan was reviewed, but no new interventions were implemented to prevent further falls. 11. On 2/24/19 at 3:00 P.M., Resident #65 sustained an unwitnessed fall in the dining room. The Resident was found by staff sitting on the floor. No apparent injuries were noted. On 2/25/19, the care plan was updated to include: attempt to engage Resident in unit activities. 12. On 3/6/19, Resident #65 sustained another unwitnessed fall. The Resident was found by staff in the dining room on the floor lying on his/her right side. No injuries were noted. 13. On 3/9/19, Resident #65 was found in his/her room lying face down on the floor beside the bed with his/her legs wrapped in bedding. No apparent injuries were noted. On 3/11/19 the care plan was updated to include: Ensure that linen on bed is not too long on the sides, and that the linen is not too tightly tucked into the bed. The above concerns were shared with Unit Manager #3 on 4/24/19 at 10:32 A.M.

Based on staff interviews, record review and review of the Facility's Incident Report, internal investigation and Abuse Prevention Policy, the facility failed to prevent abuse for 1 Resident (#27) in a sample of 13 Residents. Findings include: Review of the Facility's Abuse Prevention Policy (9/1/2016) indicated the following: *Policy in place to identify events occurrences, patterns and trends that may constitute abuse. *Identify event incidents that have a pattern, frequency or may constitute abuse. * All personnel, residents, visitors, etc., are encouraged to report any incidents or suspected incident of mistreatment, neglect, abuse, including injuries of unknown source, and misappropriation of resident property. Such resorts may be made without fear of retaliation from the facility or its staff. Resident #27 was admitted to the facility in 11/2013. Review of the Minimum Data Set (MDS-most recent Quarterly) indicates that the Resident is dependent on staff for assist with activities of daily living (adl) and is able to make his/her needs known and understands, consistent simple, directive sentences. Review of the Resident Incident Report dated 12/25/16 indicated the following summary of the incident from witness statements: Resident #27 alleged that on the morning of 12/25/16, he/she requested assist from the medication Nurse (MN) on duty. The MN said that the CNA would assist him/her with morning care. The Resident refused to receive care from the accused CNA and repeatedly said get him out, he's bad, he's mean, I hate him. Despite the Resident's objections, the MN allowed the CNA to enter the Resident's room. There was no indication that the nurse attempted to obtain assistance from another staff member and did not provide supervision. The CNA went into the room and closed the door behind him. According to the MN, approximately 6 minutes later, after hearing the Resident yell the MN's name repeatedly and help me, the MN entered the room. The Resident was crying with a reddened face and nasal discharge. The Resident told the MN that the CNA pinched his/her nose and that it was not the first time. The Resident also said that the CNA squeezed his/her hands to try and break them. The Resident also said that the CNA threw cold water on his/her hair and face and that this was not the first time, it was the third time. The MN asked the CNA if he had pinched the Resident's nose and squeezed his/her hands. The CNA replied words to the effect of; I may have pinched his/her nose when I washed his/her face and he/she says these things. Review of the written statement from the Social Worker indicated that when the MN entered the room, the Resident's top was not on all of the way, exposing the Resident's breasts. The MN had to straighten the Resident's appearance. The CNA was in the Resident's bathroom cleaning up and had left the Resident in that condition, unattended. The Social Worker's written statement also indicated that the Resident's yelling was not typical for him/her. On 1/17/17, review of the CNA's Personnel file dated 9/19/16 (3 months prior to the abuse allegation) indicated that it contained documentation of verbal counseling. A Record of Verbal Counseling within the file indicated the following written report submitted by the (former 3:00 P.M. to 11:00 P.M.) Nursing Supervisor (NS): Spoke with CNA about attitude and the care that he gives to his residents. I told him to tell the residents what he is going to do to them and to ask if he can provide care first. The NS told him to make sure that the residents understand him before he cares for them. The CNA thought that maybe he was joking around too much with them. There was no documentation to indicate that there was a plan to re-educate or supervise the CNA. On 1/17/17 at 11:30 A.M. the former NS (now Infection Control Coordinator/ ICC) was interviewed. At first the ICC said that she did not remember who brought the concerns about the CNA to her attention but just said that the CNA was having issues. Upon further inquiry, the ICC said that residents and families had spoken to her about the CNA. They told her that they did not understand the CNA and did not like the CNA caring for their family members. The Administrator was interviewed on 1/17/17 at 3:00 P.M. The Surveyor showed the Adminstrator the Supervisor's Verbal Warning from 9/2016 or (3 months prior to the incident). The Administrator became upset and said I never saw that and if I had, I would not have let the CNA return to the facility. The Administrator said that he terminated the CNA on 1/1/17 (2 days after returning to work), because of a complaint by another resident and family member. The resident approached the Administrator and said that he/she was afraid of the same CNA.

Based on record review, facility policies and staff interview, the facility failed to ensure that effective interventions were initiated and put in place to provide adequate supervision/oversight to prevent falls with injury for 5 Residents (#1, #3, #12, #13 and #17) in a total sample of 20 Residents. Findings include: Review of the facility policies related to falls, incident reporting, fall risks, Fall Prevention Program indicates that a fall assessment and incident report are to be completed. The Fall Prevention Program indicates the following: Policy statement -To prevent falls and injuries related to falls Fall Risk assessment -To be completed on admission, quarterly, annually, with any significant change of status and after a fall. A quarterly review is done at the PI/QA meetings to determine trends of injuries and falls. The Falls Investigation Report included, but not limited to: * Interdisciplinary review * Care Plan updated * Certified Nurse Assistant (CNA) care plan updated 1. For Resident #3, the facility failed to complete comprehensive assessments and implement effective interventions to prevent 11 falls in a 4 month period (6/2016 through 10/2106) with one fall resulting in a right femur fracture. Resident #3 was admitted to the facility in 1/2016 with multiple [DIAGNOSES REDACTED]. A clinical record review indicated that on 6/5/16 at 1:30 P.M., the Resident fell while independently ambulating with a walker sustaining a right distal femur fracture. Resident #3 was then hospitalized and had an open reduction internal fixation surgical intervention (ORIF) of the right hip and returned to the facility on [DATE]. After the fall with injury, the facility failed to follow their fall policies, to comprehensively assess the Resident's status in relation to this injury by not completing the fall incident / investigations, did not update the Residents care plan, and did not update the Certified Nursing Assistant Care Card. The Resident then sustained 10 more falls with another fall with injury on 9/2/16, that resulted in another hip fracture with ORIF. - On 6/14/16 at 7:15 A.M., the Resident was found on the floor (FOF) right next to the bed. Resident explained he/she wanted to go to the bathroom. *No incident report/investigation was completed by the facility and no changes were made to the plan of care for falls. - On 6/19/16 at 2:30 P.M., it was noted that the Resident had increased agitation, increased pain and was noted to be out of bed (OOB) on mat next to bed. Resident complained of increased pain, and was sent out to the emergency room . X-Ray was negative for fracture. *No incident report/investigation was completed by the facility and no changes were made to the plan of care for falls. - On 6/20/16 on the day shift (7:00 A.M. - 3:00 P.M.) the Resident was noted to be OOB on the floor next to the bed three times. The Resident's behavior was noted to be agitated and paranoid and yelling. The Resident was incontinent of loose stools 6 times. *No incident report/investigation was completed by the facility and no changes were made to the plan of care for falls. On 7/19/16 at 7:00 P.M., the Resident was FOF next to bed. It was noted that the Resident had increased agitation and that the Resident made herself/himself slip OOB onto the floor. *The incident report / investigation was incomplete. The care plan for falls indicated on 7/7/16, the facility instituted mats on the floor by the bed. The plan of care was revised 7/12/16 to include interventions of using a low bed, supervision, physical therapy consult, toileting assistance and provide 1:1 supervision as necessary. - On 7/22/16 at 8:00 P.M., the Resident had been noted to attempt to get OOB several times. The facility implemented a 1:1 ratio with good effect. Once the staff member left the Resident, the Resident was noted to be OOB next to the bed on the floor mats. *The incident report/investigation was incomplete. - On 7/24/16 at 5:00 P.M., the Nurse found the Resident sitting on the mat next to the bed. *The incident report/investigation was incomplete. - On 7/30/16 at 6:00 P.M. the Resident was FOF on mat next to bed, screaming and on his/her back. *The incident report/investigation was incomplete and the last change to the fall plan of care was 7/12/16. The Resident continued to have more falls. - On 8/13/16 at 8:00 P.M., Resident very agitated and anxious through out shift. Frequent attempts to get OOB with assist and put self on floor. Resident was found on the floor mat 3 times. * No incident/investigation was completed. - On 8/22/16 on the 7:00 A.M. to 3:00 P.M. shift (7-3), placed self on mattress on the floor at 7:00 A.M. and 12:00 P.M. (two times). *No incident report/investigation completed. -On 8/22/16 on the 3:00 P.M. to 11:00 P.M. shift (3-11) placed self on mattress on floor at 9:30 P.M. *No incident report/investigation completed -On 9/2/16 at 5:35 A.M. the Resident was found on floor on his/her knees next to the bed, alarm was sounding. The Resident stated I had to go to the bathroom. *The incident report/investigation was incomplete. -On 9/2/16 at 4:30 P.M. the Resident was FOF. Incident Report had indicated that the Resident had self transferred from the wheelchair to the bed. The Resident was sent out to the emergency room and was admitted to the hospital with [REDACTED]. -On 9/10/16 at 6:00 P.M. the Resident was noted to slide OOB with an Activities Aide present, Resident was noted to be incontinent of stool, no injury was sustained. *The incident report/investigation was incomplete. -On 10/22/16 at 1:50 P.M. the Resident was FOF with the clip alarm still attached to the Resident. The incident report indicated that the pad alarm failed due to improper functioning. *The incident report/investigation was incomplete. The plan of care for falls had no information of an intervention for the use of the clip alarm. -The fall risk assessments completed by the facility on the Resident indicated that the Resident consistently scored over 13 which indicated the Resident was at moderate to high risk for falls and the following interventions were put in place: Mat on floor next to bed Bed in low position Personal alarms Sensor alarms Education on call bell use (as appropriate) Scheduled toileting The Sensor alarms and Personal alarms were never added to the Resident's plan of care or the CNA's care card. The above interventions were never evaluated for their effectiveness, plan of care was not changed to ensure Resident safety and investigations / incident documentation were incomplete and not evaluated for effectiveness which resulted in the Resident having continued falls, with one fall resulting in a right femur fracture. Clinical record review on 10/24/16 and 10/25/16 indicated the facility failed to complete comprehensive assessments as per facility policy/protocol. On 10/27/16 at 12:15 P.M., the Director of Nurses (DON) said that the investigations / incident reports were incomplete, with some not being completed at all. The facility failed to complete appropriate comprehensive assessments resulting in ineffective interventions to prevent the Resident from falling resulting in injury. 2. For Resident #1, the facility failed to follow the plan of care requiring two assist with transfers to prevent the Resident from falling resulting in a comminuted fracture of the right ischium (hip) and two acute fractures of the right inferior pubis ramus (pubic bone). Resident #1 was admitted to the facility in 10/2014, with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 7/19/16, and signed as complete on 7/26/16, indicated that a Brief Interview for Mental Status (BIMS) was not completed indicating that Resident #1 was severely impaired with cognitive skills for daily decision making and rarely/never understands verbal content. The MDS indicated that Resident #1 required extensive assistance with two person physical assist for transfer and was assessed at high risk for falls. Review of the fall risk care plan dated 7/26/16, indicated that Resident #1 requires the following interventions: - give frequent verbal reminders not to ambulate/transfer without assistance - provide toileting assistance as needed - wear appropriate shoes or non-skid socks when transferring or ambulating - provide 1:1 supervision Review of the fall risk care plan dated 7/26/16, indicated that the care plan was not updated after Resident #1 fell and sustained an injury on 9/13/16. Review of the nursing flow sheet, used by the nurse aide staff to document care provided to the Resident, dated September 2016, prior to the Resident's fall on 9/13/16, indicated that Resident #1 was a two person transfer and required extensive assist for toilet use. Review of the fall incident report, dated 9/13/16 at 4:30 P.M., indicated that a certified nurse aide (CNA) was assisting Resident #1 in the bathroom and the Resident was standing holding the grab bar with both hands. The CNA was behind the Resident pulling the wheelchair close to the Resident. The Resident became agitated, turned swiftly and fell . Review of the nurses note dated 9/13/16 at 4:30 P.M., indicated that Resident #1 was found sitting on the floor with legs straight outwards complaining of right sided pain, hit his/her head, and had increased swelling above the right ear. The Resident was sent to the hospital and was admitted with a fracture of the right ischium and 2 acute fractures of the inferior pubis ramus. The responsible family member elected for no corrective surgery and the Resident returned to the facility the evening of 9/14/16. Review of the ADL plan of care card, used by a Certified Nurse Aid (CNA) to know what kind of care to provide to a Resident, dated 10/14/16 continued to indicate that Resident #1 required a two person assist for transfer. Surveyor #4 interviewed the Director of Nurses (DON) at 3:00 P.M. on 10/21/16. The DON said she did not re-educate the CNA, or refer the CNA to the Staff Development Coordinator for re-education, regarding transferring the Resident with only one assist when Resident #1 required a two person assist for transfers, or that the CNA allowed the Resident to stand alone while she pulled the wheelchair closer to the Resident. Surveyor #4 interviewed Unit Manager #2 at 12:00 P.M. on 10/25/16 Unit Manager #2 said there was only one CNA in the bathroom with Resident #1 when he/she fell and there was supposed to be two CNAs. Unit Manager #2 said Resident #1 has not walked since the fall on 9/13/16, and requires a wheelchair for mobility. 3. For Resident #13, the facility failed to provide effective interventions to prevent falls for a Resident at high risk for falls. The Resident's clinical record was reviewed on 10/25/16. Resident #13 was admitted to the facility in 8/2016 with diagnose that included Rhabdomyolysis, dementia, high blood pressure, chronic kidney disease, dysphasia, adult failure to thrive and a history of repeated falls. The Fall Risk Assessment Tool was inaccurately completed by a nurse on 8/30/16 which indicated that the Resident was at moderate risk for falls, when the Resident was actually at high risk for falls. Further review indicated that the tool was inaccurate for the questions pertaining to medication and fall history. Interview with Unit Manager #1 on 10/25/16 at 12:00 P.M. confirmed the inaccuracy of the assessment and said that the Resident should have been triggered at high risk for falls when the assessment was initially completed on 8/30/16. A new care plan was developed on 9/8/16 and indicated that the Resident was at moderate risk for falls related to Rhabdomyolysis, deconditioning and unaware of safety needs as a result of confusion. Interventions include: 1. Ensure that Resident is wearing appropriate footwear (white sneakers, non skid socks) when ambulating or mobilizing in wheel chair. 2. Evaluate for appropriate adaptive equipment. Reevaluate as needed for the continued appropriates and to ensure the least restrictive device or restraint. 3. PT evaluation and treat. Review of the nursing notes dated 10/18/16 indicated at 1:50 A.M. the Resident was found sitting on the bathroom floor in front of the toilet. The Resident pulled the bathroom call light. The fall was unwitnessed and the bed pad alarm did not sound. The nurse documented that she could not determine if the Resident shut off the alarm or if the alarm was broken. The Resident had a large hematoma (a swelling of clotted blood within the tissues) on his/her left side of the forehead. Review of the facility incident report dated 10/18/16 indicated that the Resident fell in the bathroom, resulting in a hematoma on the left side of the Resident's forehead. The incident report indicated that prior to the fall the Resident had a low bed, mats on the floor next to their bed, but the bed pad alarm was not working. The incident report did not elaborate on this finding nor were there any documented staff interview that were working that shift, on the unit, at the time of the fall. Unit Manager #1 was interviewed on 10/25/16 at 3:30 P.M. and said that the Resident would frequently ask to go to the bathroom, approximately every 15 minutes, but due to poor memory issues the Resident would forget that they just were toileted. The surveyor asked if the Resident had been evaluated and a care plan developed for a Toileting plan or establish a bladder pattern. Unit Manager #1 said no. Unit Manager #1 did say that staff placed a wheel chair next to the Resident's bed at night in case he/she got up, he/she would transfer themselves to the wheel chair and not try to ambulate, however the Resident required assist of one staff to transfer. the Care plan did not address the frequent toileting needs of the Resident. 4. For Resident #17, the facility failed to provide supervision and effective interventions to prevent four falls. The Resident's clinical record was reviewed on 10/26/16. Resident #17 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. The Fall Risk Assessment Tool was completed by a nurse on 9/9/16 which indicated that the Resident was at high risk for falls. Review of the initial care plan dated 9/9/16 indicated that the Resident was at risk for falls but did not identify any interventions to prevent falls. The Minimum Data Set (MDS) assessment signed as completed on 9/19/16, indicated that the Resident had severely impaired vision, scored a 2 of 15 on BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment, and required extensive assistance with transfer, ambulation, dressing and eating. The MDS also indicated that the Resident used a walker and wheelchair for mobility and had fallen prior to admission. The Resident also received an antipsychotic and antidepressant medication daily. A new care plan was developed on 9/16/16 that indicated that the Resident was at risk for falls related to dementia with decrease safety awareness, reconditioning, gait/balance problems and psychoactive drug use. The interventions included: 1. Be aware that (Resident) does not use call light. 2. Ensure that Resident is wearing appropriate footwear when transferring or mobilizing in wheel chair. 3. Alarm in place when in bed or wheel chair. 4. Follow facility fall protocol. 5. PT (Physical Therapy) to evaluate and treat as ordered or PRN (as needed). 6. Resident needs a safe environment with floors free from spills and/or clutter, adequate glare-free light, bed in low position at night, siderails as ordered, handrails. Review of the nurse's notes dated 9/19/16 indicated that the Resident was found lying next to the bed on the floor mats wrapped in their blanket. The Resident was assisted to the bathroom to void then returned back to bed. There were no injuries noted. Review of the facility incident report dated 9/19/16 indicated that the Resident's alarm did not sound because the Resident was sitting on it (which was not clarified on the incident report). The documented interventions included Resident education, pad alarm, fall mats, bed in low position and slipper sox. There were no new interventions identified after the fall. On 9/25/16 the nurse documented that at 5:30 A.M. the staff heard an alarm sounding and found the Resident sitting on the floor mats next to the bed. The Resident was assisted to the bathroom and voided. There were no injuries noted. Review of the facility incident report dated 9/25/16 indicated that the Resident was provided education and to continue with low bed, mats on floor, alarms and to consider a video monitor, however there were no change to the care plan and providing education to a cognitively impaired resident was ineffective. On 10/14/16 the nurse documented that at 10:30 P.M. the Resident was found sitting on the floor on the mat next to the bed. The nurse documented that the Resident was toileted and returned to bed. Review of the facility incident report dated 10/14/16 indicated that the the Resident most likely needed Toileting and the CNAs were doing rounds and just next door to the Resident's room. The investigation did not identify if the alarms were sounding at the time of the fall. There were no new interventions put into place after this fall. On 10/22/16 the nurse documented that the Resident had a fall on the unit in the hallway at 3:00 P.M. The Resident was attempting to stand without assistance. Review of the facility incident report dated 10/22/16 indicated that the Resident had a fall in the hallway at 3:00 P.M. The report further indicates that the Resident removed his/her body alarm, so it did not sound during the fall. Interventions indicated were to reattach the body alarm and contact the Rehab Department. In addition to the 4 falls, the nurses documented 13 times between 9/10-10/22/16 that the Resident was up frequently during the 11:00 P.M.-7:00 A.M. shift and had to be brought out to the nurse's station for supervision due to insomnia and agitation. Although Psychiatric Consult identified insomnia on the 9/22/16 visit there was no interventions to assist the resident in keeping safe. The Director of Nurses was interviewed on 10/26/16 at 3:00 P.M. and said that she was aware of the third fall and that the Resident should have been toileted sooner. The surveyor asked if the Resident had a Toileting plan based on a three day Toileting pattern, and the DON said no but that would be a good idea. 5. For Resident #12, who had 7 falls within 5 weeks, the facility failed to implement effective interventions and adequate supervision to prevent falls. Resident #12 had 7 falls, 6 of the 7 were unwitnessed, in 5 weeks. Resident #12 was admitted ,[DATE] for rehabilitation following hospitalization for falls secondary to [DIAGNOSES REDACTED] (a disorder in which low platelet count which may prolong bleeding times) and urinary tract infection requiring antibiotics. Review of the initial Minimum Data Set (MDS) assessment with a reference date of 9/22/16, indicated that the resident was cognitively impaired, had demonstrated behavior symptoms directed toward others and was dependent on facility staff for most activities of daily living, including incontinence care. The Resident was coded as receiving anti-psychotic, anti-anxiety and anti-depressant medications and had a restraint (chair that prevents rising).The Resident was coded with a 30 day and 2-6 month history of falls. Review of the Care Plan for fall initiated 9/28/16 and revised 10/6/16 (the DON interviewed on 10/25/16 said that their interim care plan did not include falls) included the following interventions: - Blue chip alarm when in bed or wheelchair - Safe environment, free from clutter - Be aware that resident does not use the call light properly - A monitor is in place when in bed (later identified as baby monitor) Review of a Restraint Care Plan initiated 9/28/16 and revised 10/6/16 identifies that the restraint - a lap tray on a wheelchair- was initiated when out of bed due to danger to self with attempt to self transfer and unsteady gait with labile alertness. Review of the ADL (activities of daily living) Plan of Care Card dated 9/15/16 which provides guidance to nurse aide staff on the care needs of the Resident and identified that the Resident was a high fall risk with an alarm (type not specified), low bed and mats on the floor. The ambulation/bed and transfers were emphasized as moderate amount of care needed with 2 persons, toileting was emphasized but left blank and restraints were not identified. Review of the clinical record indicated that the Resident had 7 falls since admission on the following dates 9/15/16, 9/29/16, 10/2/16, 10/3/16, 10/6/16, 10/7/16 and 10/23/16. Review of the 3:00-11:00 P.M. shift nurse's admission note (dated 9/15/16), indicated at 7:30 P.M. the Resident's family member found the Resident on the floor by the bed. The nurse implemented a low bed, bed alarms and mats and obtained an emergency order to place the Resident in a wheel chair with a lap tray for 24 hours. On 9/27/16 the 11:00 P.M.-7:00 A.M. nurse indicated that the Resident was in the chair with the lap tray in place to help maintain safety and was making multiple attempts to stand. On 9/29/16 the 7:00 A.M.-3:00 P.M. nurse indicated that at 8:10 A.M. the Resident was found lying on the floor next to the bed with the alarm sounding. No injury was incurred. No new interventions were initiated. On 10/2/16 at 2:00 P.M. the day shift nurse's note indicated that the Resident slid down off the wheelchair, under the lap tray and was assisted three times to the sitting position. There was no incident investigation. On 10/3/16 at 3:50 A.M. the 11:00 P.M.-7:00 A.M. nurse heard a noise and found the Resident on the floor next to the bed. Review of the incident report indicated that the alarm was not working. Review of the care plan with the nurse indicated that no new revisions were implemented. Review of the nurse's note dated 10/6/16, indicated that at 4:30 P.M. the Resident was observed lying on the floor between the wheelchair and the beds. No apparent injury was reported. The nurse indicated that she left a message with the rehabilitation (rehab) department of the fall and to re-evaluate the lap tray on the wheelchair in the morning. On 10/7/16 at 6:00 A.M. the Resident was found on the floor next to the bed with the alarm sounding. No injury was identified. On 10/7/16 the rehab department switched the Resident to a low pedal Broda chair with a lap tray and a gel cushion. The fall care plan and nurse aide care card did not include this intervention. On 10/10/16 the health care agent gave approval for video monitoring set up of the Resident's room (provides direct observation of the Resident). The fall care plan and nurse aide care card did not include this intervention. On 10/23/16 at 4:50 A.M. staff responded to the alarm sounding and the nurse aide witnessed the Resident standing between the bed and window and then fall to the floor. The incident report failed to indicate if the video monitoring of the Resident was functioning. The resident sustained [REDACTED]. On 10/24/16 at 3:00 P.M. the Director of Nurses was interviewed and reviewed existing documentation regarding Resident #12's multiple falls. The DNS said that she had no information regarding the 9/15/16 and 10/2/16 falls. The DON said that she could not explain why interventions were not implemented as indicated on the incident reports. Refer to F353.

Based on record review, observation and interviews, the Facility failed to ensure for 1 of 13 sampled Residents (Resident #4), received effective pain management when the Resident complained of a toothache that began on 12/25/16. Findings include: For Resident #4, the facility failed to provide effective pain management when the Resident complained of a toothache that began on 12/25/16. Resident #4 was admitted to the facility in 3/2016 and had active [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment with a reference date of 1/1/17, indicated that the Resident was cognitively impaired, had daily behaviors, was coded with pain and was receiving hospice services. Review of the clinical record dated 12/25/16 on the 11-7 shift indicated that the Resident began complaining about a toothache. Further review of the Nurse's notes from 12/25-12/28/16 indicated that the Resident continued to complain about the toothache and received Tylenol PRN (as necessary) which the nurses' indicated was effective. On 12/29/16 the 11:00 P.M.-7:00 A.M. nurse's note indicated that the Resident was awake all night complaining about mouth pain, was yelling out and crying for help. The nurse medicated the Resident for agitation at 2:08 A.M. with the PRN antianxiety medication, AB gel ([MEDICATION NAME] (antianxiety) with [MEDICATION NAME] ([MEDICATION NAME]) along with the antipsychotic medication, [MEDICATION NAME] gel PRN and a narcotic, [MEDICATION NAME] 5 milligrams orally PRN which were all assessed as ineffective (all of the medications listed above were previously ordered medications.) Review of the Medication Administration Record [REDACTED].M.-7:00 A.M. shift nurse administered PRN AB gel with the [MEDICATION NAME] gel and PRN [MEDICATION NAME] that she assessed as ineffective. The location of the pain was not documented. Review of the corresponding nurse's note for 1/1/17 at 3:53 A.M. indicated that the Resident was yelling, screaming and swearing, no hallucinations at this time. Continue to monitor. On 1/1/17 at 6:25 A.M. the nurse continued to report that the Resident was yelling, screaming, crying and hitting with ineffective medication administration. On 1/7/17 at 2:39 P.M. the Nurse's note indicated that the Resident was administered the PRN [MEDICATION NAME] at 10:30 A.M., assessed as ineffective results and then at 2:40 P.M. administered the [MEDICATION NAME] gel for general discomfort and increase in agitation. There was no assessment of the location of the pain and no further assessment if the Resident's increase in agitation corresponded with the Resident's prior complaints of a toothache. On 1/11/17 the facility social service progress note indicated that a Hospice meeting was held on January 4 and that the Resident had declined mentally in the past 2 weeks where (he/she) is having more hallucinations .PRN meds are ordered and given as needed. The Social Worker made no mention of the Resident's complaints of tooth/mouth pain or need for pain medication. On 1/11/17 at 3:00 P.M. the interim charge nurse (ICN) was interviewed and reviewed existing nursing documentation with the surveyor. The ICN said that she was unaware that the Resident was complaining of a toothache. The ICN said that the MD progress note of 12/25/16 did not indicate that the physician was made aware of the Resident's initial complaint of a toothache the previous night and there was no further documentation by the MD in the clinical record. The ICN said that nursing staff were documenting that the Resident had generalized pain but did not identify the location of the pain. The ICN was asked if the nursing staff had assessed if the Resident's escalation in behaviors was due to being in pain and said she was unsure if that was considered. The ICN said she was going to contact the physician to have the Resident assessed. On 1/12/17 at 11:30 A.M. the ICN followed up with the Surveyor and indicated that the Physician had visited earlier that morning (no note was made available during the survey) and indicated that the Resident currently had no acute pain but ordered a dental consult. The ICN said that a dental consult would be completed sometime next week but no date was given. On 1/12/17 at 12:00 P.M. the family member was interviewed and said that the Resident had been complaining about a toothache beginning a couple of weeks ago and that he/she tried to get a dental appointment but the insurance would not cover it. On 1/17/17 at approximately 10:30 A.M. the Interim Charge Nurse (ICN) reported that Resident #4 was visited by the Dentist on 1/16/17. The ICN said that the Dentist indicated that the Resident had no acute pain but had a fractured tooth which required a procedure for the dentist to smooth over the tooth (to prevent jagged edges).

Based on staff interviews, record review and review of the facility's Incident Report, internal investigation and Abuse Prevention Policy, the facility failed to follow their Abuse Prevention Policy, failed to ensure allegations were immediately reported to the Administrator and the state agency, failed to thoroughly investigate incidents with written statements from all staff members and Residents and failed to notify the Resident's family (HCP) and physician following alleged incidents following an incident of alleged abuse for 2 (#24 & #27) Sampled Residents, from a total sample of 13 Residents reviewed during the follow up survey completed on 1/17/17. Findings include: Review of the facility's Abuse Prevention Policy indicated the following pertinent bullets: *Identify event incidents that have a pattern, frequency or may constitute abuse. *All personnel must immediately report any incident or suspected incident of mistreatment, neglect or abuse to facility Administrator immediately. *When an alleged violation is reported, the Facility Administrator will immediately notify officials in accordance with the State Survey and Certification Agency. 1. Resident #27 was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED] (a progressive [DIAGNOSES REDACTED] characterized by speech impairment), with repetitive speech and anxiety. The Resident's Health care Proxy was invoked. Review of the most recent quarterly Minimum Data Set (MDS) indicated that the Resident was dependent on staff for assist with activities of daily living (adl), due to ([DIAGNOSES REDACTED]) cognitive problems with sequencing and follow through with task initiation. He/she was able to make his/her needs known and understands consistent, simple, directive sentences. Review of the Resident Incident Report dated 12/25/16 indicated the following summary of the incident from witness statements: Resident #27 alleged that on the morning of 12/25/16, he/she requested assist from the Medication Nurse (MN) on duty, who was passing medications. The MN said that the CNA would assist him/her with morning care. The Resident refused to receive care from the accused CNA and repeatedly said get him out, he's bad, he's mean, I hate him. Despite the Resident's objections, the MN allowed the CNA to enter the Resident's room. There was no indication that the nurse attempted to obtain assistance from another staff member and did not provide supervision. The CNA went into the room and closed the door behind him. According to the MN, approximately 6 minutes later, after hearing the Resident yell the MN's name repeatedly and help me, the MN entered the room. The Resident was crying with a reddened face and nasal discharge. The Resident told the MN that the CNA pinched his/her nose and that it was not the first time. The Resident also said that the CNA squeezed his/her hands to try and break them. The Resident also said that the CNA threw cold water on his/her hair and face and that this was not the first time, it was the third time. The MN asked the CNA if he had pinched the Resident's nose and squeezed his/her hands. The CNA replied words to the effect of; I may have pinched his/her nose when I washed his/her face and he/she says these things. The written statement from the Social Worker indicated that when the MN entered the room, the Resident's top was not on all of the way exposing the Resident's breasts and the MN had to straighten the Resident's appearance. The CNA was in the Resident's bathroom cleaning up and had left the Resident in that condition. The Social Worker's written statement also indicated that the Resident's yelling was not typical for him/her. On 1/17/17, review of the CNA's Personnel file dated 9/19/16 (3 months prior to the abuse allegation) indicated it contained a verbal counseling form. A Record of Verbal Counseling within the file indicated the following written report submitted by the (former 3:00 P.M. to 11:00 P.M.) Nursing Supervisor: Spoke with CNA about attitude and the care that he gives to his residents. I told him to tell the residents what he is going to do to them and to ask if he can provide care first. The NS told him to make sure that the residents understand him before he cares for them. The CNA thought that maybe he was joking around too much with them. Specifics of the incident were not documented on the counseling record. There was no documented plan for re-education or supervision. On 1/17/17 at 11:30 A.M. the former Nursing Supervisor (now Infection Control Coordinator/ ICC) was interviewed. At first the ICC said that she did not remember who brought the concerns about the CNA to her attention but just said that the CNA was having issues. Upon further inquiry, the ICC said that residents and families had spoken to her about the CNA. They told her that they did not understand the CNA and did not like the CNA caring for their family members. On 1/17/17 at 3:00 P.M. Surveyors #1 and #2 interviewed the Administrator. The Administrator said that he was not notified of the incident until 3 hours later, at approximately 12:45 P.M. The Administator said that the Medication Nurse (MN) told him that she did not send the CNA home immediately after the incident because the unit would have been left short-staffed. The Surveyor asked if there was any staff in charge on that day, and the Administrator said no, that he was available by phone. The Administrator said that the MN was aware that the Resident did not like the CNA. The Administrator also said that the MN never notified the Resident's family or physician. The Surveyors asked what time the CNA left the building. He said he thought that it was right after his telephone conversation with the MN at 12:45 P.M The Surveyors told the Administrator that the business records indicated that the CNA worked the entire 7:00 A.M.- 3:00 P.M. shift providing care to Residents. The Administrator said that the CNA was suspended during the investigation. The facility concluded that no conclusive evidence of abuse occurred, therefore the CNA was allowed to return to work. The Medication Nurse (MN) did not obtain a written statement from all of the staff on the day of the incident. The Administrator was not aware of a previous (9/2016) Supervisor's written Warning about the manner in which the CNA cared for Residents and allowed the CNA to return to work. The Surveyor showed the Administrator the CNA's Verbal Warning from 9/2016. The Administrator became upset and said I never saw that and if I had, I would not have let the CNA return to the facility. The Administrator said he terminated the CNA on 1/1/17 (2 days after returning to work) due to a family and Resident complaint. The Resident approached him and said that he/she was afraid of the same accused CNA. The Administrator terminated the medication Nurse on 12/30/16 for failing to follow the facility's Abuse Prevention Policy. 2. For Resident #24, the facility failed to report an allegation of physical abuse to the State Agency. Resident #24 was to the facility 12/2016 for long term care following hospitalization for urinary tract infection [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED]. Review of the medical record on 1/17/17 indicated that that the Resident was not his/her own decision maker for health care needs. The 12/30/16 physician's initial note indicated that the Resident had baseline dementia and declined mentally during hospitalization . Review of a 1/2/17, 3:34 P.M. nurse's note indicated that during the Resident's Rehab therapy session he/she reported an allegation of abuse to the therapy staff. The Nurse discussed the allegation with the Resident when he/she returned from therapy. The Resident said that on the first night in the facility a man punched him in the shoulder during the night hours. The Resident could not identify if the man was white or of color, had an accent or not, or said anything else distinguishing said it was too dark and the man did not speak to him. The Resident complained that his/her shoulder hurt and an shoulder x-ray was completed which was negative. The Resident's family member (health care agent) was contacted and indicated to staff that the Resident made a similar complaint of being punched in the shoulder prior to admission. The Resident was visited by the Social Worker on 1/3/17 regarding the Resident's allegation of abuse. Review of the Social Worker's interview indicated that the Resident denied any staff being rough with him/her and that the resident felt safe. The Administrator was interviewed on 1/17/17 at approximately 3:00 P.M. and was asked if he reported the Resident's allegation of abuse to the state health agency as required, said no.

Based on observation, record review and interviews, the facility failed to notify the physician of changes in conditions for 2 Residents (#1 and #8), from a total sample of 20 residents. 1. For Resident #8, the facility failed to notify the physician of 3 separate weight gain events (greater than 3 pounds in 1 day), according to the physician's orders [REDACTED]. Findings include: Resident #8 was admitted to the facility in 9/2016 with the following pertinent Diagnoses: [REDACTED]. On 10/21/16 at 8:30 A.M., Surveyor #3 interviewed Resident #8. The Surveyor observed that Resident #8 had 3 different beverage cups on his/her table. The Resident said that he/she was extremely thirsty and was drinking as much as possible to help get rid of the infection. The Resident also said that he/she was on fluid pills and used the bathroom a lot, but still had swelling in the arms and legs. On 10/21/16, review of the physician's orders [REDACTED]. Review of the Care Plan for potential of [MEDICAL CONDITIONS] due to pacemaker removal (created on 10/19/16 or 1 month after admission), indicated the following: *give cardiac medications as ordered. *monitor lab work. *monitor signs or symptoms of [MEDICAL CONDITION] ([MEDICAL CONDITION], weight gain, increased heart rate, lethargy, disorientation. Review of the computer generated weights from admission 9/2016 to 10/21/16 indicated the following pertinent weight recordings: 9/20/16- 222.0# 9/27/16- 228# (first notification to the MD @ 6# weight gain with medication change) 10/14/16-233.4# 10/21/16-241# (7.6# gain with no notification) On 10/21/16 at 11:30 A.M., Surveyor #1 reviewed the weight gains with the UM and the observations of excessive fluids on the Resident's table. The Surveyor reviewed the Nursing Progress Notes. There were no notes indicating an MD/NP notification of weight gain between 10/5/16 and 10/21/16 (date the Surveyor interviewed the UM). Subsequently, after interview with the Dietician, review of the Dietary Progress Note for 10/21/16, indicated that the Dietician was re-assessing the Resident for fluid overload and documented a total weight gain of 19# since admission (some in part attributed to increased appetite). The Dietician's note indicated that the Resident was to have a more restrictive diet including no cold cuts, chips, bacon or salty foods and was notifying the MD for some guidance. Review of the Nurse Practitioner Note on 10/24/16 indicated a new order to increase from [MEDICATION NAME] 20 mg. (2 tablets by mouth 2 x/day for a total dose of 40 mg) to a new total dose of 60 mg. for the current weight of 240#, initiate a fluid restriction and plan for a Cardiology follow-up appointment. Please refer to F282. 2. For Resident #1, the facility failed to notify the physician when the Resident refused the prescribed [MEDICATION NAME] Sprinkles (a medication used to treat [MEDICAL CONDITION] or manic behaviors), thirteen times in 10/2016. Review of the facility's Physician/Nurse Practitioner Notification Policy indicates the following: The attending or covering physician or nurse practitioner will be notified of the refusal of treatment or medication after consecutive times and the attending or covering physician or nurse practitioner will be notified when it is part of an order in which it has been specified for a condition or follow up. Resident #1 was admitted to the facility in 10/2014, with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 7/19/16, and signed as complete on 7/26/16, indicated that a Brief Interview for Mental Status (BIMS) was not conducted for Resident #1. The MDS indicated that Resident #1 was severely impaired with cognitive skills for daily decision making and rarely/never understands verbal content. Review of the physician orders [REDACTED].#1 was prescribed [MEDICATION NAME] Sprinkles 125 milligrams (mg) once a day related to an anxiety disorder. Review of the Medication Administration Record [REDACTED]. Review of the nurses notes dated 10/1/16 through 10/21/16, indicated that there was no evidence in the documentation that Resident #1's physician or nurse practitioner was notified of the Resident's continued refusal of the [MEDICATION NAME] Sprinkles. The Surveyor interviewed Nurse #1 at 2:45 P.M. on 10/21/16. Nurse #1 said if a Resident refuses a medication it should be documented in the nurses notes. Nurse #1 said the policy is to notify the physician or nurse practitioner if a Resident refuses a medication twice in a row. There was no documentation indicating that the MD/NP was notified of the multiple refusals of the medication. The surveyor interviewed the Nurse Practitioner (NP) at 11:00 A.M. on 10/25/16. The NP said the nursing staff had not notified her Resident #1 was refusing the physician prescribed [MEDICATION NAME] Sprinkles.

Based on interviews and record review for one of three sampled residents (Resident #1), who was at risk for falls, the Facility failed to provide adequate supervision to prevent a fall with injury. Resident #1's plan of care, including the CNA Care Card (used by the direct care staff to know a resident's care needs), indicated Resident #1 was not to be left unattended in the bathroom due to his/her high risk for falls. On 1/27/14, Resident #1 was left unattended on his/her toilet, stood up and fell . Resident #1 complained of pain following the fall and x-rays were completed, which indicated Resident #1 had a fractured right tenth rib. The finding included: Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 12/1/13, indicated Resident #1 was severely cognitively-impaired. Resident #1's CNA Care Card, in effect on 1/27/14, indicated Resident #1 was a high risk for falls and was not to be left unattended in the bathroom. Resident #1's Fall Risk Care Plan, initiated 9/5/13 and updated 12/12/13, indicated Resident #1 was at risk for falls and required moderate assistance for transfers. The Fall Risk Care Plan interventions did not include interventions to indicate the staff were not to leave Resident #1 alone in the bathroom, which was not consistent with the CNA Care Card. The Surveyor interviewed the ADON at approximately 11:30 A.M. and throughout the day of the survey. The ADON review Resident #1's fall prevention plan of care with the Surveyor on 2/26/14. The ADON said the fall prevention plan of care did not include the intervention to not leave Resident #1 alone in the bathroom, but it was an oversight and should have been written as an intervention, at added it on 2/26/14. The ADON provided te Surveyor with a printed version of Resident #1's audio taped CNA Care Card , dated 9/19/13 through 2/5/14. The ADON said the toileting section of Resident #1's Care Card indicated Resident #1 was not to be left unattended in the bathroom and that he/she was at high risk for falls. The nurse's note, dated 1/27/14, indicated at 4:00 P.M., Resident #1 attempted to transfer off of the toilet and fell . The note indicated when assessed, Resident #1 had redness on the right side and complained of pain, and an x-ray was obtained. The radiology report, dated 1/27/14, indicated Resident #1 had a fracture involving the lateral portion of the right tenth rib with minimal displacement. The Surveyor interviewed CNA #1 at 2:50 P.M. on 2/26/14. CNA #1 said she placed Resident #1 on his/her bathroom toilet and left the room to find a second caregiver to assist with transferring Resident #1 off the toilet. CNA #1 said she knew that she was not supposed to leave Resident #1 alone in the bathroom. CNA #1 said she did not ring the bathroom call bell to get help, but just stepped out of the bathroom to find assistance.

Based on interviews and record review for one of three sampled residents (Resident #1), the Facility failed to ensure direct care staff implemented the plan of care. Resident #1's CNA care card (used by staff to know a resident's care needs) indicated Resident #1 was not to be left unattended in the bathroom. On 1/27/14, CNA #1 left Resident #1 alone while seated on the toilet, Resident #1 stood up from the toilet, and fell to the floor. Resident #1 complained of discomfort on his/her right side and received x-rays at the Facility, which indicated Resident #1 had a fractured right tenth rib. The finding included: Resident #1's CNA Care Card, for 9/19/13 through 2/5/14, indicated Resident #1 was a high risk for falls and was not to be left unattended in the bathroom. The Surveyor interviewed CNA #1 at 2:50 P.M. and CNA #2 in the afternoon on 2/26/14. CNA #1 and CNA #2 stated they knew that Resident #1 was not to be left unattended in the bathroom because it was indicated on Resident #1's CNA Care Card. Resident #1's Fall Risk Care Plan, initiated 9/5/13 and updated 12/12/13, indicated Resident #1 was at risk for falls and required moderate assistance for transfers. The Fall Risk Care Plan interventions did not include interventions to indicate the staff were not to leave Resident #1 alone in the bathroom. The Surveyor interviewed the ADON at approximately 11:30 A.M. and throughout the day of the survey. The ADON review Resident #1's fall prevention plan of care with the Surveyor on 2/26/14. The ADON said the fall prevention plan of care did not include the intervention to not leave Resident #1 alone in the bathroom, but it was an oversight and should have been written as an intervention, at added it on 2/26/14. The ADON said the Facility used an audio taped CNA Care Card and the interventions communicated to the nursing assistants was developed based on a specific resident's plan of care. On 2/26/14, the ADON provided the Surveyor with a printed version of Resident #1's audio taped CNA Care Card, in effect since 9/19/13. The ADON said the toileting section of Resident #1's Care Card indicated Resident #1 was not to be left unattended in the bathroom and that he/she was at high risk for falls. The Surveyor interviewed Unit Manager #1 at 1:48 P.M. on 2/26/14. Unit Manager #1 said CNA #1 informed her that she was aware Resident #1 was not to be left unsupervised in the bathroom but told Unit Manager #1 she stepped out of the bathroom on to obtain assistance from another staff member. The Surveyor interviewed CNA #1 at 2:50 P.M. on 2/26/14. CNA #1 said on 1/27/14, she placed Resident #1 on his/her bathroom toilet and left the room to find a second caregiver to assist with transferring Resident #1 off the toilet. CNA #1 said she knew that she was not supposed to leave Resident #1 alone in the bathroom, but also felt Resident #1's transfer off the toilet would be safer if a second caregiver assisted her (CNA #1). CNA #1 said she did not ring the bathroom call bell to get help, but rather stepped out of the bathroom to find assistance.

Based on interview and record review, for one of three sampled residents (Resident #1), the Facility failed to ensure that two staff members immediately reported allegations of abuse of Resident #1, who was cognitively impaired, by the Accused CNA. CNA #1 reported observing the Accused CNA flick Resident #1's ear and poke Resident #1 on the waist, which was annoying and startling to Resident #1. CNA #2 reported observing the Accused CNA push Resident #1 onto the toilet and threaten to leave Resident #1 in the bathroom. Findings included: The annual Minimum Data Set (MDS) assessment, dated 9/17/10, indicated that Resident #1 had problems with short and long-term memory, and that Resident #1 had severely impaired cognitive skills for decision-making (never/rarely made decisions). The MDS indicated that Resident #1 was rarely understood and rarely understood others. The MDS indicated that Resident #1 required extensive assistance with transfer. The ADL Plan of Care for Resident #1, dated 11/24/10, indicated that Resident #1 required a two or more person physical assist for transfers. CNA #1 was interviewed on 12/2/10 at 12:20 PM. CNA #1 reported observing the Accused CNA flicking Resident #1's ear and hair on more than one occasion (dates unknown). CNA #1 said the Accused CNA thought this was funny, but it annoyed Resident #1. CNA #1 also saw the Accused CNA poke Resident #1's waist to get Resident #1's attention (date unknown). CNA #1 said these actions annoyed and scared Resident #1. CNA #1 did not think it was right for the Accused CNA to treat Resident #1 in this manner, but did not report the concerns. CNA #2 was interviewed on 12/2/10 at 1:25 PM. CNA #2 said that on an unknown date, the Accused CNA pushed Resident #1 onto the toilet. CNA #2 reported that the Accused CNA told Resident #1 that if Resident #1 did not use the toilet at that time, the Accused would leave Resident #1 there all night. CNA #2 said the Accused CNA told Resident #1 to shut up and go. CNA #2 said Resident #1 tried to slap the Accused CNA in response. CNA #1 and CNA #2 said they did not report their observations to a supervisor, so that an investigation into the alleged incidents could be conducted.