Every finding on record at Mission Care at Holyoke

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had a diagnosis of dementia with agitation and was looking for assistance from staff, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 06/26/26, a staff member witnessed Certified Nurse Aide (CNA) #1 interact with Resident #1 in a demeaning and derogatory manner.Findings include:Review of the Facility Policy titled Resident Rights and Responsibilities, dated as revised July 2015, indicated the facility will protect and promote the rights of each resident as set forth in the Resident [NAME] of Rights. Further review of the Policy indicated that residents had the right to be treated with consideration, respect and full recognition of their dignity and individuality. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/26/26, indicated that Resident #1 was agitated and yelling around 4:00 P.M. The Report indicated that a staff member alleged that CNA #1 responded (to this behavior) by telling Resident #1 to stop yelling like an idiot. The Report further indicated that a few moments later, when Resident #1 complained that staff had not responded quickly enough to his/her request for assistance, CNA #1 explained that she had been assisting another resident. The Report indicated that Resident #1 responded, fuck them, and CNA #1 replied, Well, fuck you too. Resident #1 was admitted to the Facility in June 2021, diagnoses included dementia with agitation, Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD). Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/23/26, indicated Resident #1 was cognitively intact with a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 was wheelchair-bound and dependent on staff for mobility and Activities of Daily Living (ADLs). Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her Quarterly MDS, completed 05/23/26, indicated that Resident #1 should be approached in a calm and reassuring manner during incidents of increased anger or agitation. During an interview on 07/28/26 at 11:20 A.M., Certified Nurse Aide (CNA) #2 said that she witnessed a verbal altercation between Resident #1 and CNA #1 on 06/26/26 around 4:00 P.M. CNA #2 said that Resident #1 was agitated and distressed after experiencing an episode of bowel incontinence and was yelling loudly that he/she wanted a shower. CNA #2 said that CNA #1 responded to Resident #1 by telling him/her to stop yelling like an idiot. CNA #2 further said that Resident #1 required the assistance of two staff members for care, so she offered to assist CNA #1. CNA #2 said that after Resident #1's shower was completed, he/she was crying and complaining that staff had taken too long to assist him/her. CNA #2 said that CNA #1 explained to Resident #1 that she had been assisting another resident and he/she responded, fuck them! CNA #2 said that CNA #1 responded to Resident #1 by saying, well, fuck you too! Review of the Director of Nurses (DON's) Written Summary of her interview with Resident #1, dated 06/29/26, indicated Resident #1 told her that the CNA who provided his/her shower on Friday (later identified as CNA #1) had called him/her an idiot. The Summary further indicated that Resident #1 told the DON that CNA #1 also used the word fuck while addressing him/her. The Summary indicated Resident #1 was pleased that CNA #1 would no longer provide him/her with care. Resident #1 declined the surveyor's request for an interview. During a telephone interview on 07/28/26 at 12:41 P.M., Certified Nurse Aide (CNA) #1 said that on 06/26/26 during the evening shift, Resident #1 was agitated and yelling loudly and demanding a shower. CNA #1 said that she and CNA #2 assisted Resident #1 with the shower. CNA #1 further said she did not recall using profanity or telling Resident #1 to stop yelling like an idiot. During an interview on 07/28/26 at 1:15 P.M., the Director of Nurses (DON) said that the Facility's investigation concluded that Certified Nurse Aide (CNA) #1 failed to treat Resident #1 with dignity and respect during an interaction on 06/26/26. The DON said the conclusion was based on consistent witness statements provided by CNA #2 and Resident #1.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had been allegedly witnessed by a staff member on 5/10/26 to have been subjected to verbal abuse by another staff member, the Facility failed to ensure staff consistently implemented and followed their Abuse Policy related to the requirement to immediately report an allegation of abuse to Facility Administration when the Director of Nursing was not notified until 06/01/26 about the incident, which had occurred several weeks earlier.Findings include:Review of the Facility Policy titled Resident Abuse (Screening, Training, Prevention, Reporting, Investigation), dated as effective 11/03/20, indicated it is the policy of the Facility that abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of property is prohibited.The Policy indicated it included the following definition of verbal abuse as: any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families or within their hearing distance, to describe residents regardless of their age, ability to comprehend, or disability.Further review of the Policy indicated the staff member who hears an allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor in person or by phone. The Policy indicated that the administrator or on-call Designee and Director of Nursing Services are to be notified immediately.Review of the Facility's Investigation Summary, undated, indicated that on 05/31/26 at 9:20 P.M., (the correct date was 06/01/26 per interview with the Director of Nursing (DON), the DON was notified that a Certified Nurse Aide (later identified as CNA #1) had accused Nurse #1 of having called Resident #1 a derogatory name.Further review of the Investigation Summary indicated it included a written statement from the DON, dated 06/05/26, that indicated Human Resources (HR) notified her on the evening of 05/31/26, (which per the DON, was a typographical error and the date she was notified 06/01/26), CNA #1 sent an e-mail communication to HR with multiple concerns about Nurse #1 going back to the beginning of May 2026, one of which was an allegation of potential verbal abuse. The DON's statement indicated a report was made to the Department of Public Health (DPH) and an investigation was initiated at that time.Review of CNA #1's e-mailed statement to HR, dated 06/01/26 at 7:53 P.M., indicated that on 05/10/26 (exact time not provided), she (CNA #1) witnessed Nurse #1 call Resident #1 a motherfucker and told him/her that he/she stinks.Resident #1 was admitted to the Facility in April 2024, diagnoses included unspecified dementia with unspecified severity and agitation.Review of Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 05/03/26, indicated he/she was moderately cognitively impaired with a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact).During an in-person interview on 06/23/26 at 11:00 A.M., Resident #1 said he/she did not remember an incident where Nurse #1 called him/her a motherfucker or being told he/she stinks.During a telephone interview on 06/23/26 at 2:25 P.M. and a follow up telephone interview on 06/24/26 at 4:00 P.M., CNA #1 said on 05/10/26 at around 8:00 P.M. (exact time unknown), Nurse #1 was at the medication cart and Resident #1 was seated in a chair nearby. CNA #1 said Resident #1 constantly asks for staff to pour him/her water, so much so that they place a pitcher of water with cups accessible to him/her so he/she could pour it him/herself, which he/she is able to do.CNA #1 said on the evening of 5/10/26, despite this intervention, Resident #1 continued to ask Nurse #1 to pour water for him/her. CNA #1 said at one point Nurse #1 responded to Resident #1 in a rude manner and called him a stinky motherfucker. CNA #1 said Resident #1 became angry and stood up from his/her chair and in response, Nurse #1 shouted over the facility intercom that she was assaulted and needed muscle. CNA #1 said a male CNA from a different unit responded to the overhead page and escorted Resident #1 to his/her room with no further incidents the rest of the shift.CNA #1 said she reported this incident in detail to Nursing Supervisor #1 twice on 05/10/26. CNA #1 said she initially notified Nursing Supervisor #1, explaining in detail the interaction with Nurse #1 and Resident #1, about the incident around 8:43 P.M. and said she specifically told Nursing Supervisor #1 that Nurse #1 was verbally abusive toward Resident #1. CNA #1 said she thought about the incident all night long and said when she saw Nursing Supervisor #1 seated at the reception desk in the lobby as they were clocking out on 05/11/26 at 7:23 A.M., said she brought up the incident to her again. CNA #1 said Nursing Supervisor #1 told her that she would report the alleged incident to the DON.During a telephone interview on 06/24/26 at 10:11 A.M., Nursing Supervisor #1 said on 05/10/26, CNA #1 told her that Nurse #1 was verbally abusive toward Resident #1, said she was not sure of the exact time CNA #1 made the report, and said she thought it was after Nurse #1 went home for the evening after 11:00 P.M.Nursing Supervisor #1 further said the more she thought about it, said that CNA #1 did not report this incident to her until 05/11/26 at shift change (exact time unknown).Nursing Supervisor #1 said when the DON arrived that morning (05/11/26) she told her that CNA #1 reported to her that she (CNA #1) was concerned that Nurse #1 was verbally abusive towards Resident #1.During an interview on 06/23/26 at 3:50 P.M., the Director of Nursing (DON) said on the morning of 05/11/26, Nursing Supervisor #1 told her that CNA #1 was unhappy with Nurse #1 and had not specifically reported that CNA #1 had alleged that Nurse #1 had verbally abused Resident #1. The DON said the first she heard of the verbal abuse allegation was after HR contacted her (on 06/01/26) to inform her they had received an e-mail from CNA #1 with multiple concerns about Nurse #1, including an allegation that Nurse #1 had verbally abused Resident #1 on 05/10/26. The DON said if CNA #1 had a concern that Nurse #1 verbally abused Resident #1, it was the expectation that CNA #1 inform Nursing Supervisor #1 immediately. The DON further said once Nursing Supervisor #1 was made aware of a verbal abuse allegation, it was expected that Nursing Supervisor #1 implement the Facility's Abuse Policy and inform either herself or the Administrator immediately. The DON said Facility staff did not implement their Abuse Policy regarding reporting allegations of Abuse immediately.On 06/23/26, the Facility presented the Surveyor with a Plan of Correction with an effective date of 06/03/26, that addressed the areas of concern identified in this survey. The Plan of Correction is as follows:A. Resident #1 was assessed, he/she showed no signs of distress or change in behavior as a result of the alleged incident, and he/she continues to be monitored and supported by staff as needed. B. On 06/01/26 and weekly thereafter, the Director of Nurses interviewed residents that resided on the unit where Nurse #1 was employed to determine whether there were any further allegations of verbal abuse and to assess their overall well-being, with no additional instances found or reported. Random resident interviews will continue to be conducted bi-weekly for two months, then monthly for two months by the Director of Nurses. C. On 06/02/26, the Director of Nurses immediately initiated an investigation into the allegation, and the facility was unable to substantiate the allegation of verbal abuse. D. On 06/02/26, the Personnel Development Coordinator and/or her designee completed re-education (Topic: Reporting) and reviewed the Facility's abuse policy with all Facility staff. E. On 06/03/26, Social Services and Behavioral Health staff interviewed and assessed Unit 3 (where the allegation of verbal abuse occurred) residents to determine whether they felt safe in their environment, and random interviews will continue as needed, and ongoing support and monitoring for mood and behavior changes will be provided. F. The results of the resident interviews will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for four months. G. The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was cognitively impaired and was dependent on staff to meet his/her care needs, the Facility failed to ensure nursing notified the Provider when he/she was observed to have a new area of bruising around the corner of his/her right eye, of unknown origin.Findings include:Review of the Facility's policy titled, Physician Notification-Change of Condition, review date 10/15/25, indicated:-It is the policy of this facility to notify the physician when the residents' condition or status changes unexpectedly or substantially. -If a resident is evaluated by a charge nurse to have a change in condition, the charge nurse will notify the RN Supervisor on duty.-The RN Supervisor will do a follow-up assessment to ensure that the assessment is documented and reported to the Physician.-The Physician will (or alternate) will be contacted to report findings. Resident #1 was admitted to the facility May 2024, diagnoses included vascular dementia, depression, age-related osteoporosis (bone disease causing weak, brittle bones), history of cerebral infarction (stroke) and aphasia (speech impairment).Review of Resident #1's Nurse Progress Note, dated 11/04/25, indicated he/she had a red-purple, non-tender bruise on his/her right eye. There was no documentation to support that the Provider had been notified by nursing staff of a new right eye bruise.During an interview on 12/03/25 at 1:30 P.M., Nurse #1 said that she had discovered that Resident #1 had a new bruise above his right eyebrow while she was making rounds at the start of her 7:00 A.M to 3:00 P.M. shift on 11/04/25. Nurse #1 said that she could see the bruise as soon as she saw Resident #1, even with the light off. Nurse #1 said that she notified the Unit Manager as soon as he came to work and he helped her to complete the Incident Report, New Skin Tear or Bruise Report, and obtain witness statements. Nurse #1 said that she was unable to determine how Resident #1 had obtained the bruise. Nurse #1 said that she did not notify the Physician of Resident #1's new eye bruise of unknown origin.During an interview on 12/03/25 at 2:00 P.M., the Unit Manager said that Nurse #1 had notified him that Resident #1 had a bruise surrounding his eye. The Unit Manager said that he assessed the bruise to be at the corner of Resident #1's right eye. The Unit Manager said he instructed Nurse #1 to complete the Skin/bruise packet and to get statements from staff. The Unit Manager said he had not notified the Provider or the Director or Nursing of Resident #1's eye bruise of unknown origin.Review of the Facility Skin Tear or Bruise Report, dated 11/04/25, indicated Resident #1 was observed to have a 2 centimeter (cm) by 2 cm red-purplish, round bruise on the corner of his/her right eye. The Report indicated the Resident was unable to say how the bruise had happened.Review Resident #1's Nurse Progress Note, dated 11/05/25, indicated he/she had a bruise on his/her right eye. Review of Resident #1's Nurse Progress Notes, dated 11/04/25 through 11/09/25, indicated there was no documentation to support nursing notified the Provider that he/she had a new area of bruising on the corner of his/her right eye.Review of Resident #1's Physician Assistant (PA) Note, dated 11/09/25, indicated Nursing staff notified the PA of Resident #1's altered mental status and self-removal of an indwelling urinary catheter. The Note indicated Resident #1 was to be transferred to the Hospital Emergency Department (ED) for evaluation.There was no documentation in the PA's Progress note to support that the PA was aware of and/or had been notified by nursing staff of the bruise to Resident #1's right eye.During a telephone interview on 12/05/25 at 9:50 A.M., Physician #1 said that he not been notified by the Facility that Resident #1 had new bruise on his/her right eye and had learned about the bruise during the Facility's investigation. Physician #1 said the nursing staff should have notified the Provider of the new eye or facial bruise because if there was a concern for facial injury, the resident would have been sent to the ED for an evaluation.Review of the Report submitted by the Facility via the Health Care Reporting System (HCFRS), dated 11/11/25, indicated [after transferring Resident #1 to the ED for evaluation for altered mental status and self-removal of his/her indwelling catheter] the Facility was notified by the hospital that Resident #1 had a CT (computed tomography or CAT scan) that indicated he/she had a right anterior temporal bone (upper section forming the side of the skull) nondisplaced fracture and subarachnoid hemorrhage (brain bleed). Review of Resident #1's Hospital Neurosurgery Consult note, dated 11/10/25, indicated he/she had a right non-displaced temporal skull fracture with subarachnoid hemorrhage and no reported trauma. During an interview on 12/03/25, at 3:00 P.M., the Director of Nursing (DON) said that on 11/11/25, she had been notified by the Hospital that Resident #1 had a skull fracture and subarachnoid hemorrhage. The DON said that on 11/11/25 she started an investigation including a review of Resident #1's clinical record which indicated that on 11/04/25 nursing staff had observed Resident #1 with a new bruise on his/her face by his/her right eye. The DON said that nursing staff should have notified herself and the Physician, on 11/04/25, when the bruise to Resident #1's eye was observed, but they had not, as required. On 12/03/25, the Facility presented the Surveyor with a plan of correction, with an effective date 11/18/25, that addressed the areas of concern identified in this survey, the Plan of Correction is as follows:A. Resident #1 returned to the Facility, his/her plan of care has been updated. Therapy services are in place. B. On 11/13/25 the Regional Clinical Director completed re-education of the Administrator and Director of Nurses on the Risk Management Module Policy to ensure events are entered into the Risk Management Portal, are thoroughly investigated and reviewed for accuracyC. On 11/13/24 the Director of Nurses and/or designee completed an initial Risk Management (RMS) audit and initiated ongoing daily audits of current residents. RMS audits will continue daily for 30 days, then weekly for four weeks then monthly for two months. D. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on the Physician Notification-Change of Condition Policy.E. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on the Fall Protocol Policy.F. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on Neurological Checks and Vital Signs policies. G. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on the Resident Abuse Policy including reportable injuries of unknown origin.H. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on the Clinical Alert Dashboard in the electronic medical record. I, On 11/14/25 the Director of Nurses and/or designee completed re-education of nurses on the Risk Management Module Policy to ensure events are entered into the Risk Management Portal, thoroughly investigated and reviewed for accuracy.J. On 11/18/25 the Director of Nurses and/or designee completed an initial skin audit and initiated ongoing weekly skin audits of current residents. Random skin audits will continue weekly for eight weeks then monthly for three months. K. On 11/18/25 the Quality Assurance Performance Improvement Committee discussed the areas of concern related to this incident. L. The Director of Nursing and/or designee are responsible for compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) the Facility failed to ensure that after being made aware that Resident #1 had an injury of unknown origin on 11/11/25 by the Hospital, that they reported the injury to the Department of Public Health (DPH) within two hours as required, when it was not reported to DPH until 11/17/25, (6 days later).Findings include:Review of the Facility's policy titled, Resident Abuse (Screening, Training, Prevention, Reporting, Investigation), dated as reviewed 10/15/25, included but was not limited to the following:Allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of property are to be reported to the Massachusetts Department of Public Health:a. Immediately but not later than two hours after the allegation is made if the allegation involves abuse or resulting in serious bodily injury or if there is reasonable suspicion of a crime as defined by the Elder Justice Act.b. No later than 24 hours if does not involve abuse or serious bodily injury.Review of the Report submitted by the Facility via the Health Care Reporting System (HCFRS), dated 11/17/25, indicated the Facility was notified by the hospital that Resident #1 had a CT [computed tomography or CAT scan] that indicated he/she had a right anterior temporal bone [front part of the bone on the right side of the skull} non displaced fracture and subarachnoid hemorrhage [brain bleed]. The Report indicated the Facility had conducted an investigation including a review of the medical record that indicated a Nurses' Note, dated 11/04/25, described a purple/red bruise to Resident #1's right eye [injury of unknown origin]. The Report indicated that Resident #1 said he/she did not know what had happened to cause the bruise. The Report indicated that staff interviews were obtained without identifying a cause for the bruise to Resident #1. Resident #1 was admitted to the facility May 2024, diagnoses included vascular dementia, depression, age-related osteoporosis (bone disease causing weak, brittle bones), history of cerebral infarction (stroke) and aphasia (speech impairment).Review of Resident #1's Nurse Progress Note, dated 11/04/25, indicated he/she had a red-purple, non-tender bruise on his/her right eye. Review of the Facility Incident Report, dated 11/04/25, indicated the Nurse had noted a bruise on the side of Resident #1's right eye. The note indicated the bruise was described as [above his/her right eyebrow] purple-red and without bleeding. The Report indicated a warm compress was applied.Review of Nurse #1's written statement, dated 11/11/25, indicated that Nurse #1 had shown Resident #1 a picture of his/her bruise, and that Resident #1 stated he/she did not know what had happened. The Statement indicated that Nurse #1 had asked Certified Nurse Aides (CNA's) and an Activity Aide, if they knew what had happened but was told that none of them had noticed anything. During an interview on 12/03/25 at 1:30 P.M., Nurse #1 said that she had discovered that Resident #1 had a bruise above his right eyebrow while she was making rounds at the start of the 7:00 A.M. to 3:00 P.M. shift on 11/04/25. Nurse #1 said that she could see the bruise as soon as she saw him/her, even with the light off. Nurse #1 said she had not heard that Resident #1 had a bruise in report and that she did not find that a bruise had been documented in his/her medical record. Nurse #1 said that she reported to bruise to the Unit Manager as soon as he came to work and he helped her to assess Resident #1 and complete the Incident Report and obtain staff statements. Nurse #1 said that Resident #1 did not have side rails on his/her bed and that she was unable to determine how Resident #1 had obtained the bruise. Nurse #1 said she was unaware that an injury of unknown origin should be reported to DPH.During an interview on 12/03/25 at 2:00 P.M., the Unit Manager said that Nurse #1 had notified him that Resident #1 had a bruise on his/her eye. The Unit Manager said that he assessed the bruise to be at the corner of Resident #1's right eye. The Unit Manger said that he had seen Resident #1 on the previous day and he/she did not have a bruise. The Unit Manager said he instructed Nurse #1 to complete the Skin/bruise packet and to get statements from staff. The Unit Manager said that he had been under the impression that Resident #1 had side rails on his/her bed but learned afterwards that he/she did not. The Unit Manager said that he did not know how Resident #1 had obtained the bruise on his/her right eye [above the eyebrow]. During an interview on 12/03/25, at 3:00 P.M., the Director of Nursing (DON) said the facility policy is that any bruise or injury of unknown origin is investigated immediately and reported to DPH within two hours. The DON said the Nursing staff should have notified her of Resident #1's eye bruise of unknown origin immediately which then should have been reported to DPH within two hours but had not been. Although the DON was made aware of Resident #1's injury by the hospital on [DATE], and started an investigation, the injury of unknown origin {which was first found by nursing staff on 11/04/25] was not reported to DPH until 11/17/25 (6 days later). On 12/03/25, the Facility presented the Surveyor with a plan of correction with an effective sate of 11/18/25, that addressed the areas of concern identified in this survey, the Plan of Correction is as follows:A. Resident #1 had returned to the Facility, his/her plan of care has been updated. Therapy services are in place. B. On 11/13/25 the Regional Clinical Director completed re-education of the Administrator and Director of Nurses on the Risk Management Module Policy to ensure events are entered into the Risk Management Portal, are thoroughly investigated and reviewed for accuracyC. On 11/13/24 the Director of Nurses and/or designee completed an initial Risk Management (RMS) audit and initiated ongoing daily audits of current residents. RMS audits will continue daily for 30 days, then weekly for four weeks then monthly for two months. D. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on the Physician Notification-Change of Condition Policy.E. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on the Fall Protocol Policy.F. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on Neurological Checks and Vital Signs policies. G. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on the Resident Abuse Policy including reportable injuries of unknown origin.H. On 11/13/25 the Director of Nurses and/or designee completed re-education of nurses on the Clinical Alert Dashboard in the electronic medical record. I. On 11/14/25 the Director of Nurses and/or designee completed re-education of nurses on the Risk Management Module Policy to ensure events are entered into the Risk Management Portal, thoroughly investigated and reviewed for accuracy.J. On 11/18/25 the Director of Nurses and/or designee completed an initial skin audit and initiated ongoing weekly skin audits of current residents. Random skin audits will continue weekly for eight weeks then monthly for three months. K. On 11/18/25 the Quality Assurance Performance Improvement Committee discussed the areas of concern related to this incident. L. The Director of Nursing and/or designee are responsible for compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) whose diagnoses included Post Traumatic Stress Disorder (PTSD) and anxiety, with behaviors that included repeatedly entering and exiting his/her room and pacing on the unit when anxious, the Facility failed to ensure that he/she was free from involuntary seclusion by means of confinement, when on 10/14/25 during the evening shift, Nurse #1 prevented Resident #1 from exiting his/her room by physically holding the door shut. Resident #1's anxiety escalated while he/she was confined to his/her room and he/she was heard crying, banging on the door and yelling to be let out.Findings include:Review of the Facility Policy titled Resident Abuse (Screening, Training, Prevention, Reporting, Investigation)-MA, dated as effective 11/03/20, indicated it is the policy of the Facility that abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property is prohibited. Further review of the Policy indicated it included the following definition of involuntary seclusion: the separation of a resident from other residents or from his/her room against the resident's will or the will of the resident's legal representative. Review of the Facility's Investigation Summary, undated, indicated that Resident #1 reported, and two alert and oriented residents also said that on 10/14/25 at around 6:45 P.M., they witnessed Nurse #1 closing and holding Resident #1's room door closed while Resident #1 [who was confined inside] was asking to leave the room. The Summary further indicated that based on resident and staff interviews, Facility administration substantiated the allegation that Nurse #1 prevented Resident #1 from leaving his/her room, against his/her will and that Nurse #1's employment was terminated.Resident #1 was admitted to the Facility in April 2025, diagnoses included neurocognitive disorder with Lewy bodies (a degenerative brain disorder also known as Lewy body dementia), post-traumatic stress disorder (PTSD) and anxiety disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated as completed 10/05/25, indicated he/she was cognitively intact with a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #1 ambulated independently and required the use of a walker.Review of Resident #1's Behavioral Care Plan, reviewed and revised on 10/06/25, indicated that he/she had the potential to scream at others, swear and have flashbacks of early trauma related to Lewy body dementia, Parkinsonism, PTSD and ineffective coping skills. The Care Plan indicated the following interventions were to be implemented when Resident #1 becomes agitated:-intervene before agitation escalates-guide away from source of distress-engage calmly in conversation.-if Resident #1's response is aggressive, staff is to calmly walk away, and approach later.Resident #1's written statement, (as told by him/her to the Director of Nurses (DON)), dated 10/16/25, indicated that not last night, but the night before Nurse #1 shut the door to his/her (Resident #1's) room despite his/her stated preference to leave the door open. The Statement indicated that when Resident #1 attempted to open the door, he/she was unable to do so because Nurse #1 was holding the door shut. Resident #1 was on Medical Leave of Absence (unrelated to this incident) from the facility at the time of survey and was therefore unavailable to be interviewed. Review of the DON's investigation notes indicated that CNA #1 told the DON that she observed Nurse #1 standing in front of Resident #1's closed door at the time of the incident, but that CNA #1 could not recall whether or not Nurse #1 was holding the door shut. Review of Resident #2's admission MDS assessment, dated as completed 10/06/25, indicated he/she was cognitively intact with a score of 13 out of 15 on the BIMS. Review of Resident #3's admission MDS assessment, dated as completed 09/17/25, indicated he/she was cognitively intact with a score of 13 out of 15 on the BIMS. During an interview on 11/25/25 at 1:20 P.M., Resident #2 said that he/she witnessed an incident between Nurse #1 and Resident #1 more than a month ago (exact date unknown). Resident #2 said he/she was watching television in the common area at the end of the hall when he/she heard loud banging and raised voices in the hallway and heard Resident #1 yelling, Open the door. Resident #2 said that when he/she went into the hallway to investigate the commotion, he/she observed Nurse #1 holding Resident #1's door closed with both hands. Resident #2 said that Nurse #1 was grasping onto the doorknob, had both feet firmly planted on the floor, and was leaning his body away from the door to maintain leverage, preventing Resident #1 from exiting his/her room. Resident #2 said that while Nurse #1 held the door shut, he/she could hear Resident #1, who was inside the room, yelling, crying, and banging on the door, attempting to get out. Resident #2 said that after a few minutes, Nurse #1 released the door after he/she (Resident #2) confronted him, Resident #2 said he/she asked Nurse #1 how he would feel if the same thing occurred to his family member. Resident #2 also reported that CNA #1 was present during the altercation. During an interview on 11/25/25 at 1:15 P.M., Resident #3 said that he/she observed Nurse #1 hold Resident #1's door shut while he/she was seated across the hall. Resident #3 said that prior to the incident, Resident #1 had been yelling in the hallway regarding something he/she wanted, and Nurse #1 instructed him/her (Resident #1) to return to his/her room. Resident #3 said this sequence occurred two or three times, with Resident #1 returning to his/her room briefly before exiting again. Resident #3 said that on the third occasion when Resident #1 attempted to leave his/her room, Nurse #1 closed the door (while Resident #1 was still in the room) and held it firmly for a few minutes before reopening it. Resident #3 said that Resident #1 appeared to be pulling on the door from the inside to open it while Nurse #1 held it closed. Resident #3 said the incident lasted a few minutes. Resident #3 further said that another resident, Resident #2, who was present, yelled at Nurse #1 for keeping the door closed and asked Nurse #1, How would you feel if that was your family member? During an interview on 11/25/25 at 2:50 P.M., Certified Nurse Aide (CNA) #2 said that despite working at the Facility for only a few months, she was familiar with Resident #1's behavior because she worked full time from 7:00 A.M. to 7:00 P.M. on Resident #1's unit. CNA #2 said that Resident #1 often paced in the hallway and perseverated about when his/her next medications were scheduled. CNA #2 said that limit-setting and redirection were not always effective interventions for Resident #1. CNA #2 said that on the evening of 10/14/25, Resident #1's anxiety began to escalate prior to mealtime and that he/she continued pacing the unit after dinner. CNA #2 said that around 6:45 P.M., while she was providing care to a resident a few doors away, she heard a commotion in the hallway involving Resident #1 and Nurse #1. CNA #2 said she heard banging on a door, consistent with someone rattling a door and attempting to open it. CNA #2 said that when she entered the hallway, she observed Nurse #1 releasing the handle of Resident #1's door. CNA #2 said she did not witness whether Nurse #1 had been holding the door shut. CNA #2 said that Resident #2 was in the hallway, appeared very upset and had yelled at Nurse #1, stating that he should not have held Resident #1's door shut because he/she was not well and did not know any better. CNA #2 said she provided care to Resident #1 immediately after the incident and assisted him/her back to bed. CNA #1 said that during care, Resident #1 appeared overwhelmed and very upset. During an interview on 11/25/25 at 1:33 P.M., Nurse #2 said that she was working from 7:00 A.M. to 7:00 P.M. on Resident #1's unit on 10/14/25. Nurse #2 said that shortly before shift change that evening, she was on the opposite end of the unit passing medications when she heard Nurse #1 tell Resident #1 to return to his/her room. Nurse #2 said she heard a commotion between Resident #1 and Nurse #1, but siad she was not in a position to see what occurred. Nurse #2 said that approximately 15 minutes later, when she arrived back on that end of the unit, she overheard Resident #2 on his/her cell phone stating that he/she had witnessed a Nurse holding a resident's door shut. During a telephone interview on 11/26/25 at 10:43 A.M., Nurse #1 said that on the evening of 10/14/25, Resident #1 was very anxious, agitated and repeatedly requesting assistance from a CNA to make his/her bed. Nurse #1 said that he informed Resident #1 several times that staff were occupied with providing care to other residents but assured him/her that someone would assist him/her as soon as possible. Nurse #1 said he redirected Resident #1 to go back to his/her room several times; however, he/she continued to leave the room and repeatedly voiced the same concern. Nurse #1 said that at one point Resident #1 began to exit his/her room through the partially closed door, and that he held the door open to allow him/her to pass safely. Nurse #1 said he did not at any time hold the door closed to prevent Resident #1 from exiting. During an interview on 11/25/25 the Director of Nurses (DON) said that Nurse #1 was suspended on 10/15/25, pending investigation. The DON said that the Facility's investigation substantiated the allegation of involuntary seclusion and as a result and said that Nurse #1 employment with the Facility was terminated.

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #4), the Facility failed to ensure staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of abuse to Facility administration, when: 1.) On 10/14/25, Nurse #2 and Nurse #3 became aware during the evening shift, of an allegation of involuntary seclusion by means of confinement, when Nurse #1 prevented Resident #1 from exiting his/her room at will, however, neither of them reported the allegation immediately, as required. 2.) Certified Nurse Aide (CNA) #4 reported an allegation of verbal abuse involving Nurse #1 and Resident #4 on 10/02/25 to the Charge Nurse, however, Facility administration was not notified until a few days later, on 10/04/25. Findings include:Review of the Facility Policy titled Resident Abuse (Screening, Training, Prevention, Reporting, Investigation)-MA, dated as effective 11/03/20, indicated it is the policy of the Facility that abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property is prohibited. The Policy indicated it included the following definition of involuntary seclusion: the separation of a resident from other residents or from his/her room against the resident's will or the will of the resident's legal representative. Further review of the Policy indicated the staff member who hears an allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor in person or by phone. The Policy indicated the Administrator or on-call designee and Director of Nursing Services are to be notified immediately.1). Review of the Facility's Investigation Summary, undated, indicated that Resident #1 reported, and two alert and oriented residents said that on 10/14/25 at around 6:45 P.M., they witnessed Nurse #1 closing and holding Resident #1's door closed while Resident #1 [who was confined inside] was asking to leave the room. The Summary further indicated that based on resident and staff interviews, the Facility administration substantiated the allegation that Nurse #1 prevented Resident #1 from leaving his/her room against his/her will and that Nurse #1's employment was terminated.Resident #1 was admitted to the Facility in April 2025, diagnoses included neurocognitive disorder with Lewy bodies (a degenerative brain disorder also known as Lewy body dementia), post-traumatic stress disorder (PTSD) and anxiety disorder. Resident #1's written statement, (as told by him/her to the Director of Nurses (DON)), dated 10/16/25, indicated that not last night, but the night before Nurse #1 shut the door to Resident #1's room despite his/her stated preference to leave the door open. The Statement indicated that when Resident #1 attempted to open the door, he/she was unable to do so because Nurse #1 was holding the door shut. During an interview on 11/25/25 at 1:33 P.M., Nurse #2 said that she was working from 7:00 A.M. to 7:00 P.M. on Resident #1's unit on 10/14/25. Nurse #2 said that shortly before shift change that evening, she was on the opposite end of the unit passing medications when she heard Nurse #1 tell Resident #1 to return to his/her room. Nurse #2 said she heard a commotion between Resident #1 and Nurse #1, though she was not in a position to see what occurred. Nurse #2 said that approximately 15 minutes later, when she arrived back at that end of the unit, she overheard Resident #2 on his/her cell phone stating that he/she had witnessed a Nurse holding a resident's door shut. Nurse #2 said she did not report the incident to Facility administration.During an interview on 11/25/25 at 1:20 P.M., Resident #2 said that he/she witnessed an incident between Nurse #1 and Resident #1 more than a month ago (exact date unknown). Resident #2 said he/she was watching television in the common area at the end of the hall when he/she heard loud banging and raised voices in the hallway and heard Resident #1 yelling, Open the door. Resident #2 said he/she observed Nurse #1 holding Resident #1's door closed with both hands, and Nurse #1 was grasping onto the doorknob, had both feet firmly planted on the floor, and was leaning his body away from the door to maintain leverage, preventing Resident #1 from exiting his/her room. During a telephone interview on 12/04/25 at 1:44 P.M., (which also included a review of her written witness statement dated 10/15/24) Nurse # 3 said that while she was the acting Supervisor during the evening shift on 10/14/25, Resident #2 reported to her that he/she witnessed an altercation between Resident #1 and Nurse #1. Nurse #3 said that around 8:00 P.M., Resident #2 reported that earlier that evening, he/she saw Nurse #1 hold Resident #1's door closed, while he/she (Resident #1) was inside the room, preventing him/her from leaving the room. Nurse #3 said she observed that Resident #1 was in bed, watching television and appeared safe, therefore she did not further investigate the allegation and did not report it to Facility administration. During an interview on 11/25/25 at 2:00 P.M., the Director of Nurses (DON) said that Nurse #2 and Nurse #3 did not immediately report the allegation to Facility administration as required. The DON further said that she was not notified about the incident until it was reported to her by Resident #2 on the morning of 10/15/25. 2). Resident #4 was admitted to the Facility in April of 2021 with diagnoses including moderate dementia with mood disturbance, major depressive disorder and anxiety disorder.Review of Resident #4's Quarterly MDS assessment, dated as completed 09/07/25, indicated he/she was moderately cognitively impaired with a score of 9 out of 15 on the BIMS. Review of Certified Nurse Aide (CNA) #4's Written Statement, dated 10/04/25, indicated that on the previous Thursday (10/02/25), when CNA #4 attempted to provide care to Resident #4, he/she refused care and was yelling loudly. The Statement indicated that Nurse #1 told Resident #4, You are a faggot racist and that is why you won't let her clean you.During an interview on 11/25/25 at 2:47 P.M., CNA #4 said that one day she had worked in early October 2025, she reported to Nurse #1 that Resident #4 had refused care. CNA #4 said that Nurse #1 responded by confronting Resident #4, accusing him/her of being racist, and called him/her a faggot. CNA #4 said that she reported the incident to the Charge Nurse. CNA #4 further said that although she could not recall the date of the incident during the interview, it was documented in the written witness statement that she provided to Unit Manager #1.CNA #4 said that (10/02/25) was not the first time she had witnessed Nurse #1 call Resident #4 a faggot racist although she could not recall details or dates for any of the previous incidents and further said that she had not reported them to her supervisor.During an interview on 11/25/25 at 3:44 P.M., Unit Manager #1 said that while she was acting as the weekend supervisor on 10/04/25, a Charge Nurse reported that CNA #4 told her that Nurse #1 had called Resident #4 a faggot racist. Unit Manager #1 said that the Charge Nurse did not report the allegation to Facility administration immediately as required.Unit Manager #1 said that both the Charge Nurse and CNA #4 should have reported the allegation to Facility administration immediately. During an interview on 11/25/25 at 4:28 P.M., the Director of Nurses (DON) said that on 10/04/25 Unit Manager #1 reported CNA #4's allegation involving Nurse #1 and Resident #4, and that CNA #4 could not recall the exact date of the incident. The DON said that it wasn't until she reviewed CNA #1's written statement, dated 10/04/25, that she noticed the incident had occurred on the previous Thursday, (two days earlier).During an interview on 11/25/25 at 4:45 P.M. the Administrator said the expectation is for all allegations of suspected abuse to be reported to Facility administration immediately.

Based on records reviewed and interviews, for one of four sampled residents (Resident #4), who was moderately cognitively impaired, the Facility failed to ensure that an allegation of verbal abuse was reported to the Massachusetts Department of Public Health (DPH) as required, when on 10/04/25, the Director of Nurses (DON) was made aware of the allegation made by Certified Nurse Aide #4 against Nurse #1, however, the Facility had not reported the allegation to DPH as of 11/25/25 (52 days later).Findings include:Review of the Facility Policy titled Resident Abuse (Screening, Training, Prevention, Reporting, Investigation)-MA, dated as effective 11/03/20, indicated it is the policy of the Facility that abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property is prohibited. Further review of the Policy indicated allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of property are to be reported to the Massachusetts Department of Public Health:a. Immediately but not later than two hours after the allegation is made if the allegations involve abuse or result in serious bodily injury or if there is reasonable suspicion of a crime as defined by the Elder Justice Act.b. No later than 24 hours if it does not involve abuse or serious bodily injury.Resident #4 was admitted to the Facility in April of 2021 with diagnoses including moderate dementia with mood disturbance, major depressive disorder and anxiety disorder.Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment, dated as completed 09/07/25, indicated he/she was moderately cognitively impaired with a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of Certified Nurse Aide (CNA) #4's Written Statement, dated 10/04/25, indicated that on the previous Thursday (10/02/25), when CNA #4 attempted to provide care to Resident #4, he/she refused care and was yelling loudly. The Statement indicated that Nurse #1 told Resident #4, You are a faggot racist and that is why you won't let her clean you. During an interview on 11/25/25 at 2:47 P.M., CNA #4 said that in early October 2025, she had reported to Nurse #1 that Resident #4 had refused care. CNA #4 said that Nurse #1 responded by confronting Resident #4, accusing him/her of being racist, and called him/her a faggot. CNA #4 said that she reported the incident to the Charge Nurse. CNA #4 further said that although she could not recall the date of the incident during the interview, it was documented in the written witness statement that she provided to Unit Manager #1.Review of the Health Care Facility Reporting System (HCFRS), indicated that between 10/02/25 and up to the date of survey (11/25/25) the Facility had not reported any incidents involving Nurse #1 and Resident #4.During an interview on 11/25/25 at 3:44 P.M., Unit Manager #1 said that while she was acting as the weekend supervisor on 10/04/25, a Charge Nurse reported that CNA #4 had alleged that when she told Nurse #1 that Resident #4 had been combative during care, Nurse #1 had confronted Resident #4, accused him/her of being racist, and called him/her a faggot. Unit Manager #1 said that when she spoke to Resident #4, he/she was unable to recall any incidents with Nurse #1, and only told her, That Nurse (#1) doesn't like me. Unit Manager #1 said she instructed CNA #4 to complete a written witness statement about the incident, and she reported the allegation to the Director of Nurses (DON).During an interview on 11/25/25 at 4:28 P.M., the Director of Nurses (DON) said that on 10/04/25, she was notified that CNA #4 had witnessed Nurse #1 direct a derogatory slur at Resident #4, and that CNA #4 said she could not recall the exact date the incident occurred. The DON said that when she reviewed CNA #4's Written Witness Statement, she felt it conflicted with her (CNA #4's) verbal statement, and that she (the DON) did not feel it was specific enough to investigate or to report to DPH.

Based on interviews, and record reviews, the facility failed to address and implement licensed Pharmacist recommendations in a timely manner for two Residents (#106 and #117) of five applicable residents, out of a total sample of 24 residents. Specifically: 1. For Resident #106, the facility failed to implement the licensed Pharmacist's recommendation, which the Physician agreed with, to discontinue administration of a Multivitamin and initiate the use of Nephrocaps (vitamins for individuals with renal failure) when the Resident had a diagnosis of End Stage Renal Disease (ESRD) and administration of the Multivitamin was not recommended for use for individuals with an active ESRD diagnosis, increasing the Resident's risk for renal toxicity. 2. For Resident #117, the facility failed to ensure that the licensed Pharmacist's recommendation to evaluate the use of Acetaminophen-Codeine (medication used to treat pain) was addressed in a timely manner by the Physician when the Resident was on dialysis and Acetaminophen-Codeine was recommended to be avoided for dialysis patients. Findings include: Review of the facility policy titled Drug Regimen Review-Monthly indicated the following: -the Prescriber/Licensed Designee: >shall act upon the Drug Regimen Review findings/recommendations in a timely manner of 7-14 days or less. >shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation made and provide a brief clinical rationale if no change is to be made. 1. Review of the National Kidney Foundation guidance titled Vitamins and Minerals in Chronic Kidney Disease, 2025, reviewed at https://www.kidney.org/kidney-topics/vitamins-and-minerals-chronic-kidney-disease, indicated the following: -You may need to avoid some vitamins and minerals if you have kidney disease. -Some of these vitamins include Vitamin A, E, and K. -These vitamins are more likely to build up in your body and can cause harm if you have too much. -Over time, they can cause dizziness, nausea, and even death. Resident #106 was admitted to the facility in July 2024 with diagnoses including ESRD. Review of Resident #106's Physician orders, dated 10/3/24, indicated: -Multivitamin Mineral Oils Tablet, give one tablet by mouth one time a day, related to Unspecified Protein-Calorie Malnutrition. Review of Resident #106's Medication Regimen Review (MRR), dated 10/3/24, indicated the following: -The Resident was currently receiving Multivitamin. -Multivitamin was not recommended for use with an active diagnosis of ESRD because it contains Vitamin A and E. -Please evaluate and switch to Nephrocaps . if appropriate. -The Provider/ Physician reviewed and agreed with the licensed Pharmacist's recommendation. -The date the Provider agreed with the recommendation was not indicated on the MRR Physician Referrals/Findings Form, but the signed form was uploaded into the Resident's electronic health record (EHR) on 11/26/24. Review of Resident #106's Medication Administration Records (MARs) from October 2024 through April 2025 indicated the following: >October 2024 - The Multivitamin Mineral Oils Tablet was administered to the Resident 24 times between 10/3/24 and 10/31/24. >November 2024 - The Multivitamin Mineral Oils Tablet was administered to the Resident 17 times between 11/1/24 and 11/30/24. >December 2024 - The Multivitamin Mineral Oils Tablet was administered to the Resident 24 times between 12/1/24 and 12/31/24. >January 2025 - The Multivitamin Mineral Oils Tablet was administered to the Resident 27 times between 1/1/25 and 1/31/25. >February 2025 - The Multivitamin Mineral Oils Tablet was administered to the Resident 28 times between 2/1/25 and 2/28/25. >March 2025 - The Multivitamin Mineral Oils Tablet was administered to the Resident 30 times between 3/1/25 and 3/31/25. >April 2025 - The Multivitamin Mineral Oils Tablet was administered to the Resident 28 times between 4/1/25 and 4/30/25. >May 2025 - The Multivitamin Mineral Oils Tablet was administered to the Resident 15 times between 5/1/25 and 5/21/25. Review of Resident #106's Medication Regimen Review (MRR), dated 5/13/25, indicated: -The Resident was currently receiving Multivitamin. -Multivitamin was not recommended for use with an active diagnosis of ESRD because it contains Vitamin A and E. -Please evaluate and switch to Nephrocaps . if appropriate. -The Provider reviewed and agreed with the licensed Pharmacist's recommendation. Review of Resident #106's clinical record indicated: -The Multivitamin Mineral Oils Tablet was not discontinued until 5/21/25. -Nephrocaps were not started until 5/21/25. During an interview on 6/6/25 at 11:45 A.M., Nurse Consultant (NC) #1 (the previous Director of Nursing) said when the Physician agrees with the recommendations of the licensed Pharmacist, the nursing supervisor is required to transcribe the order into the Resident's clinical record. NC #1 said the orders based on the licensed Pharmacist's recommendations from October 2024 to discontinue the Multivitamin and initiate Nephrocaps were not implemented timely, so Resident #106 continued to receive the Multivitamin until 5/21/25. NC #1 also said Nephrocaps were not initiated for Resident #106 until 5/21/25. 2. Resident #117 was admitted to the facility in April 2025 with diagnoses including ESRD and Dependence on Renal Dialysis. Review of Resident #117's Physician orders from April 2025 through June 2025 indicated the following: -Acetaminophen-Codeine Tablet 300-30 mg, Give 2 tablets by mouth three times a day for pain, initiated 4/1/25 and discontinued 4/17/25 -Acetaminophen-Codeine Tablet 300-30 mg, Give 1 tablet by mouth three times a day for pain, initiated 4/17/25 and discontinued 4/28/25 -Acetaminophen-Codeine Oral Tablet 300-30 mg, Give 1 tablet by mouth three times a day, every Mon, Wed, Fri for pain, initiated 4/28/25 and active. Review of Resident #117's admission MRR dated 4/3/25, indicated: -the Resident was currently receiving Acetaminophen-Codeine 300-30 mg, 2 tablets TID (three times a day) for pain. -Recommended to avoid this medication in dialysis patients. Please evaluate. -Consider switch to alternative pain management such as Tramadol (opioid pain medication) if appropriate. -the Provider signature portion of the MRR document was left blank. Review of Resident #117's April 2025 MAR indicated: -the Resident received Acetaminophen-Codeine 300-30 mg, 2 tablets three times a day as ordered from 4/2/25 through 4/16/25. -the Resident received Acetaminophen-Codeine 300-30 mg, one tablet three times a day as ordered from 4/17/25 through 4/28/25. -the Resident received Acetaminophen-Codeine 300-30 mg, one tablet three times a day on dialysis days (Monday, Wednesday, Friday) on 4/30/25. Review of Resident #117's May 2025 MAR indicated: -the Resident received Acetaminophen-Codeine 300-30 mg, one tablet three times a day on dialysis days (Monday, Wednesday, Friday) as ordered. Review of Resident #117's June 2025 MAR indicated: -the Resident received Acetaminophen-Codeine 300-30 mg, one tablet three times a day on dialysis days (Monday, Wednesday, Friday) as ordered. During an interview on 6/6/25 at 9:21 A.M., NC #1 said the admission MRRs had not been addressed until today, 6/6/25, but should have been addressed promptly after the MRR was completed by the Consultant Pharmacist. NC #1 further said that admission MRRs had been sent to the email of a Supervisor who had been out on FMLA and the MRRs had not been seen by the facility until today, 6/6/25.

Based on observations, interviews, and record reviews, the facility failed to ensure proper sanitation and food handling practices in the facility main kitchen and cleaning in three (Floor One, Two and Three) out of the three kitchenettes on the resident care units. Specifically, the facility failed to: 1. ensure that dietary staff maintained and performed appropriate hand hygiene practices while preparing and serving meals for residents in the facility main kitchen. 2. ensure that cooking utensils, dishes, and countertops were properly cleaned and sanitized in the facility main kitchen. 3. ensure that the kitchenettes on Floors One, Two and Three were properly cleaned, and that utensils were stored in accordance with food service standards, putting the residents at risk for foodborne illness, cross-contamination, and food contamination. Findings include: Review of the facility policy titled Manual Ware Washing and Testing Sanitizer Concentration, effective October 2022, indicated but was not limited to the following: -Foods can become contaminated by coming into contact with surfaces that are not clean and sanitized. -Manual ware washing is used in most every unit daily, and the proper process must be followed every time wares are washed. -Manual ware washing steps must be followed in order as outlined below: 1. Sink set-up 2. Pre-clean 3. Wash: Agitate and scrub equipment and utensils in the wash compartment to remove visible grease and soils from the surface. 4. Rinse: Move equipment or utensil to the rinse compartment to remove any visible soils and soap . 5. Sanitize: Submerge equipment or utensil into the third sink for 60 seconds . 6. Air dry: Place equipment or utensils onto a clean surface to air dry. Do not dry with a towel or other method. 7. Return to storage -Must train associates on the proper ware washing procedure, including proper water temperatures, sanitizer concentration, the 60 second submersion time in sanitizer, and sanitizer testing. -Must monitor associates who are manually ware washing to ensure they are following the proper process. Review of the U.S. FDA's 2022 Food Code, February 2023, indicated but was not limited to the following: -Equipment food-contact surfaces and utensils shall be cleaned .at any time during the operation when contamination may have occurred. -Equipment food-contact surfaces and utensils shall be sanitized. - .Cleaned equipment and utensils .shall be stored in a clean, dry location; Where they are not exposed to splash, dust, dust or other contamination . Review of the facility policy titled Hand Hygiene, revised January 2025, indicated but was not limited to the following: >In the Food and Nutrition Services Department: All associates associated with the handling of food shall wash hands. >Hands are washed with soap and water at the following times, including but not limited to: -Before putting on gloves -After touching hair, skin, beard or clothing -After using tobacco products, eating or drinking -After handling soiled silverware/utensils -After removing gloves -After any other activity that may contaminate the hands Review of the facility policy titled Common Area Cleaning, effective May 2025, indicated but was not limited to the following: -Common areas will be cleaned per an established schedule . 1. On 6/5/25, the surveyor observed the following in the facility main kitchen: -At 11:48 A.M., the [NAME] took a sip of a beverage using gloved hands, then removed her gloves, wiped her face with her hands, and then applied new gloves. The surveyor intervened at this time to discuss hand hygiene practice concerns with the Cook. -At 11:52 A.M., Dietary Aide #2 adjusted his beard guard with his gloved hands, and continued to assist in the tray service line, touching residents' clean meal trays. -At 12:03 P.M., Dietary Aide #2 adjusted his beard guard with his gloved hands, and continued to assist in the tray service line, touching residents' clean meal trays. -At 12:04 P.M., Dietary Aide #2 adjusted his beard guard with his gloved hands, and then continued to assist in the tray service line, touching residents' clean meal trays. -At 12:10 P.M., Dietary Aide #3 adjusted his surgical mask to cover his mouth and nose using his gloved hands, then continued to open the refrigerator door and touch multiple covered food items. Dietary Aide #3 then rubbed his left eye with gloved hands and proceeded to open a package of rice. During an interview on 6/5/25 at 11:48 A.M., the [NAME] said when she touched her face with her hands, she should have washed her hands with soap and water prior to donning (putting on) new gloves, but she did not wash her hands with soap and water. During an interview on 6/5/25 at 1:15 P.M., Dietary Aide #3 said he should perform hand hygiene if he touched his surgical mask or his eye. Dietary Aide #3 said he typically used the back of his gloved hand to touch his surgical mask, and that this method was an acceptable practice. Dietary Aide #3 said the importance of proper hand hygiene practices was to keep residents safe. During an interview on 6/5/25 at 2:50 P.M., Dietary Aide #2 said he should remove contaminated gloves after touching his beard guard. Dietary Aide #2 said he should then perform hand hygiene, and apply new gloves. Dietary Aide #2 said the concern with not performing proper hand hygiene practices was that residents could get sick. During an interview on 6/5/25 at 4:34 P.M., the Food Service Director (FSD) said that he expected food service staff working in the main kitchen to remove contaminated gloves, wash hands with soap and water, and don clean gloves at the time the gloves were contaminated. The FSD said the concern with not performing proper hand hygiene practices was food contamination. 2. On 6/5/25 the surveyor observed the following in the facility main kitchen: >At 11:57 A.M., Dietary Aide #4 utilized the three-compartment sink for manual ware washing and performed the following steps: -Rinsed the spatula over the garbage disposal. -Washed the spatula in the wash sink. -Rinsed the spatula in the rinse sink. -Dipped the spatula in the sanitizer sink. -Rinsed the spatula over the garbage disposal. -Wiped the spatula off with a paper towel. Dietary Aide #4 was observed using the spatula to make peanut butter and jelly sandwiches, and dipping the spatula in a container of jelly. >At 12:10 P.M., Dietary Aide #3 scooped water into a bucket from the wash sink of the three-compartment sink for manual ware washing. The water in the wash sink was observed to contain dishes and food debris. The water scooped into the bucket was then used to wash the contaminated countertop. The countertop was then observed to be utilized to plate mashed potatoes. >At 12:16 P.M., Dietary Aide #4 utilized the three-compartment sink for manual ware washing and performed the following: -Rinsed the spatula over the garbage disposal. -Dipped the spatula in the wash sink. -Dipped the spatula in the sanitizer sink. -Rinsed the spatula over the garbage disposal. -Wiped the spatula off with a paper towel. Dietary Aide #4 was observed using the spatula to make sandwiches, and buttering bread with the spatula. >At 12:27 P.M., Dietary Aide #4 utilized the three-compartment sink for manual ware washing and performed the following: -Rinsed the spatula over the garbage disposal. -Washed the spatula in the wash sink. -Rinsed the spatula in the rinse sink. -Dipped the spatula in the sanitizer sink. -Dipped the spatula in the rinse sink. -Placed the spatula on the counter to dry. >At 12:28 P.M., Dietary Aide #4 removed a spatula from a drawer, rinsed the spatula over the garbage disposal, and then wiped the spatula with a paper towel. Dietary Aide #4 then used the spatula to make tuna fish sandwiches. During an interview on 6/5/25 at 1:15 P.M., Dietary Aide #3 said he washed contaminated countertops using the soapy water from the hose over the wash sink of the three-compartment sink. Dietary Aide #3 said if he was not going to use the countertop any longer, he obtained sanitizer solution from the hose over the sanitizer sink of the three-compartment sink and sanitized the countertop. During an interview on 6/5/25 at 2:45 P.M., Dietary Aide #4 said the steps involved in using the three-compartment manual ware washing sink were as follows: -Rinse food debris into the garbage disposal. -Wash the dish/utensil in the wash sink. -Rinse the dish/utensil in the rinse sink. -Put the dish/utensil in the sanitizer sink. -Rinse the dish/utensil in the rinse sink again if there is soap on the dish/utensil. -Dry off the dish/utensil with a paper towel. Dietary Aide #4 further said the dish/utensil should soak in the sanitizer sink for 30 minutes. Dietary Aide #4 said she never received training on proper use of the three-compartment manual ware washing sink. Dietary Aide #4 said no one had ever told her to wash and sanitize the dishes/utensils in the three-compartment sink any other way. During an interview on 6/5/25 at 4:34 P.M., the FSD said placing a dish/utensil back into the rinse sink of the three-compartment ware washing sink after sanitizing in the sanitizer sink could cause the dish/utensil to accumulate debris and could cause cross-contamination and pose a risk for foodborne illness. The FSD said dishes/utensils that had already been sanitized should not be rinsed off over the garbage disposal. The FSD said the water pressure from that faucet could cause debris from the garbage disposal to splash onto the clean dish/utensil and contaminate the dish/utensil. The FSD said use of a dish/utensil after being rinsed off over the garbage disposal could cause cross-contamination and pose a risk for foodborne illness. The FSD said it was important for dishes/utensils to soak in the sanitizer sink of the three-compartment manual ware washing sink per facility policy so that the dishes/utensils could be sanitized properly. The FSD said it was not sufficient to dip dishes/utensils in the sanitizer sink. The FSD also said that countertops should be cleaned between food preparations, using sanitizer solution. The FSD said using water from the wash sink of the three-compartment sink to wash countertops could contaminate the countertops and cause cross-contamination and pose a risk for foodborne illnesses. 3. On 6/6/25 at 11:36 A.M., the surveyor and the FSD observed the following in the Floor Two kitchenette: -Dried food splatter inside the microwave. -Dried liquid spillage on the bottom of the lower cabinet, with an open Cheerios container and spilled Cheerios in the cabinet. -Liquid spillage inside the resident refrigerator freezer. -Opened ceiling tile with exposed insulation and pipes over the microwave and open-top toaster oven. -Unpackaged disposable spoons, condiment packages, coffee packages and oatmeal packages were stored on top of the microwave. -Ice chest with a large crack, exposing foam insulation. -Ice scoop sitting on top of the utility cart in a puddle of water, the utility cart was observed with debris. During an interview at the time, the FSD said the open ceiling tile could allow for debris to fall onto the food packages and unpackaged spoons on top of the microwave as well as into the toaster oven. The FSD said the exposed insulation in the ice chest could cause physical contamination of insulation in residents' beverages. The FSD said the ice scoop should be stored in the provided container on the wall and should not be sitting on the utility cart. On 6/6/25 at 11:45 A.M., the surveyor and the FSD observed the following in the Floor Three kitchenette: -Dried food splatter in the microwave. -Inside cover of the ice chest with debris. -Dried spillage covering the majority of the outside (left side) of the resident refrigerator. -Liquid spillage inside the resident refrigerator on the bottom shelf. During an interview at the time, the FSD said the spilled food could grow mold and pose a risk for foodborne illnesses. On 6/6/25 at 11:54 A.M., the surveyor and the FSD observed the following in the Floor One kitchenette: -Dried food splatter in the microwave. -Debris and dried spillage on top of the microwave. -Excessive crumbs in the toaster oven. -Ice scoop sitting on top of the utility cart and the utility cart was observed with debris. -Opened sugar packets, empty soda bottles, bags of pretzels, and liquid spillage on the bottom of the lower cabinet. -Resident freezer with spillage. During an interview at the time, the FSD said the opened packets of sugar and spilled food and beverages could pose a risk for pests. Review of the Kitchenette Cleaning Logs from 6/6/25 through 6/10/25 indicated the following: -Kitchenette on Floor One: Documentation failed to indicate cleaning of the kitchenette from 6/6/25 through 6/10/25. -Kitchenette on Floor Two: Documentation failed to indicate cleaning of the kitchenette on 6/7/25 and 6/8/25. -Kitchenette on Floor Three: Documentation failed to indicate cleaning of the kitchenette from 6/7/25 through 6/10/25. During an interview on 6/10/25 at 9:15 A.M., Housekeeper #2 said the housekeeping department is responsible for cleaning the kitchenettes, including the refrigerators, toast ovens, and microwaves. Housekeeper #2 said the kitchenettes are cleaned once daily, around 7:30 A.M. Housekeeper #2 said the housekeeping staff completed the cleaning log when the kitchenette was cleaned. On 6/10/25 at 9:40 A.M., the surveyor and the Housekeeping Supervisor observed the following in Floor Three kitchenette: -Dried spillage covering the majority of the outside (left side) of the resident refrigerator. -Two dead bugs on the inside windowsill. -Dried food splatter in the microwave. During an interview at the time, the Housekeeping Supervisor said the housekeeping department is responsible for cleaning the kitchenettes on all three floors. The Housekeeping Supervisor said the cleaning logs posted in the kitchenettes should be completed by housekeeping staff when the kitchenettes were cleaned. The Housekeeping Supervisor said spillage of food/beverage and crumbs anywhere in the kitchenettes was a risk to the residents. On 6/10/25 at 9:55 A.M., the surveyor and the Housekeeping Supervisor observed the following in Floor Two kitchenette: -Dried food splatter in the microwave. -Liquid spillage in the resident freezer. -Ice chest with a large crack, exposing foam insulation. On 6/10/25 at 10:00 A.M., the surveyor and the Housekeeping Supervisor observed the following in Floor One kitchenette: -Dried food splatter in the microwave. -Excessive crumbs in the toaster oven. -Liquid spillage on the bottom shelf and door of the resident refrigerator. -Ice scoop sitting on top of the utility cart. During an interview at the time, the Housekeeping Supervisor said the expectation is that the housekeeping staff cleaned the kitchenettes, including but not limited to the refrigerators, cabinets, microwaves, and countertops.

Based on observations, interviews, and record reviews, the facility failed to provide a dignified existence by recognizing the individuality of one Resident (#1), out of a total sample of 24 residents. Specifically, for Resident #1, the facility failed to promote the dignity of the Resident when staff walked by, looked into the Resident's room, and failed to intervene and cover the Resident's lower body when he/she was observed from the hallway to be uncovered in bed with his/her underwear briefs clearly visible. Findings include: Resident #1 was admitted to the facility in April 2021 with diagnoses including Dementia and Neurosyphilis. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of a possible score of 15. -was dependent on staff for lower body dressing. On 6/6/25 from 8:14 A.M. through 8:45 A.M., the surveyor observed the following: -Resident #1 was visible from the hallway lying in his/her bed, uncovered by the bedsheet, with his/her underwear brief visible. -at 8:14 A.M., CNA #2 was observed walking past Resident #1's room, paused to look into the room, and then continued on down the hallway. -at 8:34 A.M., CNA #3 was observed walking past Resident #1's room, paused to look into the room, and then continued on down the hallway. -at 8:45 A.M., Nurse #3 wheeled her medication cart outside Resident #1's doorway facing the door, looked into the room, and then began to prepare medications for administration. On 6/6/25 at 8:45 A.M., the surveyor, Nurse #3, and CNA #3, observed the Resident from the hallway. During an interview at the time, CNA #3 said she could see Resident #1 from the door and that the Resident was uncovered. Nurse #3 said the Resident throws off the covers frequently. CNA #3 and Nurse #3 both said that if the Resident is observed uncovered that they should offer to cover the Resident. At this time, CNA #3 and Nurse #3 then went into the room and assisted Resident #1 to cover up with the bedsheet without issue. During an interview on 6/6/25 at 11:00 A.M., Nurse Consultant #1 (the previous Director of Nursing [DON]) said that if a Resident is observed to be uncovered or have their briefs visible from the door, the expectation is that staff would cover or offer to cover the Resident. Nurse Consultant #1 further said that even if the Resident frequently removes the blankets (covers) an attempt to cover the Resident should be made.

Based on interview, and record review, the facility failed to uphold Resident Rights for one Resident (#70), out of a total sample of 24 residents, relative to rights exercised by the Resident's Representative. Specifically, for Resident #70, the facility failed to implement an effective discharge planning process including documentation of referrals made and response from referrals that focused on the Resident Representative's goals of discharging the Resident to a skilled nursing facility closer to involved family members, putting the Resident at risk of decreased family visits. Findings include: Review of the Resident's [NAME] of Rights, revised in October 2024, indicated the following: -you have the right to exercise your rights as a resident and as a citizen. The facility must protect and promote your rights and support, encourage and assist you in exercising them. -you have the right to make choices about aspects of your life that are significant to you. Review of the facility Policy titled Discharge-Routine, review date 11/13/24, indicated the following: -the facility will provide a resident requesting a routine discharge with referrals and information necessary for their continuing care or aftercare needs. -the Social Work Department will attempt to ensure that a resident's home situation, financial resources, social needs, community resources, and personal goals are considered along with nursing requirements in routine discharge decisions. Resident #70 was admitted to the facility in July 2023, with diagnoses including unspecified Dementia with Psychotic Disturbance, Schizoaffective Disorder bipolar type, and catatonic disorder. Review of Resident #70's Massachusetts Health Care Proxy (HCP) Form, signed 7/23/20 by the Resident appointed Family Member #1 as a Health Care Agent. Review of Resident #70's Health Care Proxy activation form dated 4/31/24, indicated the Resident had their Health Care Proxy activated due to permanent and severe mental incapacity related to Dementia. Review of the Social Services Quarterly Note dated 9/13/24, indicated Resident #70's family's goal was to transfer the Resident to another facility closer to his/her family. Review of the Comprehensive Care Plan for Resident #70, initiated 9/13/24, indicated the following: -It was the desire of the Resident to be discharged to another facility closer to family. -The goal was to be assisted with information and referrals, if needed, regarding community-based services or other facilities in accordance with needs and preferences. -Interventions included the facility providing information that would help the Resident with continuing care needs. Review of Resident #70's Social Services Quarterly Note indicated the facility was currently working on a referral to another facility for placement because the goal was for Resident #70 to be closer to family and it was a financial burden for family to travel long distance using Uber services on the following dates: -12/10/24 -3/18/25 Review of a Resident Care Conference Progress Note dated 12/18/24, indicated there was a continued search for a Skilled Nursing Facility (SNF) that would allow the Resident to be closer to family as it was a hardship for family to visit the Resident. The Social Worker (SW) would continue to research potential facilities. Review of the Psychosocial Progress Note dated 1/30/25, indicated the facility spoke with a representative of another facility closer to the family, but the Resident's referral was not accepted. Review of the Comprehensive MDS dated [DATE], indicated Resident #70: -was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) assessment score of 7 out of a possible 15. -had a Healthcare Proxy that had been invoked. -goal was to be discharged to another facility. Further review of the clinical record failed to indicate any referrals or follow-up calls were made to other nursing facilities for Resident #70's placement since January 2025. During an interview on 6/5/25 at 11:15 A.M., Resident #70's Family Member (who was asked to speak on behalf of the HCP) said that it has been extremely difficult for family to visit Resident #70 because it is a far drive and expensive to travel because the family need to pay for an Uber ride. The Family Member said that they had numerous conversations with staff at the facility about having Resident #70 transferred closer to the family because they can only visit once every few weeks because of the distance. The Family Member said he/she did not feel the facility was making enough effort to help them find another facility. During an interview on 6/5/25 at 2:10 P.M., the Social Worker (SW) said Resident #70 has a HCP that has been invoked and family is responsible for making decisions for the Resident. The SW said the facility has not contacted other facilities to make additional referrals for alternate placement since January 2025. The SW said that the facility made referrals to other facilities in 2024 but the SW could not provide evidence relative to the referrals. The SW said that she had multiple meetings with Resident #70's HCP who had consistently expressed that it was a long distance to travel and a financial hardship for them to visit. The SW said it was the Health Care Proxy's preference to have Resident #70 transferred to a facility closer to the family. During a follow-up interview on 6/5/25 at 4:03 P.M., the SW said that it is the facility's responsibility to make referrals to other facilities when a Resident is looking for placement. The SW said they should have been actively pursuing one to two facilities at a time and should have followed through consistently but did not. The SW said that she was aware there had been no referrals made in the past six months and said this was not reasonable especially since the family was making their preferences known. During an interview on 6/10/25 at 11:40 A.M., the Administrator said that the SW is responsible to coordinate discharges and should have done more to assist Resident #70 with alternate placement closer to the family, especially since the family had been requesting assistance. The facility failed to provide any additional documentation pertaining to referrals and/or placement at another nursing facility for Resident #70 to the survey team at the time of survey exit.

Based on observations, record reviews, and interviews, the facility failed to ensure a clean and homelike environment was maintained for one Resident (#48) out of a total sample of 24 residents. Specifically, for Resident #48, the facility failed to maintain a clean and homelike environment relative to G-tube (gastrostomy tube: medical device inserted into the abdomen to deliver food, fluids, medications) feeding equipment and the surrounding space in the Resident's room. Findings include: Review of the facility policy titled 5&7 Step Daily Room Cleaning, undated, and utilized by the housekeeping staff indicated the following: -Spot clean all vertical surfaces/Clean IV (Intravenous) poles. -Spot clean walls. Resident #48 was admitted to the facility in March 2021 with diagnoses including Protein Calorie Malnutrition, history of diseases of the digestive system, Gastric Ulcer, Dysphagia and Adult Failure to Thrive. Review of Resident #48's Care Plans indicated the following in part: -Resident #48 was NPO (nothing by mouth) and a new G-tube was placed on 5/7/21 for severe Dysphagia. The surveyor observed the following while Resident #48 was lying in bed, on: -6/3/25 at 10:04 A.M. -6/5/25 at 10:34 A.M. -6/5/25 at 10:43 A.M. -The EnteraFlo (nutrition delivery system) pump (not in use), located to the left of the Resident's bed and attached to an IV pole, had a dried brownish colored substance built up, and was splattered on multiple spots including the pump, IV pole and the base of the IV pole. -The corkboard located on the wall to the left of Resident #48 had dried brownish color splatter marks. -The wall just beneath the corkboard had dried brownish color splatter marks. -The Resident's headboard of the bed had dried brownish color splatter marks on the left side. -The wall behind the Resident's bed had dried brownish color splatter marks. During an interview on 6/5/25 at 10:43 A.M., Nurse #8 said the Resident's G-tube pump, wall, headboard of the bed, and corkboard behind the Resident's bed were dirty with some type of dried brownish substance and should be cleaned. Nurse #8 said she was not sure how something like that would happen and that these areas should have been cleaned at the time it (spill) occurred. Nurse #8 said she was not sure who was responsible to clean the Resident's G-tube pump but thought that housekeeping would be responsible for the wall, headboard of the bed, and corkboard. During a follow-up interview on 6/5/25 at 10:59 A.M., Nurse #1 (shift supervisor) said he learned that housekeeping was responsible for daily cleaning of the Resident's G-tube pump, the IV pole which the pump hung from and the area around it including the headboard to the bed, the wall and corkboard. During an interview on 6/5/25 at 1:14 P.M., the Administrator said the Resident's G-tube pump should be cleaned daily by housekeeping. The Administrator further said that if staff had dropped or spilled the G-tube bag containing the nutritional supplement, the staff should have cleaned it immediately or called housekeeping to address the spill but had not.

Based on observations, interviews, and record reviews, the facility failed to notify the state mental health authority (Pre-admission Screening and Resident Review [PASRR] Office) promptly of the need for Resident Review for one Resident (#107) out of a total sample of 24 residents,when the Resident experienced a significant change in his/her mental condition from his/her initial Level I PASRR. Specifically, the facility failed to notify the PASRR Office of the need for Resident Review when Resident #107: -had diagnoses of Post Traumatic Stress Disorder (PTSD) and Personality Disorder. -newly expressed homicidal ideation (HI) and suicidal ideation (SI). -had psychotropic medication that was newly ordered and administered to the Resident to stabilize his/her mood. Findings include: Review of the facility's policy titled PASRR - MA (Massachusetts), dated 11/17/20, indicated the following: -The facility would follow Federal regulations and State required procedures for the screening of persons being admitted to, and residing in the facility for serious mental illness (SMI) . through the MA Department of Mental Health or its designee, the PASRR Unit, . -The facility would make post-admission referrals to the appropriate PASRR authority in accordance with the requirements of MassHealth Nursing Facility Bulletin 143 (July 2019). Resident #107 was admitted to the facility in July 2024, with diagnoses including Post-Traumatic Stress Disorder (PTSD) and Personality Disorder. Review of Resident #107's Level I PASRR, dated 6/26/24, indicated the following: -The Resident did not have any documented diagnosis of a mental illness or disorder (MI/D: Schizophrenia, Somatoform Disorder, Delusional Disorder, Mood, PTSD, Severe Anxiety/Panic Disorder, Schizoaffective Disorder, Other Psychotic Disorder, Paranoia, Personality Disorder, other mental disorder that may lead to chronic disability). -The Resident's screen for SMI was negative. -A Level II PASRR Evaluation was not indicated. Review of Resident #107's clinical record failed to indicate the Resident was ordered for any psychotropic medication when he/she was admitted to the facility. Review of Resident #107's Psychiatric Assessments indicated the following: >7/29/24 - The Resident was seen for initial evaluation and had a diagnosis of Other Specified Depressive Episodes. The Resident denied feelings of depression and anxiety. No evidence of delusions, paranoia, agitation, or aggression. Does not receive psychotropic medication. >8/7/24 - Assessed for mood and behavior and was having difficulty adjusting to a new roommate. The Resident was not on any psychotropic medications. >8/27/24 - Assessed for increased behaviors: aggressive, refusal of medications, physical with residents and staff. The Resident was not sleeping and had depressive episodes. >9/17/24 - Assessed for being sexually inappropriate to residents of the opposite gender, attempted to leave, and hit staff. The Resident refused to discuss the use of a mood stabilizer. >9/26/24 - Assessed for mood and behavior, and continued to be aggressive, combative, and exit seeking. The Resident had no HI/SI. The Resident experienced depressive episodes. >10/1/24 - Assessed for increased behaviors and was positive for HI/SI and made the following statement: I'm going to stab myself and will mess up my roommate by stabbing [him/her] when [he/she] falls asleep. Further review of this note indicated the Behavioral Health Provider notified the Nursing Supervisor at the facility. >10/10/24 - The Resident was agreeable to start on a mood stabilizer and Lamotrigine (medication that can be used to treat Bipolar Disorder, prevent episodes of depression, mania, and other mood changes) was recommended. >10/31/24 - Positive for HI/SI. >11/1/24 - Consent for Lamictal (brand name for Lamotrigine) was obtained. >12/27/24 - Restless, agitated, preys on nonresponsive residents. Start Sertraline and discontinue Lamictal. Review of Resident #107's Physician orders indicated the following: -Lamotrigine Oral Tablet Chewable 25 milligram (mg), give one tablet by mouth one time a day related to Adjustment Disorder with Depressed Mood (start date 11/2/24, discontinued 12/27/24). -Sertraline HCl (antidepressant medication) 25 mg tablet, give one tablet by mouth one time a day for Depression related to Adjustment Disorder with Depressed Mood (start date 12/28/24, with no stop date). Review of Resident #107's clinical record failed to include any evidence that Resident #107 was referred to the PASRR Office for Resident Review when the Resident experienced a change in mental condition from his/her initial Level I PASRR, dated 6/26/24. During an interview on 6/3/25 at 9:33 A.M., Resident #107 said he/she was very depressed and was getting more depressed living in the facility. The surveyor observed the Resident with a furrowed brow and the Resident did not make eye contact with the surveyor during the interview. On 6/4/25 at 9:40 A.M., the surveyor observed Resident #107 use his/her wheelchair to move through the hallway toward the surveyor. During an interview when Resident #107 reached the surveyor, the Resident said, . If I can't get out of here, I will commit suicide . I don't care . I'm sick of living . I will show them, and I have a date . The surveyor immediately reported the statements made by Resident #107 to a staff member at the nurses station. During an interview on 6/5/25 at 4:03 P.M., the Social Worker (SW) said Resident #107 had not been referred to the PASRR Office for Resident Review when the Resident experienced a change in mental condition and required implementation of psychotropic medication. The SW said that the Resident's change in behavior and the implementation of medication to treat the Resident's symptoms was considered a significant change in the Resident's mental condition. The SW said if she had submitted a request for Resident Review when the Resident experienced a significant change in mental condition, the Resident would have screened positive for SMI and triggered the need for a Level II PASRR Evaluation.

Based on observations, interviews, and record reviews, the facility failed to safely provide feeding assistance for two Residents (#14 and #5), out of a total sample of 24 residents, when both Residents required assistance for eating, putting both residents at risk for aspiration. Specifically, 1. For Resident #14, the facility failed to ensure that safe swallow strategies recommended by the Speech Therapist (ST) were implemented and that liquids provided to the Resident were the ordered consistency. 2. For Resident #5, the facility failed to ensure the Resident was provided with nectar (mildly) thick beverages during the breakfast meal. Findings include: Review of the facility's Fluid Consistencies Chart, undated, indicated Honey consistency was described as a liquid that coats a fork and slowly sinks through the prongs (e.g. Yogurt, Honey). Review of the facility's Feeding (Dependent Feeding) Policy, revised 6/19/23, indicated the following: -Residents will be fed by staff that have appropriate training in feeding residents. -Prior to serving food, check diet slip to ensure proper resident and appropriate diet. -Cut or divide food into small portions and give resident a small amount at a time. -Give liquids slowly. -Alternate food and liquid. Review of the Facility Thick and Easy Honey Consistency Packet 6.5 grams (g) included the following directions: -Add 1 packet 6.5 g Thick and Easy Instant food and beverage thickening powder to 4 fluid ounces (fl.oz.) of liquid. -Stir with a spoon or fork for approximately 15 seconds or until thickener is dissolved. -Allow 1-4 minutes for product to reach desired thickness. 1. Resident #14 was admitted to the facility in January 2025, with diagnoses including Dysphagia, Frontotemporal Neurocognitive Disorder and Mild Intellectual Disability. Review of Resident #14's Minimum Data Set (MDS) dated [DATE], indicated the following: -Brief Interview of Mental Status (BIMS) Assessment score of 6 out a possible 15, indicating severe cognitive impairment. -required supervision for eating. -was prescribed a mechanically altered diet. Review of the Dysphagia Care Plan for Resident #14, initiated 1/15/25, indicated he/she was at risk of aspiration with the following interventions: -alternate small bites and sips. Use a teaspoon for eating. Do not use straws, effective 1/15/25. -instruct the Resident to eat slowly and to chew each bite thoroughly, effective 1/15/25. -provide with the dependent level of assistance for eating, revised 6/3/25 -provide him/her with honey thick liquids via teaspoon only, revised 6/4/25. -Resident to eat with dependent assistance of one staff member, revised 6/4/25. Review of a Nursing Progress Note dated 6/1/25, indicated Resident #14 was coughing during breakfast and breathing heavy and fast and the Provider was updated. Review of the Speech Therapy Evaluation and Plan of Treatment, start 6/2/25, indicated the following: -reason for referral: . Past medical history significant for dementia and dysphagia. Patient recently was diagnosed with Pneumonia following a suspected aspiration event. Patient is now on 2 Liters of Oxygen via Nasal cannula, is fully dependent for eating assistance and diet level is now NDD1 (National Dysphagia Diet Level 1- diet designed for people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. Close or complete supervision and alternate feeding methods may be required) with Honey Thick liquids via teaspoon. -Recommendations Included: >Solids = Puree consistencies >Liquids = Honey Thick Liquids, Liquids by teaspoon. >Supervision for Oral Intake = Close Supervision Review of the Education Sign-In sheet dated 6/3/25, indicated Resident #14: -needed Honey Thick Liquids -was dependent for eating -staff were to give liquids by teaspoon. -the Education Form was signed by CNA #1. Review of the Provider Progress Note dated 6/3/25, indicated Resident #14: -had started on antibiotics for Pneumonia -diet had been downgraded -speech therapy was following -was on aspiration precautions Review of Resident #14's June 2025 Active Physician orders, indicated: -Honey thick consistency liquids and pureed food texture, effective 6/3/25. -Azithromycin (antibiotic) Tablet 250 mg for 5 days for infection, effective 6/3/25. Review of the Dietician Progress Note dated 6/4/25, indicated Resident #14: -was dependent on staff for eating -was on honey thick liquids -had Aspiration Pneumonia On 6/4/25 at 9:35 A.M., the surveyor observed the following during the breakfast meal: -CNA #1 was assisting Resident #14 with the breakfast meal (pureed eggs, pureed hashbrowns with onion, cream of wheat, pureed wheat toast, applesauce and 8 ounces of Lactaid milk). -CNA #1 was mixing hot food items with the applesauce on the spoon before giving the Resident bites. -CNA #1 poured the Lactaid milk into a cup, added 2 packets of thickener and immediately started providing Resident #14 large sips from the cup without verifying the consistency was appropriate. -Resident #14 was heard gulping his/her Lactaid milk from across the room. -CNA #1 gave Resident # 14 multiple over heaping teaspoons of food and only waited seconds in between bites (7 seconds/ 5 seconds/ 8 seconds/ 6 seconds/9 seconds), without verifying the Resident had tolerated the previous bite. -CNA #1 was observed providing Resident #14 bites of food before the Resident could fully swallow the previous bite. -Resident #14 was observed coughing and throat clearing during the meal. The surveyor observed when the Resident started coughing, CNA #1 lifted the cup of milk to Resident #14's mouth and gave him/her a swallow from the edge of the cup and instructed the Resident to take another sip. During an interview on 6/4/25 at 11:01 A.M., CNA #1 said that she was using applesauce to mix with some of the foods but did not tell anyone because she felt the pureed food was too dry. CNA #1 said she was not sure what the 'brown stuff' was on the tray and was unsure if the Resident knew what he/she was being fed. CNA #1 said that she did not have any concerns how Resident #14 had tolerated his/her breakfast and thought the Resident did well because he/she ate 100% of the meal. CNA #1 failed to recognize any concerning symptoms such as coughing or gulping and when the surveyor asked, said that there were no special feeding techniques to use for Resident #14, but you need to thicken his/her liquids to honey. CNA #1 said that during the breakfast meal she had forgotten that Resident #14 needed honey thick liquids and had given him/her some sips without thickening it first and did not tell anyone. CNA #1 said she added thickener to the milk and should have spoon fed it to Resident #14 but didn't, and realized the surveyor observed the Resident drink from the cup versus the spoon. CNA #1 said the Resident had Pneumonia but did not know why or what may have caused it. CNA #1 said that if a Resident had a change in diet or consistency, then the Speech Therapist would tell the staff. During an interview on 6/4/25 at 11:31 A.M., Nurse #1 said Resident #14 is prescribed antibiotics for Pneumonia and the CNAs are responsible for supervising meals and making sure liquids are thickened according to their order. Nurse #1 said if any Resident experiences coughing, not eating, swallowing hard or gulping, the Nurses should be told right away so they can evaluate the Resident and do a respiratory assessment. Nurse #1 also said that if any Resident receives honey thickened liquids, they should be spoon fed the thickened liquid. During an interview on 6/4/25 at 11:33 A.M., the Speech Therapist (ST) said Resident #14 liquid consistency was changed from nectar to Honey thick consistency on 6/3/25 because he/she was not tolerating the nectar well. The ST said staff including CNA #1 were educated on 6/3/25 about the change in fluid consistency and instructed that all honey liquids needed to be fed by teaspoon. The ST said the kitchen staff send up the thickener packets on the meal tray and the CNAs are responsible for thickening the liquids. The ST said Resident #14 has obvious oral motor manipulation [sic], and another bite should not be given unless he/she stops making those movements and his/her mouth is clear. The ST said the Resident should be offered teaspoon fed drinks in between bites. The ST said all feeding should be stopped if the Resident starts coughing or has throat clearing. The ST said staff should not be adding applesauce to other foods, because this alters the taste of foods and could be a quality-of-life issue. During an interview on 6/4/25 at 11:54 A.M., with Nurse Consultant (the previous Director of Nursing[DON]) #1 and Nurse Consultant (NC) #2, NC #1 said staff should be monitoring for signs and symptoms of aspiration during meal assistance, such as coughing or shortness of breath and update the Nurse right away. NC #1 said honey thick liquids should be spoon fed if directed by the ST, to avoid aspiration. NC #1 said CNA #1 was educated on 6/3/25 that Resident #14 required honey thick liquids by teaspoon, and CNA #1 should have used the teaspoon to give the Resident his/her drinks. NC #2 said that staff should wait to for Residents to swallow bites before giving another bite and that apple sauce should not have been mixed with Resident #14's other foods. 2. Resident #5 was admitted to the facility in March 2021, with diagnoses including pneumonitis due to inhalation of food and vomit, recurrent Pneumonia, acute respiratory failure with hypoxia, hypoxemia, dysphagia oropharyngeal phase, disturbances of salivary secretion, Dementia, and other frontotemporal neurocognitive disorder. Review of the Speech Therapy Evaluation and Plan of Treatment, completion date 4/16/24, indicated Resident #5: -had a diagnosis of dysphagia and was evaluated for swallowing function. -Goals of Care indicated: >that the Resident would tolerate the safest, least restrictive diet without signs or symptoms of aspiration. -The ST recommended the Resident be provided with a puree texture and nectar thick liquid consistency. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #5: -was severely cognitively impaired as eveidenced by a score of three out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. -had a diagnosis of dysphagia. -required a mechanically altered diet (pureed food, thickened liquids, etc.). -was dependent on a caregiver for eating assistance. Review of Resident #5's active Dysphagia Care Plan initiated 8/16/24, indicated: -was at risk for aspiration. -was dependent on staff for assistance with eating. -the goal of care was for the Resident to eat foods on his/her current diet and not have signs or symptoms of aspiration. -Interventions included: >If the Resident had an increased temperature, diminished breath sounds, coughing, or a gurgle sound to his/her voice, the Resident may have aspirated, initiated 8/16/24 -Diet was to be provided as ordered, initiated 8/16/24 Review of Resident #5's June 2025 Physician orders indicated the Resident was ordered for a house diet, pureed texture, and nectar thick consistency of liquids related to dysphagia, initiated 7/26/24. Review of Resident #5's breakfast dietary slip dated 6/6/25, indicated the Resident should be provided with a puree texture and nectar thick fluids. The dietary slip further indicated beverages would include nectar thick diet cranberry juice, nectar thick milk, nectar thick orange juice, and nectar thick chocolate health shake. On 6/6/25 at 9:23 A.M., during a dining observation, the surveyor observed Resident #5 lying in his/her bed, being assisted with the breakfast meal by Certified Nurses Aide (CNA) #4. During an interview at the time, CNA #4 said the Resident had just finished his/her breakfast meal. CNA #4 said the Resident drank all the beverages provided, as he/she typically did. The surveyor observed the beverage containers (cranberry juice, milk, orange juice, and health shake) were all empty. The surveyor observed the remaining few drops of cranberry juice to easily slide back and forth on the bottom of the empty cranberry juice container. CNA #4 said that the Resident's health shake was already available in a pre-thickened nectar thick consistency, and the other beverages would need to be thickened. When the surveyor asked CNA #4 if thickener was added to the Resident's cranberry juice, milk, and orange juice that were consumed, CNA #4 was observed to look around on the meal tray, pick up the plate and then pick up a packet of thickener that was located under the plate, and said that he had not seen the thickener. CNA #4 was observed adding the thickener to the Resident's empty milk container. The surveyor requested to speak with CNA #4 away from the Resident and asked if the thickener was added to the Resident's cranberry juice, milk, and orange juice before distributing to the Resident, and CNA #4 said he added thickener to the milk and the orange juice, but not to the cranberry juice. When the surveyor further asked CNA #4 why thickener had not been added to the cranberry juice, CNA #4 said he forgot to add the thickener. CNA #4 said Residents that drink thin/non-thickened liquids when they were ordered to have thickened liquids were at risk for aspiration. During an interview on 6/6/25 at 9:59 A.M., the surveyor discussed with Nurse #7 that Resident #5 drank non-thickened beverages during the breakfast meal. Nurse #7 said she believed the Resident was ordered a puree texture and nectar thick consistency diet. Nurse #7 said she would follow-up related to the Resident having received beverages that had not been thickened according to the Physician's order. During an interview on 6/6/25 at 10:10 A.M., the Director of Nursing (DON) said her experience in the facility was that residents' dietary slips were compared to their electronic medical records when the Nurses checked the meal trays and diets during meal pass. The DON said this process occurred with the Nurses standing alongside the CNA's. The DON said the kitchen provided thickener on the residents' trays, and sometimes there were more packets than were needed for the beverages on the tray. During an interview on 6/6/25 at 11:45 A.M., NC #1 said the staff assisting a Resident with eating would be responsible to ensure that liquids were thickened according to the Physician's order. NC #1 said providing the incorrect consistency of liquids to a Resident could pose a risk for aspiration, pneumonia, or illness.

Based on observations, interviews, and record reviews, the facility failed to provide nutrition and hydration services as required for one Resident (#75) out of a total sample of 24 residents. Specifically, for Resident #75, the facility failed to provide health shakes as ordered at the breakfast meal, putting the Resident at risk for compromised nutritional status. Findings include: Review of the facility policy titled Nourishments and Supplements, effective May 1995 and revised in January 2024, indicated but was not limited to the following: -Policy statement: High calorie food options .may be offered when a resident requires additional calories or nutrients. -Dining services will prepare nourishments as ordered. -Nursing staff will deliver nourishments/supplements to residents as ordered . Resident #75 was admitted to the facility in August 2021, with diagnoses including dysphagia, acquired absence of other specified parts of digestive tract, Dementia, and history of traumatic brain injury (TBI). Review of Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #75: -scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam, indicating the Resident's cognition was moderately impaired. -required set-up or clean-up assistance with meals. -had a significant weight loss (loss of five percent [%] or more in the last month or loss of 10% or more in the last six months) and was not on a Physician-prescribed weight loss regimen. -required a therapeutic diet. Review of Resident #75's Nutrition Progress Note dated 4/17/25, indicated: -the Resident had a 13.5 pound (lb.) weight loss over a four-month period, resulting in a weight loss percentage of 9.5%. -shakes would be added to the Resident's meal trays to increase calorie intake. Review of Resident #75's June 2025 Physician's orders indicated the Resident was ordered for one Mighty Shake (health shake) with meals for supplement, initiated 4/18/25. On 6/6/25 at 8:35 A.M., Resident #75 was observed eating breakfast in his/her bedroom and no health shake was provided on the Resident's meal tray. During an interview at the time, Resident #75 said he/she received health shakes at lunch and dinner and that he/she liked the health shakes and drank them all. Resident #75 said he/she did not receive a health shake with breakfast at this time. During an interview on 6/6/25 at 8:42 A.M., Nurse #6 said health shakes were provided to Residents by the kitchen and should come up on the Residents' meal trays. Nurse #6 reviewed Resident #75's Physician orders and said the Resident was ordered for health shakes with meals. Nurse #6 then reviewed the Resident's meal tray and said there was no health shake on the meal tray, but that there should have been a health shake on the meal tray. Nurse #6 reviewed the Resident's dietary slip and said the health shake was not indicated on the dietary slip. On 6/10/25 at 8:26 A.M., Resident #75 was observed to be eating breakfast in his/her bedroom and no health shake was provided to the Resident on the meal tray. The surveyor observed that the dietary slip failed to indicate that a health shake should have been provided on the meal tray. During an interview at the time, Resident #75 said he/she did not receive a health shake this morning. Resident #75 also said he/she did not receive a health shake the previous morning. During an interview on 6/10/25 at 8:45 A.M., Certified Nurses Aide (CNA) #5 removed Resident #75's meal tray from his/her bedroom, and said the Resident did not receive a health shake with his/her breakfast. CNA #5 said nutritional supplements should be written on Residents' dietary slips and the nutritional supplements should be provided by the kitchen. CNA #5 said she is Resident #75's regular CNA and had worked at the facility for about one year. CNA #5 said the Resident does not typically receive a health shake on his/her breakfast tray. On 6/10/25 at 8:59 A.M., the surveyor observed CNA #5 providing a health shake to Resident #75. During an interview at the time, CNA #5 said she was prompted to provide the Resident with a health shake due to the surveyors' questions. CNA #5 said she could see in the Resident's electronic medical record (EMR) that he/she should have received a health shake with breakfast but he/she did not receive a health shake with breakfast. At this time, the Resident showed the surveyor the health shake and said thanks. During an interview on 6/10/25 at 9:05 A.M., Nurse #4 said Resident #75 had recent weight loss and was ordered to be provided with health shakes. Nurse #4 said the Resident did not receive the health shakes with meals, and she had called the kitchen to request the kitchen deliver the health shakes. Nurse #4 said when a Resident is ordered for a nutritional supplement, it is indicated on the Resident's dietary slip. Nurse #4 said when a Nurse entered a Physician's order for a nutritional supplement, the Nurse should also complete a Diet Requisition and Dietician Communication Form and submit this form to the kitchen so that the nutritional supplement was provided on the Resident's meal trays. During an interview on 6/10/25 at 9:23 A.M., Nurse #5 said when a Nurse entered an order to administer a nutritional supplement with meals, the Nurse completed the Diet Requisition and Dietician Communication Form and provided the completed form to the kitchen so that the order could be added to the Resident's dietary slip by the kitchen. During an interview on 6/10/25 at 11:50 A.M., the Dietician said Resident #75 had experienced weight loss and the Dietician had recommended the Resident receive health shakes beginning in April 2025. The Dietician said the kitchen failed to indicate on Resident #75's breakfast dietary slip that he/she had been ordered to receive a health shake with breakfast. The Dietician also said the kitchen had indicated that Resident #75 had been ordered to receive a health shake with lunch and dinner only.

Based on observation, record review, and interview, the facility failed to assist one Resident (#89), out of a total sample of 24 residents, in obtaining routine dental services. Specifically, the facility failed to schedule dental appointments when consent was given, to ensure that Resident #89 received routine dental services as requested. Findings include: Resident #89 was admitted to the facility in April 2023 with diagnoses including Alzheimer's Disease. Review of the Request for Service Form, dated and signed 5/15/23, by the Resident Representative requested Dental Services. Review of a Physician's order dated 7/26/24, indicated: -May have Vision, Auditory, Dental, Podiatry, Wound Consult. Review of Resident #89's Dental Care Plan initiated 10/17/24, indicated: -the Resident has broken natural teeth and cavities noted on admission to the facility. -coordinate arrangements for dental care. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #89: -was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 0 out of 15. -was dependent on staff for completion of oral hygiene. -has obvious or likely cavity or broken natural teeth. During an interview on 6/5/25 at 1:09 P.M., the Medical Records (MR) staff member said she oversees managing dental services and makes the referral request after the family signs the permission form. The MR staff member said when Resident #89 was admitted in April 2023, the request for services was signed by the Resident Representative but the Resident did not receive Dental Services due to an insurance issue. The MR staff said that Resident #89's insurance issue was resolved about six months later and he/she should have started dental services at that time but the services did not start. During an interview on 6/10/25 at 8:58 A.M., the Administrator said that Resident #89 should have been seen by Dental Services but was not. The Administrator said he was not aware that the Resident had not been seen by Dental Services and had they known, they could have made other arrangements to have Resident #89 seen by a different Dentist.

Based on observations, and interviews, the facility failed to adhere to infection control standards of practice while serving meals to residents on one Unit (3rd Floor) out of three Units observed. Specifically, the facility failed to ensure that staff distributing food during the lunch meal service on the 3rd Floor Unit performed appropriate hand hygiene to prevent contamination and the spread of foodborne illnesses. Findings include: Review of the facility policy titled Hand Hygiene, last revised 6/19/24, indicated: -Hand hygiene will be performed in accordance with national standards from the Centers for Disease and Prevention and the World Health Organization (WHO). >Hand hygiene should be performed: -When coming on duty. -Before entering a resident's room and upon exiting a resident's room. -Before and after handling peripheral vascular catheters and other invasive devices. -After removing gloves or aprons. -After completing duty. >Alcohol-based hand rub may be used for all other hand hygiene opportunities (for example [e.g.] when soap and water is not indicated). -After caring for a resident including after removing gloves. -After contact with the resident environment. >Procedure for using Alcohol Sanitizer. -The alcohol hand sanitizer may be used routinely for hand hygiene unless hands are visibly soiled, then soap and water handwashing is required. On 6/5/25 at 12:40 P.M., the surveyor observed the following during the lunch tray meal pass observation on the 3rd Floor: -The meal truck was brought to the unit by kitchen staff and four Unit staff approached the meal truck, opened the truck and began removing meal trays from the truck without performing hand hygiene first. -Nurse #1, Nurse #2, and 2 Certified Nurses Aides (CNAs) on the 3rd floor Unit were observed passing out meal trays to residents in their rooms. -Nurse #1, Nurse #2, and the 2 CNA's, were observed entering resident's room, placing meal trays on the bedside tables, moving items off the bedside tables and positioning the bedside tables in front of the residents. -The surveyor observed the 4 staff members exiting resident rooms without performing hand hygiene after touching items in the resident rooms and continued passing meal trays from the meal truck to other residents. -The surveyor observed alcohol-based hand sanitizer available on the walls of the 3rd floor hallway. -The surveyor observed Nurse #2 exit a residents' room with gloves on his bilateral hands, and Nurse #2 removed the gloves while approaching Nurse #1. -Nurse #1 and Nurse #2 entered a resident room together without performing hand hygiene before entering the room. -The surveyor observed Nurse #1 and Nurse #2 assessing and examining the residents' intravenous line (IV). -The surveyor observed Nurse #1 and Nurse #2 exit the residents' room without performing hand hygiene, walk towards the meal truck outside and continued serving meal trays to residents in their rooms without performing hand hygiene. -The surveyor observed the 2 CNA's exiting the resident rooms with dirty meal trays in their hands, place the dirty trays on top of meal truck and continue to enter other resident rooms to distribute meal trays removed from the meal truck without performing hand hygiene between handling the dirty and the clean meal trays. During an interview on 6/5/25 at 1:15 P.M., Nurse #1 said that typically staff use the alcohol-based hand hygiene outside the resident rooms to clean their hands prior to entering resident rooms and then again upon exiting resident rooms to prevent cross contamination and spreading of infection to residents. Nurse #1 further said that he forgot to perform hand hygiene when he entered and exited resident rooms, and he should have been using the alcohol-based hand hygiene available to clean his hands to prevent the spread of infections to residents. During an interview on 6/5/25 at 1:28 P.M., Nurse #2 said that he had come out into the hallway with gloves on his bilateral hands but had washed his hands prior to applying the gloves. Nurse #2 further said that he was assessing a residents' IV, as it was his responsibility to ensure that the IV line was functioning appropriately. During an interview on 6/5/25 at 1:55 P.M., the Infection Control Nurse (ICP) said that the expectation for nursing staff on the unit during meal tray pass was that staff use the alcohol-based hand sanitizer that was available on the wall in the hallways to sanitize their hands prior to entering and exiting a resident room to prevent cross contaminations and the spread of infections to residents. The ICP also said that gloves were not to be worn by staff when staff were in the hallway. The ICP further said that staff were to remove gloves from their hands and perform hand hygiene prior to exiting resident rooms.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose care plan interventions included dependent with staff member assistance while eating, and that all food items were required to be pureed in consistency due to dypshagia (difficulty swallowing), the Facility failed to ensure nursing consistently implemented and followed interventions identified in his/her care plan related to eating. On [DATE] around 7:45 P.M., Certified Nurse Aide (CNA) #1 delivered Resident #1 a peanut butter and jelly sandwich as an evening snack to him/her in his/her room, CNA #1 did not remain with Resident #1 to assist him/her while he/she ate the sandwich, and left Resident #1 unsupervised with the sandwich, which was not the correct conisistency per his/her care plan. Fifteen minutes later, Resident #1 was found by staff unresponsive and without a pulse, CPR was initiated, 911 was activated, however Resident #1 was pronounced dead at the facility. Findings Include: Review of the Facility's Policy, titled Comprehensive Care Plan, dated as revised [DATE], indicated that the care plan is as follows: - Developed by the Interdisciplinary Team for each resident includes measurable objectives and timelines to accommodate preferences, and identified special medical, nursing and psychosocial needs. - Provides residents with all necessary care and services to enable them to achieve the highest quality of life. - Right to receive the services or items in the care plan. Resident #1 was admitted to the Facility in [DATE], diagnosis included dementia with agitation, dysphagia (difficulty swallowing), and schizophrenia. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 2 out of 15 (,d+[DATE] suggests severe cognitive impairment, ,d+[DATE] suggests moderately impaired cognition, and ,d+[DATE] suggests a resident is cognitively intact). The MDS further indicated Resident #1 was dependent for eating. Review of Resident #1's Physician's Orders, dated as effective [DATE] (and remained active on his/her [DATE], physician's order), indicated he/she was on a Pureed/National Dysphagia Diet Level 1 (NDD1), consisting of only pureed textured foods related to dysphagia. Review of article related to Standardization for Optimal Care, by the American Dietetic Association; titled National Dysphagia Diets, indicated the following: - NDD1-Level 1 diet consists of foods that are pureed, homogenous (uniform structure throughout) and cohesive (how food stays together). -Foods should be pudding-like. -Foods that require bolus formation, controlled manipulation and chewing are not allowed. Review of Resident #1's Care Plan titled, Dysphagia, reviewed and renewed with the [DATE] MDS, indicated he/she was at risk for aspiration and interventions included the following: - dependent on one staff member for assistance for eating due to hand tremors, - provide him/her with the diet as ordered, NDD1 with thin liquids, -alternating small bites of pureed food, and sips of liquids. Review of Resident #1's Activities of Daily Living (ADL) Care Plan related to Eating, reviewed and renewed with the [DATE] MDS, indicated he/she had cognitive loss, and to provide dependent level assistance of one staff member for eating. Review of Resident #1's Care Card (utilized by the CNA's to ensure required level of care is provided to individual residents on a CNA's assignment), dated [DATE], indicated he/she was dependent with assistance of one staff member for eating, alternate small bites and sips of liquids, teaspoon for eating, instruct him/her to eat in upright position, and eat slowly. Review of the Facility's Investigation Report, dated [DATE], at 9:00 P.M., indicated on [DATE], Resident #1 died after aspirating (inhaling food or liquid into the lungs instead of esophagus) on a sandwich in his/her room, experienced a medical event and education began immediately for staff on diet levels. Review of CNA #3's Witness Statement, dated [DATE], (as documented by facility Administrative Staff during a telephone interview) indicated that (on [DATE]) at around 8:00 P.M., she entered Resident #1's room, saw that he/she was pale, his/her lips were blue, he/she had no pulse and she called for the nurse. Review of CNA #1's Witness Statement, dated [DATE], (as documented by facility Administrative Staff during a telephone interview) indicated that (on [DATE]) at around 7:45 P.M. (snack time), she gave Resident #1 a peanut butter and jelly sandwich and exited the room. The Statement indicated she (CNA #1) did not check Resident #1's CNA care card prior to providing him/her the snack. During a telephone interview on [DATE] at 12:58 P.M., CNA #1 said she has worked at the facility for [AGE] years, had taken care of Resident #1 in the past, but that it had been a few months since she last had him/her on her assignment. CNA #1 said that on [DATE] at around 7:45 P.M., she gave Resident #1 a peanut butter and jelly sandwich for his/her evening snack, that she did not check the CNA Care Card for level of supervision he/she required or his/her diet, left him/her unattended in his/her room and then continued passing out snacks to other residents on the unit. CNA # 1 said she knew how to check the residents' CNA Care Cards in the Electronic Medical Record (EMR) and that she should have checked it before handing out the snacks. During an interview on [DATE], at 12:16 P.M., the Rehabilitation Director (who is also the Speech Language Pathologist (SLP) said they last had Resident #1 on speech therapy caseload in November of 2023, and his/her diet was downgraded to pureed at that time. The Rehab Director said Resident #1 required close supervision with 1:1 provided by a staff member while eating. The Rehab Director said Resident #1 required a staff member present for safety reasons due to him/her eating too quickly, even on the pureed diet. The Rehab Director said Resident #1 was on a full a pureed diet and should not have been given a peanut butter and jelly sandwich. During an interview on [DATE], at 12:09 P.M., the Dietician said Resident #1 was dependent for eating, and was on a pureed consistency diet for safety while eating. The Dietician said Resident #1 should not have been left unattended with any food items and should not have been given a peanut butter and jelly sandwich. During an interview on [DATE], at 12:27 P.M. Nursing Supervisor #1 said Resident #1 was on a pureed diet, was dependent on staff for assistance when eating due to decreased cognition levels and should not have been given a sandwich or left alone with a food item. During an interview on [DATE] at 12: 30 P.M., the Director of Nurses said that CNA #1 should have reviewed and followed interventions from Resident #1's Plan of Care/Card, which included only giving him/her pureed food items, and that CNA #1 should have remained with Resident #1 in his/her room while he/she was eating. On [DATE], the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. On [DATE], an investigation along with the education of staff was initiated by the evening Nursing Supervisor on diet levels immediately following the incident with Resident #1. B. On [DATE], an AD HOC Quality Assurance Performance Improvement (QAPI) meeting was conducted, Resident #1's choking incident was reviewed and corrective action plan was developed. C. On [DATE], a Facility wide audit was initiated by the Director of Nursing to ensure all Residents had the correct consistency and required level of staff assistance with meals and snacks, accurately indicated on CNA Care Cards and Care Plans. D. The following changes (per the Director of Nursing) were immediately implemented related to the process for meal and snack tray delivery: - Dietary labels bins and separates snacks according to diet consistency - Education to dietary staff when loading the snack cart in the Kitchen and Nourishment Rooms on the units that they are assembled with identified sections that correlate by snack consistency and laminated lists of appropriate food items for specific diet levels. -Education to Nursing, Activities and Rehabilitation Staff on the updated process of checking diet orders and level of supervision required on the CNA Point of Care I-Pad tablet. E. On [DATE], Facility Administrative staff, Staff Development Coordinator (SDC) completed Education of all nursing staff, activity staff and rehabilitation staff on meal tray service policy, and snack policy which includes bringing the Point of Care tablet when passing snacks and meal trays prior to serving the resident's meal or snack and checking for current diet orders and consistency and providing the correct level of assistance needed. F. The Director of Nursing and or designee will conduct audits of the tray meal service, and snacks to ensure staff are providing the correct meal/diet and level of supervision. -Daily audits to be completed for one week , then three times weekly x two weeks, two times weekly x two weeks, weekly x two weeks, biweekly for one month then monthly x three months or until substantial compliance. The audits will be brought to quarterly QAPI meetings. G. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a diagnosis of dysphagia (difficulty swallowing), with diet orders for pureed foods only and was dependent on staff to provide assistance when eating, the Facility failed to ensure he/she was provided with the necessary level of staff assistance while eating to maintain his/her safety to prevent an incident of choking. On [DATE] at around 7:45 P.M., Certified Nurse Aide (CNA) #1 delivered Resident #1 an evening snack which consisted of a peanut butter and jelly sandwich, to him/her in his/her room. CNA #1 did not remain with Resident #1 to assist him/her while he/she was eating, and left Resident #1 unsupervised with the sandwich. Fifteen minutes later, Resident #1 was found by staff unresponsive and without a pulse, CPR was initiated, 911 was activated, however Resident #1 was pronounced dead at the facility. Findings Include: Review of the Facility's Policy, titled Reportable Events-Reporting Allegations and Incidents/Investigation (MA), dated as reviewed [DATE], indicated that a death that is unanticipated, not related to the natural course of the residents illness, or is the result of an error, an event that is inconsistent with facility policy that causes death or serious injury, or that places the resident in imminent danger of serious harm is reportable. Review of the Facility's Policy, titled Modified Texture Foods, dated as revised [DATE], indicated that foods requiring modification to a puree texture will have a smooth texture. Review of the Facility's Investigation Report, dated [DATE], at 9:00 P.M., indicated on [DATE], Resident #1 died after aspirating (inhaling food or liquid into the lungs instead of esophagus) on a sandwich in his/her room, experienced a medical event and education began immediately for staff on diet levels. Resident #1 was admitted to the Facility in [DATE], diagnoses included dysphagia, dementia with agitation, and schizophrenia. Review of Resident #1's Physician's Orders, dated as effective [DATE] (and remained active on his/her [DATE], physician's order), indicated he/she was on a Pureed/National Dysphagia Diet Level 1 (NDD1), consisting of only pureed textured foods related to dysphagia. Review of article related to Standardization for Optimal Care, by the American Dietetic Association; titled National Dysphagia Diets, indicated the following: - NDD1-Level 1 diet consists of foods that are pureed, homogenous (uniform structure throughout) and cohesive (how food stays together). -Foods should be pudding-like. -Foods that require bolus formation, controlled manipulation and chewing are not allowed. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 2 out of 15 (,d+[DATE] suggests severe cognitive impairment, ,d+[DATE] suggests moderately impaired cognition, and ,d+[DATE] suggests a resident is cognitively intact). The MDS further indicated Resident #1 was dependent for eating. Review of Resident #1's Care Plan titled, Dysphagia, reviewed and renewed with the [DATE] MDS, indicated he/she was at risk for aspiration and interventions included the following: - dependent on one staff member for assistance for eating due to hand tremors, - provide him/her with the diet as ordered, NDD1 with thin liquids, -alternating small bites of pureed food, and sips of liquids. Review of Resident #1's Activities of Daily Living (ADL) Care Plan related to Eating, reviewed and renewed with the [DATE] MDS, indicated he/she had cognitive loss. Interventions included, to provide dependent level assistance of one staff member for eating. Review of Resident #1's Nursing Progress Note, dated [DATE] at 08:40 A.M., indicated he/she was Dependent for eating. Review of CNA #3's Witness Statement, dated [DATE], (as documented by facility Administrative Staff during a telephone interview) indicated that (on [DATE]) at around 8:00 P.M. she entered Resident #1's room, he/she looked pale, his/her lips were blue, and she called for the nurse. The Statement indicated that CNA #3 said she saw a quarter piece of a sandwich on Resident #1's nightstand, and that Resident #1 usually gets pudding or yogurt for a snack. Review of CNA #1's Witness Statement, dated [DATE], (as documented by facility Administrative Staff during a telephone interview) indicated that (on [DATE]) at around 7:45 P.M. (snack time), she gave Resident #1 a peanut butter and jelly sandwich and exited the room. The Statement indicated that CNA #1 said she did not check the CNA Care Card prior to providing Resident #1's snack. During a telephone interview on [DATE] at 12:58 P.M., CNA #1 said she has worked at the facility for [AGE] years, had taken care of Resident #1 before, but said it had been a few months since she last had him/her on her assignment. CNA #1 said that on [DATE] around 7:45 P.M., she was handing out the evening snacks to the residents on Resident #1's unit. CNA #1 said she gave Resident #1 a peanut butter and jelly sandwich for his/her snack, without first checking his/her diet orders and CNA Care Card for level of assistance he/she required. CNA #12 said she left Resident #1 unattended in his/her room with the sandwich and continued to pass out snacks to other residents on the unit. CNA # 1 said she knew how to check the residents' CNA Care Cards in the Electronic Medical Record (EMR) and that she should have checked it before handing out the snacks. During an interview on [DATE], at 12:16 P.M., the Rehabilitation Director (who is also the Speech Language Pathologist (SLP) said they last had Resident #1 on speech therapy caseload in November of 2023, and his/her diet was downgraded to pureed at that time. The Rehab Director said Resident #1 required close supervision with 1:1 provided by a staff member while eating. The Rehab Director said Resident #1 required a staff member present for safety reasons due to him/her eating too quickly, even on the pureed diet. During an interview on [DATE], at 12:09 P.M., the Dietician said Resident #1 was dependent for eating, that a staff member had to be with him/her when eating, and that he/she had been on a pureed consistency diet for his/her safety for almost a year. The Dietician said Resident #1 should not have been left unattended with food and should not have been given a peanut butter and jelly sandwich. During an interview on [DATE], at 12:27 P.M. Nursing Supervisor #1 said she responded to Resident #1's room when the Code Blue was called, assisted in the resuscitation efforts until EMS arrived and took over care. Nursing Supervisor #1 said Resident #1 was on a pureed diet and was dependent on staff being with him/her for assistance while eating due to decreased cognition levels, and dysphagia. During an interview on [DATE] at 12: 30 P.M., the Director of Nurses (DON) said that CNA #1 should have checked to see what Resident #1's Physician's Diet Order was, should have checked his/her CNA Care Card prior to giving him/her a snack, and should have remained with Resident #1 while he/she was eating, but did not. The DON said CNA #1 had worked at the facility for twenty years and was very experienced. On [DATE], the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. On [DATE], an investigation along with the education of staff was initiated by the evening Nursing Supervisor on diet levels immediately following the incident with Resident #1. B. On [DATE], an AD HOC Quality Assurance Performance Improvement (QAPI) meeting was conducted, Resident #1's choking incident was reviewed and corrective action plan was developed. C. On [DATE], a Facility wide audit was initiated by the Director of Nursing to ensure all Residents had the correct consistency and required level of staff assistance with meals and snacks, accurately indicated on CNA Care Cards and Care Plans. D .The following changes (per the Director of Nursing) were immediately implemented related to the process for meal and snack tray delivery: - Dietary labels bins and separates snacks according to diet consistency - Education to dietary staff when loading the snack cart in the Kitchen and Nourishment Rooms on the units that they are assembled with identified sections that correlate by snack consistency and laminated lists of appropriate food items for specific diet levels. -Education to Nursing, Activities and Rehabilitation Staff on the updated process of checking diet orders and level of supervision required on the CNA Point of Care I-Pad tablet. E. On [DATE], Facility Administrative staff, Staff Development Coordinator (SDC) completed Education of all nursing staff, activity staff and rehabilitation staff on meal tray service policy, and snack policy which includes bringing the Point of Care tablet when passing snacks and meal trays prior to serving the resident's meal or snack and checking for current diet orders and consistency and providing the correct level of assistance needed. F. The Director of Nursing and or designee will conduct audits of the tray meal service, and snacks to ensure staff are providing the correct meal/diet and level of supervision. -Daily audits to be completed for one week , then three times weekly x two weeks, two times weekly x two weeks, weekly x two weeks, biweekly for one month then monthly x three months or until substantial compliance. The audits will be brought to quarterly QAPI meetings. G. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was cognitively intact, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 12/09/24 during the day shift, Maintenance Assistant #1 hugged Resident #1 and kissed him/her on the mouth, without his/her consent, which made him/her feel uncomfortable. Findings include: Review of the Facility Policy titled Resident Rights and Responsibilities, dated as revised July 2017, indicated the Facility will protect and promote the rights of each resident as set forth in the Resident [NAME] of Rights, which includes the right to be treated with respect and dignity. Resident #1 was admitted to the Facility in March 2021, diagnoses included Chronic Obstructive Pulmonary Disorder (COPD), anxiety disorder, Post-Traumatic Stress Disorder (PTSD), major depressive disorder with psychotic symptoms, and schizoaffective disorder. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 11/03/24, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of Resident #1's Medical Record indicated he/she had a court appointed guardian and treatment plan, dated as renewed on 09/09/24. Review of the Facility's Investigation Report, dated 12/09/24, indicated that Resident #1 had reported to staff that he/she was uncomfortable with a situation involving a staff member. The Report indicated that staff reported Resident #1's concern to the Social Worker and the Administrator. The Report indicated that Resident #1 told the Administrator that Maintenance Assistant (MA) #1, had hugged him/her on multiple occasions and that earlier that morning, on 12/09/24 (exact time unknown), he hugged and kissed him/her, making him/her feel uncomfortable. The Report indicated that Maintenance Assistant (MA) #1 told the Administrator that he hugged and kissed Resident #1, on the morning of 12/09/24, to comfort him/her after Resident #1 had told him that he/she was depressed. During an interview on 01/02/25 at 11:02 A.M., Resident #1 said that Maintenance Assistant (MA) #1 had hugged and kissed him/her on two other occasions and that he/she had been afraid to say anything to anyone about it. Resident #1 said that the last time Maintenance Assistant (MA) #1 had come to his/her room to say hello, he/she was still in bed, and that MA #1 was flirty during their conversation. Resident #1 said MA #1 leaned over and hugged him/her and gave him/her a 'mushy' kiss on the mouth without his/her consent. Resident #1 said the kiss didn't feel right and triggered his/her PTSD. Resident #1 said that he/she reported the incident to staff because he/she was afraid of it happening again. During an interview on 01/09/25 at 11:39 A.M., Maintenance Assistant #1 said that on the morning of 12/09/24 he had hugged Resident #1 and kissed him/her on the mouth. Maintenance Assistant #1 said that his behavior was inappropriate and that he regretted the incident. During an interview on 01/02/25 at 1:58 P.M., Laundry Assistant #1 said that on the morning of 12/09/24 (exact time unknown), she saw Maintenance Assistant #1 standing at Resident #1's bedside, and that MA #1 was laughing and conversing with him/her. During an interview on 01/02/25 at 12:50 P.M., the Director of Social Services said that when she spoke with Resident #1, on 12/09/24, he/she was weepy, fearful and reluctant to discuss the details of the incident that occurred with Maintenance Assistant #1 that morning. Review of the Notes from the Administrator and Director of Nurses (DON's) interview with Maintenance Assistant #1, dated 12/09/24 and signed by Maintenance Assistant #1, indicated that he told them he had stopped to say hello to Resident #1 that morning, while he was doing a routine water temperature check. The Notes indicated that Maintenance Assistant #1 told the Administrator and DON that Resident #1 told him that he/she was depressed, and that he gave him/her a hug and a kiss. The Notes indicated that Maintenance Assistant #1 told the Administrator and DON that he had kissed Resident #1 on the lips and he described it as just a peck. The Notes indicated that Maintenance Assistant #1 told the Administrator and DON that he considered Resident #1 a friend, that he had hugged him/her on other occasions, and that the morning of 12/09/24 was the only time that he had kissed him/her. The Notes indicated that when the Administrator asked Maintenance Assistant #1 if he acknowledged that what he had done was wrong, if he realized that he had crossed the line, and that he (Maintenance Assistant #1) responded yes. During an interview on 01/02/25 at 3:00 P.M., the Administrator said that Maintenance Assistant #1 admitted to hugging Resident #1 and kissing him/her on the mouth, on the morning of 12/09/24. The Administrator said that Maintenance Assistant #1 was suspended during the investigation and was later terminated based on his inappropriate actions toward a resident.

Based on interviews and record reviews, the facility failed to ensure its staff prevented significant medications errors for two Residents (#29 and #111), out of 24 sampled residents. Specifically, 1) Nurse #9 administered 80 units of Humulin-N insulin (an intermediate acting Insulin that lowers blood sugar, its effect typically starts in 90 minutes and lasts 24 hours) to Resident #29 without a Physician's order and the Resident was subsequently transferred to the hospital for evaluation, and 2) Nursing staff omitted the administration of Insulin as ordered by the Physician for Resident #111. Findings include: Review of the policy titled General Guidelines for Medication Administration, dated 8/2020, indicated at a minimum, the 5 Rights: right resident, right drug, right dose, right route, and right time-should be applied to all medication administration. Residents are identified before medication is administered using one method of identification. a. Checking the photograph attached to the medical record. b. Calling the resident by name (except in residents with cognitive impairment). c. Having the resident verify his/her last name. d. If necessary, verifying resident identification with other facility personnel. Review of the policy titled, General Guidelines for Medication Administration, dated 9/2018, indicated the following: -The individual who administers the medication dose records the administration on the Resident's MAR directly after the medication is given. -If a dose of regularly scheduled medication is withheld, refused, not available, the space provided on the front of the Medication Administration Record (MAR) for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. 1. Resident #29 was admitted to the facility March 2022 with diagnoses of Diabetes Mellitus Type 2 (DM II), and Neurocognitive Disorder. Review of the Minimum Data Set (MDS) Assessment, dated 7/26/22, indicated a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating the Resident had severe cognitive impairment. Review of the MAR dated August 2022, indicated the Resident was not prescribed Insulin to treat his/her Diabetes Mellitus. Review of a written statement from Nurse #9, dated 8/2/22, indicated that at approximately 7:50 A.M., Resident #29 had passed by him in the hallway, and he mistook him/her for another Resident. Nurse #9 further stated that when he questioned Resident #29 about his/her name, he/she did not respond, and allowed the Nurse to administer Insulin into his/her right arm. Nurse #9 stated that after he administered the Insulin, he went to the chart and realized the error. He notified his supervisor, and the Resident was transferred to the hospital at 8:30 A.M. Review of the facility Transfer Form, dated 8/2/22, indicated the Resident #29's blood sugar was 82 (normal blood sugar is between 70 and 100) at 5:15 A.M., and that he/she was given another Resident's 80 units of Humulin-N insulin in error. Review of the Hospital Discharge/Transfer Note dated 8/8/22, indicated the Resident was admitted to the hospital in the setting of accidental Insulin overdose and placed on D10 (intravenous fluid with a high concentration of sugar) drip to maintain his/her blood sugar. His/her hospital course was complicated by worsening hyponatremia (a condition that occurs when the level of sodium in the blood is too low) and lethargy. Review of the facility Physician Progress Note, dated 9/19/22, indicated the Resident had been admitted to the hospital from 8/2/22 through 8/8/22 after receiving 80 units of NPH Insulin in error. During an interview on 12/28/22 at 9:58 A.M. the Director of Nursing (DON) acknowledged that the medication error had occurred. 2. Resident #111 was admitted to the facility April 2022 with a diagnosis of Diabetes Mellitus Type 2 (DM II). Review of the MDS Assessment, dated 11/13/22, indicated a BIMS score of 15 out of 15, indicating the Resident was cognitively intact. Review of the Physician's Orders, dated December 2022, indicated the Resident had an order for Humulin-N insulin, inject 80 units subcutaneously twice daily, initiated 5/5/22. Review of the MAR, dated December 2022, indicated the following: -12/8/22 at 9:30 PM, nurse initials circled, documentation on the back of the MAR indicated-insulin not available/E-kit (emergency medication kit) on back order. -12/9/22 at 7:30 A.M., initials circled. No documentation on the reverse side. -12/9/22 at 9:30 P.M., initials circled. No documentation on the reverse side. -12/23/22 at 9:30 P.M., entry left blank. No documentation on the reverse side. -12/24/22 at 9:30 P.M., entry left blank. No documentation on the reverse side. -12/25/22 at 7:30 A.M., initials circled. No documentation on the reverse side. Review of the December 2022 Insulin Log (a document created by the facility where the Resident enters the date and time, he/she received insulin, and the nurse signs when the insulin is given) indicated the following: -12/8/22 at 9:30 P.M.-no medicine, written by Resident, not signed by nurse. -12/9/22 at 7:30 A.M.-no medicine, written by Resident, not signed by nurse. -12/9/22 at 9:30 P.M.-no medicine, written by Resident, not signed by nurse. -12/24/22 at 9:30 P.M.-no medicine, written by Resident, not signed by nurse. -12/25/22 at 7:30 A.M.-no Humulin at 2:30 P.M., written by Resident, not signed by nurse. -12/25/22 at 9:30 P.M.-unreadable entry by the Resident at 10:15 P.M., not signed by nurse. During an interview on 12/27/22 at 12:24 P.M., Resident #111 said that he/she had gone days without his/her insulin because it was not ordered correctly. He/she showed the surveyor the Insulin log and explained that he/she was given this by the facility to write down the time he/she received Insulin. The Resident showed the surveyor the Insulin log which consisted of columns with his/her name and space for documenting the entries to log the Insulin administration. The Resident further said that the nurses were supposed to sign the Insulin Log and showed the surveyor where he/she indicated on the log when Humulin-N insulin was not available. During an interview on 12/28/22 at 3:36 P.M. the DON said that when medications were not administered, the nurses were to circle their initials on the front of the MAR and write a note on the back of the MAR indicating why the medication was not given. The DON and the surveyor reviewed the MAR and Resident #111's Insulin Log. The DON said she had no evidence that Humulin-N had been administered to Resident #111 as ordered by the Physician on the following dates: -12/8/22 -12/9/22 -12/23/22 -12/24/22 -12/25/22 Refer to F580

Based on records reviewed and interviews, for one of three sampled residents (Resident #2) (who was receiving an anticoagulant medication), the Facility failed to ensure the physician was notified when he/she was witnessed by a Certified Nurse Aide (CNA) to fall in the bathroom, Resident #1 hit head first into the wall, and although the CNA immediately reported the incident to Nurse #1, the physician was not notified. The following day, Resident #2 was observed to have facial and head bruises, physician was notified and Resident #2 was transferred to the Hospital Emergency Department for evaluation and was diagnosed with [REDACTED]. Findings include: The Facility's Policy, titled Change in Resident's Condition, dated 5/2018, indicated that the Charge Nurse or Nurse Supervisor will notify the resident's attending Physician or on-call Physician when there has been an unusual occurrence, an accident or incident involving the resident, a need to alter the resident's medical treatment significantly or a need to transfer the resident to a hospital. Resident #2 was admitted to the Facility in January 2019, with [DIAGNOSES REDACTED]. Review of Resident #2's Medication Administration Record [REDACTED]. During an interview on 2/4/20 at 9:30 A.M., CNA #1 said that on 12/25/19 at approximately 6:40 A.M., she witnessed Resident #2 fall. CNA #1 said when Resident #2 fell he/she hit head first into the bathroom wall and that Resident #2's head hit the wall with a moderate amount of force. CNA #1 said that she immediately notified Nurse #1 (who was the Charge Nurse on the 11:00 P.M. to 7:00 A.M. shift) of the incident, including that Resident #2 had hit his/her head on the wall. CNA #1 said Nurse #1 examined Resident #2's face and head and said the bump on Resident #2's head was old. Nurse #1's witness statement, dated 12/27/19, indicated that on 12/25/19 during the 11:00 P.M. to 7:00 A.M. shift, a CNA had reported to her that Resident #2 hit his/her forehead on the bathroom wall while sitting on the toilet. The Statement indicated, a body check was completed and indicated there was a pre-existing oval movable area on Resident #2's right frontal area of his/her head. Review of Resident #2's medical record indicated there was no documentation to support that his/her physician was notified of the fall. During interviews on 2/4/20 at 8:32 A.M. and on 2/10/19 at 10:54 A.M., Unit Manager #1 said that the Physician should have been immediately notified on 12/25/19, when Resident #2 had hit his/her head on the wall. Resident #2 was at increased risk for a possible brain bleed and that anticoagulant medications were contraindicated with active bleeding, Unit Manager #1 said Resident #2 was administered 3 doses of anti-coagulants after hitting his/her head, and he/she was not immediately evaluated for potential a brain bleed. During an interview on 2/4/20 at 2:30 P.M., Nurse #2 said that on 12/25/19, she was assigned to the 7:00 A.M. to 3:00 P.M. shift and said during the shift report provided to her by Nurse #1, she was not told that Resident #2 had hit his/her head on the bathroom wall. The Nurse Progress Note, dated 12/26/19 at 12:13 P.M., indicated in the morning, Resident #2 observed to have a new bruise on his/her forehead. The Note indicated the Physician was notified and ordered stat (immediate) laboratory work, physician would be in to evaluate Resident #2, and for nursing to hold daily aspirin dose. The Facility Investigation, dated 12/26/19, indicated on 12/26/19, during the 7:00 A.M. to 3:00 P.M. shift, CNA #2 reported that Resident #2 had bruises on the front of his/her head and forehead, and a swollen forehead. Nurse #3's witness statement, dated 12/27/19, indicated on 12/26/19 at 7:30 A.M., CNA #2 reported to him that Resident #2 had head and facial bruises, a purple and bluish discoloration on his/her forehead and the mid left forehead was red and swollen. The Statement indicated there was documentation or reported history of Resident #2 hitting his/her head or of a fall. The Statement indicated Resident #2's condition declined, he/she was agitated and restless, the Physician was notified, and recommended that Resident #2 be sent to the Hospital Emergency Department. The Hospital Physician's Note, dated 12/26/19, indicated Resident #2 had a large bruise on his/her forehead, which most likely occurred from a fall and he/she was on an anticoagulant for [MEDICAL CONDITION]. A computerized tomography (CT) scan of the head indicated Resident #2 had an acute brain bleed within the brain measuring 5 centimeters (cm) in the right side of his/her brain, the back of the brain, and a small amount of acute bleeding in the subarachnoid (area between the brain and the tissue covering the brain). The Hospital Report, dated 12/28/19, indicated that Resident #2 was agitated, had extensive ecchymosis (black and blue discoloration of the skin due to bleeding) which originated in the right front and side of his/her head and extended around the eyes, which gave Resident #2 raccoon eyes (bruising around the eyes due to trauma). He/she had an extensive hematoma (collection of blood due to bleeding) in the right side of his/her torso. Resident #2 had a bleed within the brain in the setting of anticoagulation therapy. The Hospital stopped anticoagulation therapy, since anticoagulation was contraindicated. During an interview on 2/5/20 at 9:30 A.M., the Director of Nurses DON said that his investigation of Resident #2 hitting his/her head, it was determine that Nurse #1 did not notify the physician.

Based on interview and record review, the facility failed to ensure a safe transfer while using a Mechanical lift for one resident (#116) of three closed records reviewed, resulting in a fall with injury requiring the resident to be transferred to the hospital. Findings include: Resident #116 was admitted to the facility in (MONTH) of (YEAR), with multiple [DIAGNOSES REDACTED]. Review of a nurse's note, dated 9/16/19, indicated Resident #116 was observed during a transfer from bed to wheelchair by nursing and physical therapy. The note indicated the transfer looked unsafe and the resident's transfer status was changed to require a mechanical lift (hydraulic lift that uses a sling style lift pad). Review of a nurse's note, dated 9/24/19, indicated a Certified Nursing Assistant (CNA) called the nurse into the resident's room. Resident #116 was observed to be on the floor, at the end of the resident's bed, under the mechanical lift. The resident was lying on his/her back with a moderate amount of red blood coming from an open area on the left side of the resident's head, approximately 3.0 centimeters (cm) long by 0.1 cm wide. The physician was notified and the resident was transferred to the hospital. Review of the hospital emergency room note indicated Resident #116 was seen for fall from a mechanical lift. He/she had a 3 cm laceration/head contusion that required six staples and no other injuries. Review of the facility Fall Investigation Questionnaire form, dated 9/24/19, indicated Resident #116 fell from the mechanical lift, to the floor, while being transferred from his/her bed to the wheelchair. The hook (loop) to the mechanical lift pad slipped off on the right side and the resident slid to the floor onto the mechanical lift base. Review of the two involved CNA's statements, dated 9/24/19, indicated the mechanical lift pad loops were not secure on the hooks prior to transferring the resident, and the mechanical lift was missing resident clips on the hooks. Review of a post fall physical therapy screen, dated 9/25/15, indicated Resident #116 sustained a fall related to a mechanical lift that resulted in a scalp laceration and staples. The screen further indicated that there was no change in function and recommended staff education for safe transfer and safe use of mechanical lift. Review of the Fall SBAR (Situation, Background, Assessment, and Recommendation-framework for communication between members of the healthcare team) form, dated 9/25/19, indicated Resident #116 slipped from the mechanical lift while being transferred from the bed to the wheelchair. The form listed the following interdisciplinary team review interventions: -re-educate staff on how to use the mechanical lift properly -replace the anti-slid clips on the mechanical lift hooks On 11/21/19 at 8:15 [NAME]M., during an interview with the Director of Nurses (DON), she said that 2 CNA's transferred Resident #116 using the mechanical lift which was missing 2 required clips that are used to hold the mechanical lift pad loops in place. She said the clips are a second security so that the pad loops do not slip. She said if the loops were properly attached they would not come off the hook even without the clips in place. The DON further said the clips should have been with the mechanical lift, but they were not. She said Resident #116 was transferred by the CNAs using the mechanical lift without the clips and the resident had a fall and sustained a laceration requiring staples. She further said that staff should have reported that the mechanical lift was missing the required clips so it could have been addressed. She said that maintenance had extra clips and the staff should have called and gotten them. The DON said the mechanical lift did not have all the required parts when it was used and should have. On 11/22/19, the facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: [NAME] Corrective Action/Verbal Warning(s) were issued to both CNAs involved in the resident's transfer. Immediate re-education was provided on the proper use of the Hoyer lift which included the need to verify the mechanical lift pad loops are firmly secured in its cradle and to ensure the anti-slid clips are on prior to using the lift. B. CNA staff (all shifts) were re-educated on how to use the mechanical lift properly by making sure the anti-slid safety clips are in place and Hoyer lift pad loops are properly in cradle. This was completed 9/24/19 and 9/25/19. C. Audits were completed on all three units for anti-slid safety clips, mechanical lift pads and overall condition and function of the mechanical lift(s) every shift beginning on 9/24/19 3:00 P.M. - 11:00 P.M. shift through 10/2/19 3:00 P.M. - 11:00 P.M. shift and ongoing. D. Continued monitoring and review at Quality Assurance Performance Improvement (QAPI) meetings along with incidents/accidents E. The Director of Nurses or designee is responsible to ensure ongoing compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure that he/she was free from abuse, when Certified Nurse Aide (CNA) #2 physically restrained Resident #2 with a sheet tied around his/her waist, secured to the back of his/her wheelchair preventing him/her from getting up, on at least two separate occasions, so she could attend to other residents. Although Resident #2 was unable to recall the incident to the Surveyor due to his/her cognitive impairment, the Reasonable Person Concept presumes that an unimpaired individual would have mental anguish from being physically restrained involuntarily. Findings include: The Facility's Policy, titled, Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition, dated 11/2017, indicated that: -The Facility will not tolerate verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, exploitation, mistreatment, or neglect of it residents. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. -Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. -Mistreatment means inappropriate treatment or exploitation of a resident. - Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. - Corporal punishment is a physical punishment used as a means to correct or control behavior. The Facility's Policy, titled Restraints, dated 5/2008, indicated that: - The Facility will utilize the least restrictive devices for residents and only as a means to maintain or assist a resident in reaching his/her highest practical level of well-being. - Physical restraints are limited to circumstances where medical symptoms warrant their use. Restraints are never used for discipline, convenience or to prevent wandering, even at night. - Physical restraints are used only with the written order of the physician or other authorized person. The Physician order [REDACTED]. - Residents or Responsible persons are allowed to refuse restraints. Resident 2's Significant Minimum Data Set (MDS) Assessment, dated 9/14/18, indicated [DIAGNOSES REDACTED]. Resident #2's plan of care for Falls, revised 9/14/18, indicated he/she had a history of [REDACTED]. Review of Resident #2's physician's orders [REDACTED]. The Health Care Facility Reporting System (HCFRS) Report, dated 10/19/18, indicated that at approximately 6:00 A.M., Resident #2 was found by Certified Nurse Aide #3 sitting in a wheelchair with a sheet tied around him/her and knotted on the back of the wheelchair. The Report indicated CNA #2 admitted to tying the sheet around Resident #2. The Facility's Internal Investigation, undated, indicated that on 10/19/18 at approximately 6:00 A.M., CNA #3 arrived on Unit 3 and found Resident #2 sitting in a wheelchair with a sheet tied around him/her. The Report indicated CNA #3 took a picture of the restraint tied to the wheelchair, untied the knot and reported the restraint usage, which included showing the picture, to the Supervisor. The Report indicated CNA #3 said three months ago she saw Resident #2 restrained with a sheet covering his/her lower body, that the sheet then came up to waist and was tied in the back of his/her wheelchair. The Report indicated, in response to the first incident, CNA #2 told CNA #3 that Resident #2 undresses and she was just trying to keep him/her covered with a sheet. The Report indicated CNA #3 did not report this incident to anyone. The Report indicated the Administrator and Director of Nurses (DON) asked CNA #2 if she tied Resident #2 to a wheelchair with a sheet on 10/19/18, and that CNA #2 immediately responded, I did it. The Report indicated CNA #2 said she tied the resident with a sheet to the wheelchair because she needed to attend to other residents and she was afraid Resident #2 would fall, because Resident #2 leaned to the side. The Surveyor interviewed the Director of Nurses (DON) at 8:30 A.M. on 2/14/19. The DON said the investigation findings were that CNA #2 had physically retrained Resident #2. CNA #3's Witness Statement, dated 10/19/18, indicated that approximately 3 months prior to 10/19/18, she had found Resident #2 tied to the wheelchair with a sheet. The Statement indicated that, the first time CNA #3 found Resident #2 tied with a sheet, she told CNA #2 not to tie Resident #2 to the wheelchair with a sheet because it could be considered a restraint. The Statement that CNA #3 found Resident #2 again tied to the wheelchair with a sheet on 10/19/18, and reported it to the Supervisor. The Surveyor interviewed CNA #3 at 6:35 A.M. on 2/14/19. CNA #3 said that on 10/19/18 she found Resident #2 was tied up in the wheelchair at approximately 6:00 A.M., and said the previous incident, approximately three months ago, was around the same time in the morning. CNA #3 demonstrated for the surveyor with a sheet how Resident #2 was tied to the wheelchair. CNA #3 showed how the sheet was double knotted in the back, behind Resident #2, out of his/her reach, so he/she could not get out of the wheelchair nor release the restraint. CNA #2's written statement sent via email to the DON, dated 10/19/18, indicated that she (CNA #2) was unable to make Resident #2 safe in a wheelchair, due to his/her left sided weakness and tendency to fall, related to his/her posture, so she (CNA #2) tied him/her with a sheet and was responsible for this restraint. The Surveyor interviewed CNA #2 at 8:14 A.M. on 2/14/19. CNA #2 said she was afraid Resident #2 would fall, he/she leaned to the side of his/her wheelchair due to his/her stroke and he/she disrobed and the tied sheet kept him/her covered. CNA #2 said he/she needed to tie Resident #2 with a sheet to the wheelchair and did not have any other choice, if she wanted to prevent a fall. The Surveyor interviewed Resident #2 at 12:30 P.M. on 2/14/19. Resident #2 was unable to recall the incident to the Surveyor due to his/her cognitive impairment, the Reasonable Person Concept presumes that an unimpaired individual would have mental anguish from being physically restrained involuntarily.

Based on observation, record review, and interview, the facility staff failed to ensure that 2 sampled residents ( #43, and #115) out of 18 applicable residents, out of a total of 24 sampled residents, received adequate supervision and assistance to prevent accidents and failed to provide adequate interventions to prevent falls. The facility also failed to provide an environment that was free from accidents and hazards. Findings include: 1. For Resident #115, the facility failed to provide effective interventions to prevent falls, and failed to follow the plan of care regarding; the proper placement, cord length, and functioning of alarms, the completion of 15 minute checks, and the intervention that the Patient/Resident was not to be left alone in the bedroom. Resident #115 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, completed on 2/22/18, indicated the resident had minimal difficulty hearing; utilized glasses; had short and long term memory problems; was independent for decision making; required supervision with the walker off of the unit; and had no falls. Review of a Plan of Care for falls (initiated 9/16/16), related to a history of falls included the following interventions: - Call bell in reach while in room. - Ensure environment is free of clutter. - Monitor for safety during activities. - Non-skid socks as needed. - Reinforce need to call for assistance. Review of a Progress note of 5/3/18 indicated that the resident had a fall at 12:50 A.M. in his/her room and was found on the floor. The resident had a moderate sized hematoma to the back of the right posterior head. The Care Plan was updated to include a bed alarm. Review of a Progress note of 5/11/18 indicated that at 12:48 P.M., the resident had a witnessed fall in his/her room. A visitor observed the resident standing next to the closet when he/she fell backwards hitting his/her head and back on the floor. The resident was complaining of right hip and back pain and was transported to the hospital for evaluation. There was no major injury from the fall upon return from the hospital. The care plan was updated to include a chair alarm, and supervision for ambulation and transfers. Review of a Significant Change in Status Assessment completed on 5/17/18 for a decline in Activities of Daily Living, indicated a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severely impaired cognition; the resident had mood indicators including feeling down and depressed; showing little interest or pleasure in doing things; was tired and had little energy; had a poor appetite; had a decline in all areas of Activities of Daily Living; was extensive assistance for bed mobility (assist of 2), transfer, walking in the room and corridor, locomotion on the unit, and toilet use (assist of 1). The resident had 2 falls with injury (except major), since the last assessment. Review of a Fall Risk Assessment completed on 5/17/18 indicated a score of 10 (moderate risk for falls). Review of a Progress note, dated 6/17/18, indicated the resident was found on the floor next to the bed at 11:00 P.M. The resident said he/she just wanted to go to the bathroom. The fall was unwitnessed. Neurological checks were initiated. No injuries were observed. The investigation indicated that the resident had taken the Tab alarm off and the bed alarm did not sound. During an interview with the DON, (on 12/11/18 at 10:42 A.M.), she said that staff had placed a personal Tabs alarm on the resident between (6/3/18 and 6/17/18). The resident removed the personal Tabs alarm, then shut off the bed pad alarm which was in the resident's reach. New interventions included; always store the alarm box out of reach so that the resident cannot manipulate, and 72 hour bladder/bowel tracking to determine if there was a pattern for night time voiding. Results of the tracking - offer toileting assistance during night time rounds when awake. Review of a Progress Note of 6/25/18 indicated that the resident was found on the floor by the bed at 3:35 A.M The resident removed his/her personal Tabs alarm, but the bed pad alarm was sounding. The resident was assessed and no injuries were found. A medication review and Psychiatric follow up consult was added to the plan of care. Review of a Progress Note of 7/30/18 indicated that the resident was found sitting upright on the bathroom floor at 3:00 A.M The resident said that he/she hit his/her head. The resident had removed the personal Tab alarm, and the bed pad alarm did not sound as planned. During interview with the DON (on 12/11/18 at 11:00 A.M.), she said that the bed alarm malfunctioned. The fall was unwitnessed, and there were no injuries from the fall. The care plan was updated to include 15 minute checks for 72 hours. Review of the 15 minute checks, completed following the fall of 7/30/18, started on 7/30/18 at 4:00 A.M. and continued every 15 minutes through 7/30/18 at 7:15 A.M. (for 3 hours and 15 minutes), and then stopped. During an interview with the DON on (12/11/18 at 1:30 P.M.), she said the 15 minute checks were incomplete, and should have been completed for 72 hours through 8/2/18, and were not. Review of a Fall Risk Assessment completed on 8/10/18 indicated a score of 16 (high risk for falls). Review of a Significant Change in Status Assessment of 8/16/18 indicated that the resident required two assists for transfers and toileting, only ambulated in the corridor 1 to 2 times in the past 7 days, was frequently incontinent of urine and occasionally incontinent of bowel, had 2 falls with no injury, and 1 fall with injury (except major). Progress note of 8/31/18 indicated at 9:23 P.M. that staff heard an alarm sounding, and the resident was found on the floor in his/her bedroom in a pool of blood. The resident fell out of the chair while reaching into a drawer. The fall was not witnessed. The wound on the resident's forehead was 1.5 centimeters in diameter. The resident was transferred to the hospital and returned to facility on 9/3/18 with an abrasion/contusion. During review of the investigation and interview with the DON, (on 12/11/18 at 11:08 A.M.), she said that the care plan was updated to include do not leave the resident alone in his/her bedroom, and to remind the resident to ask for help. Progress note of 10/18/18 indicated that the resident had an unwitnessed fall in his/her room. The resident was found on the floor between the bed and the wheelchair at 6:45 P.M., despite the intervention (on 8/31/18) which indicated not to leave the resident alone in his/her room. Further review of the investigation and during interview with the DON (on 12/11/18 at 11:10 A.M.) she said that the Tab alarm did not sound because the cord was too long. The care plan was updated to try to keep the resident in front of the nursing station. There was no injury from the fall. Review of a Fall Risk Assessment completed on 11/14/18 indicated a score of 21 (high risk for falls). Review of a Quarterly MDS Assessment completed on 11/15/18 indicated a BIMS score of 1 out of 15 indicating severely impaired cognition, the resident only ambulated in the room once or twice; was always incontinent of bowel, and had a fall with no injury. Review of a Progress note of 11/19/18 indicated the a nurse was called to the solarium at 5:00 P.M. by another nurse, and the resident was found lying on his/her right side with towels supporting the resident's head. Profuse bleeding was found to be coming from a laceration above the right eyebrow. Pressure was applied to the wound and 911 was called. Review of the investigation indicated that the resident had a laceration and was transported to the Hospital for evaluation and treatment. On 11/20/18, the resident returned to the facility with a 3 centimeter laceration requiring 4 sutures for closure of the wound. Review of the investigation indicated that there were no staff present in the solarium when the resident fell from the wheelchair. During an interview with the DON, (on 12/11/18 at 11:20 A.M.), she said the fall was unwitnessed, as staff were gathering other residents to bring them to the solarium for the evening meal. The DON said that a CNA feeding another resident in a nearby room heard the alarm sounding, and found the resident on the floor. The care plan was updated to include that therapy would evaluate for a new wheelchair, mobility and positioning. On 12/10/18 from 11:15 A.M. to 12:00 P.M., the resident was observed sitting in front of the nursing station in the wheelchair with the alarm on. At 12:00 P.M. the resident was brought to lunch by a CNA. During interview with the DON, on 12/11/18 from 10:15 A.M. through 11:20 A.M., she said that the plan of care was not always followed and the interventions were not always effective. On 12/11/18 at 2:45 P.M., the surveyor observed Resident #115 propelling in his/her wheelchair in the hallway on the unit with the alarm on the wheelchair. During an interview, on 12/11/18 at 2:45 P.M., CNA #7 said that she was familiar with the resident's care. CNA #7 said that the resident had to be kept in an area where someone was around. CNA #7 said that the resident was a very high fall risk, frequently tried to get up out of the wheelchair and set the alarm off. CNA #7 said that the resident had a pad alarm in bed, and a chair pressure alarm. On 12/11/18 at 2:50 P.M., the surveyor observed Resident #115 alone in his/her bedroom sitting in the wheelchair, despite the plan of care indicating the resident was not to be left alone in the bedroom. As the surveyor was walking from the bedroom doorway to get a staff member, the Activity Director walked into the room to transport the resident to an Activity. The surveyor asked the Activity Director if the resident should be left alone in the room, and the Activity Director replied, I don't know, and proceeded to propel the resident down the hallway in the wheelchair. On 12/11/18 at 3:50 P.M., the surveyor observed the resident sitting in a wheelchair alone in his/her bedroom. The resident reached forward and grabbed a yellow stuffed animal from a straight back chair, and the stuffed animal fell on to the floor. The resident reached down from the wheelchair and picked up the stuffed animal. Then, the resident reached forward and threw the stuffed animal back onto the straight back chair. The Surveyor left the room and approached Nurse #2 at 3:55 P.M. Nurse #2 indicated that the resident could not be left alone in his/her bedroom, because he/she stands up on his/her own and might fall. The surveyor asked Nurse #2 to come to the resident's room. The resident was found sitting in a wheelchair leaning forward and washing his/her hands in the sink. Nurse #2 stayed and assisted the resident. The plan of care was not followed, despite the intervention not to leave the resident alone in the room. 2. For Resident #43, the facility failed to provide adequate supervision and effective interventions to prevent falls. Resident # 43, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment of 3/30/18 indicated the resident utilized eye glasses and required assist with transfers, ambulation, dressing, bathing and toileting. Review of the Falls Care Plan of 4/11/18 indicated the following interventions: bed pad alarm, wear shoes when out of bed, clutter free environment and TABS alarm in chair and in bed. Review of the 6/2/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The resident was attempting self transfer to toilet her/himself. The investigation indicated the resident was confused, exhibited an unsteady gait and to prevent further falls the facility initiated a bowel schedule. Review of the Quarterly MDS assessment of 6/29/18 remained essentially unchanged except to indicate that the resident exhibited severe cognitive deficits and had experienced a fall. Review of the 7/9/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The Progress Note indicated that the resident's bed alarm was not on, as planned. The investigation indicated the resident's Tab alarm did not sound, as planned. The Care Plan was updated to include: do not leave resident unattended in her/his room when awake. Review of the Rehabilitation (Rehab.) Screen of 7/13/18 indicated Rehab. was in agreement with the care plan regarding not leaving the resident alone in her/his room when she/he was out of bed. Review of the 8/13/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. The investigation indicated the resident had been sitting in her/his recliner chair and had attempted to self transfer. During an interview with the Director of Nursing (DON) (on 12/10/18 at 1:40 PM), she said the care plan had not been followed as the resident had been left unattended in her/his room (despite being care planned for not being alone in her/his room). The DON further said that the assigned CNA (Certified Nursing Assistant) had been educated regarding the care plan intervention previously in place. Review of the 9/25/18 Progress Note indicated the resident experienced an unwitnessed fall (in room), with no injury. During review of the investigation with the DON (on 12/10/18 at 1:40 PM), she said the resident's bed alarm did not sound, as planned. The investigation further indicated that to prevent further falls bilateral bed bolsters would be placed on the resident's bed. Review of the Quarterly MDS assessment of 9/28/18 remained essentially unchanged. Review of the 10/9/18 Progress Note indicated the resident experienced a fall, with no injury. The investigation indicated that a CNA was attempting to pull up the resident's pants, at the time of the fall. The investigation indicated that to prevent further falls the staff were to ensure that the resident holds onto the bathroom bar while being assisted after toileting. The Falls Care Plan of 10/10/18 remained essentially unchanged. Review of the Progress Note of 10/13/18 indicated the resident experienced an unwitnessed fall, (in room) sustaining a red/purple bruise on the right upper arm. During interview with the DON (on 12/10/18 at 1:40 PM), she said the resident's bed alarm did not sound (as planned) because the alarm was not placed properly in the resident's bed. During an interview with CNA #4 on 12/10/18 at 7:14 AM, she said the resident's memory is poor, (her/his) safety awareness is not good at all, and that (she/he) gets out of (her/his) bed and out of (her/his) chair a lot. During an interview with the DON on 12/10/18 at 1:40 PM, she said the resident is not aggressive, (she/he) exhibits no behaviors, (she/he) doesn't remember (she/he) can't walk alone and that (she/he) has a safety awareness deficit. A discussion was held relative to the facility failing to provide adequate supervision and effective interventions to prevent the resident's falls. Please refer to F 842. 3. The facility staff failed to provide an environment free from accident hazards related to a laundry chute on 2 of 3 units. During a third floor observation, on 12/05/18 at 9:30 A.M., two surveyors observed a Certified Nurses Aide (CNA) open an unlocked laundry chute door and deposit a bag of laundry. The key was left in the unlocked door before and after use. During a third floor observation, on 12/05/18 at 1:27 P.M., two surveyors observed a housekeeper open an unlocked laundry chute door and deposit a bag of laundry. The key was left in the unlocked door before and after use. During a first floor observation, on 12/06/18 at 10:53 A.M., the Surveyor observed the key to be in the laundry chute door in the unlocked position and was able to lift the latch and pull open the door. Housekeeper #1 said the door to the laundry chute should be locked and the key should be hung out of reach. During a third floor observation, on 12/06/18 at 10:58 A.M., the Surveyor observed the key to be in the laundry chute door in the unlocked position and CNA #1 was able to lift the latch and pull open the laundry chute door. During an interview, on 12/06/18 10:58 A.M., CNA #1 said the key to laundry chute should not have been left in the door. She further said the door should be kept locked and the key should be hung out of reach. During an interview, on 12/06/18 at 11:07 A.M., the Laundry Supervisor said the laundry chute is actively used on all three floors. She said each floor has a door to the common chute that runs from the third floor to the basement. She further said the doors are to remain locked on each unit and the key hung on the knob above the door so it cannot be easily reached by passing residents. During an interview, on 12/06/18 at 3:02 P.M., Unit Manager #1 said all of the residents on the third floor have dementia or Alzheimer's with varying levels of mild to severe cognitive impairment. She further said it is a locked unit with codes for the stairwells and a wander guard system on the elevator.

Based on observation, record review and interview, the facility staff failed to follow the plan of care relative to fall prevention and the use of compression stockings for 2 residents (#1 and #7) in a total sample of 24 residents. Findings include: 1. For Resident #7, the facility staff failed to implement the use of a chair alarm as care planned for Resident #7, for 2 falls, resulting in a [MEDICAL CONDITION] and fractured radius. Resident #7 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. Review of the falls care plan indicated an intervention, initiated on 3/2/2015, for bed and chair alarms. Personal tab alarm in bed and chair. Review of the Nurse's note, dated 12/28/15, indicated the resident stood up (unwitnessed) from his/her chair, slid to the floor and was found sitting on his/her buttocks. The fall investigation indicated the chair alarm was not in place. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 4/29/16, indicated the resident had severe cognitive impairment and required staff assistance for transfers and ambulation. Review of the Nursing notes and fall investigation documents, dated 6/25/16, indicated the resident was found lying on the floor on his/her right side at 10:40 P.M. Documentation indicated the fall was not witnessed and the alarm was not on the recliner at the time of the fall. The resident was sent to the hospital on [DATE] at 11:35 P.M. and admitted with a fractured right hip and fractured right radius. During an interview on 9/29/16 at 8:10 A.M., with the Unit Manager #1, she said the bed and chair alarms were implemented on 3/2/15 and were current interventions at the time of the falls. After the UM #1 reviewed the investigation paperwork, she said the chair alarms were not in place on 12/28/15 and 6/25/16. Please see F323 2. For Resident #1, the facility failed to apply TED stockings (used to manage leg [MEDICAL CONDITION]) as ordered by the Physician. Resident #1 was admitted to facility in 12/2015 with [DIAGNOSES REDACTED]. Review of the clinical record indicated a physician's orders [REDACTED].M. and off in the P.M. Review of the 9/2016 Treatment Administration Record (TAR) indicated the resident had TED stockings applied daily from 9/1/16 through 9/27/16, except for 9/7/16 and 9/8/16. On 9/27/16 at 1:45 P.M., the resident was observed sitting in a wheelchair dressed and wearing socks and shoes, but was not wearing TED stockings. On 9/28/16 at 9:00 A.M., the resident was observed sitting in a wheelchair in the unit dining room. The resident was dressed, had on shoes and socks but was not wearing TED stockings. On 9/28/16 at 2:50 P.M. the surveyor, accompanied by Unit Manager (UM) #1, observed Resident #7 sitting in a wheelchair in the main dining room. The resident was dressed, had on shoes and socks, but was not wearing TED stockings. During an interview on 9/28/16 at 2:55 P.M., UM #1 said Resident #1 was not wearing his/her TED stockings as ordered. She said the stockings had not been used for a while due to a [MEDICAL CONDITION] infection of the left leg. UM #1 said Nursing should not have documented the stocking were applied and should have obtained a Physician order [REDACTED].

Based on observation, interview and record review the facility failed to implement appropriate interventions and assistive devices to prevent accidents for 1 resident (#7), of 9 applicable residents, in a total sample of 24 residents, and failed to implement interventions to reduce the risk of a fire hazard. Findings include: 1. For Resident #7, the facility staff failed to implement the use of a chair alarm when the resident was in the recliner, resulting in a fractured hip and fractured radius. Resident #7 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. Review of the falls care plan indicated an intervention, initiated on 3/2/2015, for bed and chair alarms. Personal tab alarm in bed and chair. Review of the Nurse's note, dated 12/28/15, indicated the resident stood up (unwitnessed) from his/her chair and slid to the floor and was found sitting on his/her buttocks. The fall investigation indicated the alarm was not in place and did not include interventions related to the absence of the alarm. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 4/29/16, indicated the resident had severe cognitive impairment and required staff assistance for transfers and ambulation. Review of the Nursing notes and fall investigation documents, dated 6/25/16, indicated the resident was found lying on the floor on his/her right side at 10:40 P.M. Documentation indicated the fall was not witnessed and the alarm was not on the recliner at the time of the fall. The resident was sent to the hospital on [DATE] at 11:35 P.M. and admitted with a fractured right hip and fractured right radius. During an interview on 9/29/16 at 8:10 A.M. with the Unit Manager #1, she said the bed and chair alarms implemented on 3/2/15 and were current interventions at the time of the falls. After UM #1 reviewed the investigation paperwork, she said the alarms were not in place prior to the falls on 12/28/15 and 6/25/16. 2. The facility staff failed to clean the lint traps of the laundry dryers to reduce the risk of a fire hazard. Review of the undated facility policy for Laundry Dryers indicated that clothes dryers are maintained daily to ensure safety practices as they relate to fire hazards. The lint trap must be cleaned with every other dryer load up to 4 times daily. Staff will document on the Lint Trap Cleaning Schedule. Review of the Lint Cleaning Log, from 9/1/16 to 9/29/16, indicated the dryers were to be cleaned at 8:30 A.M., 1:00 P.M., 4:30 P.M. and 7:30 P.M. The log indicated that during this time period, staff had followed this schedule for only 5 of 29 days. For 22 of 29 days, no cleaning is documented for 4:30 P.M. and 7:30 P.M. For 10 of 29 days, no cleaning is documented at all. During an interview with the Laundry Supervisor on 9/29/16 at 12:15 P.M., she said there was no way of knowing if the lint traps of the dryers were cleaned according to schedule.

2. For Resident #10, the facility failed to provide provide a functioning bed alarm, non-skid floor strips, a floor mat, 15 minute resident checks, and alarm checks for functionality, as planned to prevent falls that resulted in injury. Resident #10 was admitted to the facility in 2/10. [DIAGNOSES REDACTED].. The plan of care, from 11/1/10 to present, was to have no injury from falls due to the resident's no safety awareness and forgetfulness to call for assistance. The interventions included: -Check alarms daily, -Non-skid strips at bedside and toilet, -and Bed alarm. Nurse's Notes and Investigation of 12/19/10 at 7:50 P.M. revealed that staff noted the resident on the floor in the bathroom after the resident stood up from the toilet seat and lost balance. No injury was noted, and the care plan was updated 12/20/10 to include the interventions of: Needs constant supervision." Fall prevention Committee meeting notes of 12/19/10 also recommended non-skid strips in front of the "toilet's bathroom door." The resident's "Alarm Checks" sheet for working bed and chair pressure alarms were to be completed each shift, and signed off at the beginning and end of each shift by staff. The resident's alarm checks were incomplete. For example, there were no alarm checks or signatures for the daytime and evening shifts on 8/25/11 and 8/27/11, and no evening shift alarm checks or signatures on 8/26/11. While the 8/28/11 alarm checks were checked off for all three shifts, there were no signature sign offs by staff at the end of each shift as required by the facility. Nurse's Notes and Investigation of 8/28/11 at 3:10 A.M. revealed staff heard a crash and found the resident on the right side on the floor next to the bed. The bed alarm did not sound until approximately 20 seconds after the nursing team arrived in the room. The resident had bruising and a laceration on the right orbital area, which required 6 sutures to close, after a local hospital emergency room visit. The care plan was updated 8/29/11 to have a new bed pad alarm and 15 minute checks daily. A review of the "Every 15 Minute Check Sheet" indicated incomplete checks. For example, there was no 15 minute checks done: -on 8/31/11, from 7:15 A.M. to 3:15 P.M. and from 6:45 P.M. to 10:15 P.M., -on 9/1/11, from 7:15 A.M. to 3:15 P.M., from 3:45 P.M. to 4:15 P.M. and from 5:15 P.M. to 6:00 P.M., -and on 9/3/11, from 7:15 A.M. to 2:45 P.M. Review of the resident's Alarm Checks also noted on the CNA's Cardex ("check alarm q shift for functionality"), for example, indicated the following: -on 9/1/11, there were no alarm checks for the evening shift, and/or no signatures at the beginning or end of all three shifts, as required; -on 9/3/11, there were no alarm checks or signatures for the day and evening shifts, and no signatures for the evening shift, and no signatures for the end of all three shifts, as required; -on 9/4/11, there were no alarm checks or signatures for the daytime and evening shifts, and no signature for the day and evening shifts, and no signatures for the end of the night shift, as required; -on 9/5/11, there were no alarm checks for the evening shift, and no signatures on the evening shift and no signatures at the end of each shift, as required; -and, on 9/6/11, there were no alarm checks or signatures for the day and evening shifts, and no signature for the end of the night shift, as required. Nurse's Notes and Investigation of 9/6/11 at 9:00 A.M. revealed staff found the resident on the floor next to the bed, sitting upright with back to the bed. Staff indicated the bed pressure alarm was delayed in sounding again. Review of the "Every 15 Minute Check Sheet" on 9/7/11 indicated there was no 15 minute checks or signatures for the day and evening shifts, and no signature for the end of the night shift, as required. The resident's care plan was updated 9/7/11 to include: -bed against the wall with floor mat on side of bed. Observation of the resident on 9/13/11 at 8:08 A.M., revealed the resident in the bedroom being assisted by staff with a rolling walker and gait belt to the bathroom. There was no evidence of a floor mat next to or adjacent to the resident's bed, and no non-skid strips outside of the bathroom door as planned. Review of the "Every 15 Minute Check Sheet" on 9/13/11 indicated there was no 15 minute checks or signatures for the day shift, as required. On 9/14/11 at 6:50 A.M., the resident was observed asleep in a bed against the wall, with no floor mat next to the bed as planned. Additionally, there were no non-skid floor strips in the resident's bathroom as planned. Surveyor inquired of Nurse #4 at 6:55 A.M., who acknowledged there was no floor mat next to the resident's bed and no non-skid strips outside or inside the resident's bathroom as planned. The floor mat was discovered by Nurse #4 on the other side of the privacy curtain and under the roommate's bed frame. On 9/14/11 at 2:00 P.M., the resident's falls were discussed with Unit Manager #2 and with the DON at 4:00 P.M. Both Unit Manager #2 and the DON acknowledged that the resident's care plan had not been followed for daily shift alarm checks that might have prevented the 8/28/11 fall from bed with injury happening (as the bed alarm delayed in sounding during resident transfer), of 15 minute resident checks not being done daily, of non-skid strips in and outside the bathroom not being furnished, as well as the non-use of a floor mat when the resident was in bed. Please refer to F 323, Example 2. 3. For Resident #14, the facility failed to provide the resident with a pressure chair alarm and supervision during ambulation as planned. Resident #14 was admitted to the facility in 10/08 with [DIAGNOSES REDACTED]. The resident's care plan to be free from falls/injury due to impaired cognition and poor safety awareness, dated 11/8/10 to present, indicated the resident had the following interventions -ambulates with walker and supervision, -and chair pad alarm on chair. Check alarms for functionality every shift. Nursing Notes and Investigation of 2/9/11 at 7:30 P.M. indicated the resident fell when attempting to get up and sit down again in the bedroom swivel chair. No injury was noted. The Investigation confirmed the resident did not have a chair pad alarm, as planned. Observation of the resident on 9/12/11 at 4:05 P.M. revealed the resident seated in a swivel chair without a chair pad alarm in place. At 4:10 P.M., the resident ambulated ad lib with walker from the bedroom to sit at a couch in the unit lounge area before the elevators without any staff supervision as planned. On 9/13/11 at 8:15 A.M., the resident self-transferred from the bedroom chair without a chair pad alarm present, and ambulated with walker again to the lounge couch without any staff present for supervision. At 9:05 A.M., the resident exited the elevator, ambulated to the bedroom using a walker, sat in the swivel chair, without any staff present to supervise ambulation or self transfers. The swivel chair still had no chair pad alarm attached. Interview with UM #2 on 9/13/11 at 9:10 A.M. acknowledged the facility failed to provide either supervision for resident ambulation or a chair pad alarm as planned. Based on record review, interview and observations, the facility failed for 4 residents (#1, #2, #10, and #14) of 15 residents with falls out of a total sample of 24 residents to follow the care plan to prevent falls. Findings included: 1. For Resident #1, the facility failed to apply non-skid socks, failed to insure the alarms were on and functioning, failed to perform 15 minute checks, failed to follow the toileting schedule, and failed to place resident in a common area or encourage off unit interventions, as care planned. Resident #1 was admitted to the facility in April of 2010 with [MEDICAL CONDITIONS], history of falls with a fracture, [MEDICAL CONDITION], and anxiety. Review of the care plan in place 11/6/10 to prevent falls indicated the following interventions: -Use non skid footwear. Keep items in reach. -Observe for changes in transfers and ambulation. -Ambulate with contact guard. -Answer call light promptly and keep bed in low positioned and locked. -Bed pad alarm and chair pad alarm. Wheelchair alarm. Cue for safety. Follow toileting schedule. -Monitor every 15 minutes. -Encourage off unit activities and keep in common areas as much as able. -Anti roll back device on wheelchair. -Observe for side effects of medications and give lowest possible dose. Monitor orthostatic blood pressures. Review of the Nurse's Note of 11/6/10 indicated the resident was found on the floor at 6:15 P.M. Review of the Falls Investigation indicated the resident was found on the floor near the toilet. The resident had apparently attempted self transfer and fell . Although the investigation indicated the alarm was on the chair, the investigation did not indicate that the alarm sounded. Review of the Nurse's Note of 11/22/10 indicated the resident was found on the floor at 7:00 P.M. Review of the Falls Investigation indicated the resident was found on the floor near the toilet. The resident stood up from the toilet without assistance and fell . A staff member was in the Resident's room at the time, but had left the resident in the bathroom on the toilet. The staff person was making the resident's bed at the time of the fall. No injuries were observed. The intervention to prevent further falls was to educate staff to provide contact guard while in the bathroom. Review of the Nurse's Note of 1/19/11 indicated the resident was found on the floor at 1:15 A.M. Review of the Falls Investigation indicated the resident was found on the floor next to the resident's bed. No injuries were observed. The investigation indicates a bed alarm was in place but did not indicate if it sounded. Review of the Nurse's Notes of 1/23/11 at 2:00 P.M. indicated that the resident was experiencing increased agitation propelling up and down the hallway, stating he/she wanted to "go home". Further review of the Nurse's Note of 1/23/11 indicated that the resident was found on the floor in his/her room at 2:15 P.M (shortly after staff observation that the resident was agitated). Review of the Falls Investigation did not refer to the nurse's note that described the resident as agitated prior to the fall on 1/23/11. The investigation did not address why the resident was left alone in the resident's room when he/she was agitated and not in a group activity or common area as care planned. Review of the Nurse's Note of 3/5/11 indicated that the resident was found on the floor at 3:30 P.M. Review of the Falls Investigation indicated the resident was found on the floor in the resident's room. This investigation indicated the resident fell from the bed and that the bed alarm did not sound. The investigation indicated the alarm was in the "off" position. The intervention to prevent further falls was to educate staff to make sure the alarm is in the "on" position when the resident is in bed. Review of the Nurse's Note of 3/15/11 indicated that the resident was found on the floor, lying on the resident's right hip, at the foot of the bed. Review of the Falls Investigation indicated the resident was found on the floor at the foot of the resident's bed at 9:10 P.M. The Falls Investigation did not indicate whether or not the alarm sounded. This investigation indicated the resident did not have slipper socks on at the time of the fall as care planned. The intervention to prevent further falls was to place slipper socks on feet at bedtime (already on care plan since 4/14/10) and to toilet before getting into bed for the evening. Review of the Nurse's Note of 4/8/11 indicated the resident was found on the floor in his/her room. Review of the Investigation of the fall indicated that the resident was found face down at 6:40 A. M. The resident complained of left wrist pain. An X-ray of the left wrist showed a [MEDICAL CONDITION]. Further review of the Falls Investigation Report indicated at the time of the fall the resident's bed alarm did not sound and the resident was not wearing slipper socks, as care planned. This investigation indicated that the new interventions to prevent further falls was to provide CNA (Certified Nursing Assistant) education to ensure proper placement of bed alarm. Care plan interventions in place following the annual MDS (Minimum Data Set) assessment of 4/10/11 included: -Use non skid footwear and insure on when in bed. Keep items in reach. -Observe for changes in transfers and ambulation. -Ambulate with contact guard in bathroom. Gray mat on floor. -Answer call light promptly and keep bed in low position and locked. -Self release wheelchair alarmed seatbelt, check alarm whenever resident is placed in wheelchair. -Bed pad alarm and chair pad alarm. Check alarms for placement. Cue for safety. -Monitor every 15 minutes. -Encourage off unit activities and keep in common areas as much as able. -Anti roll back device on wheelchair. -Observe for side effects of medications and give lowest possible dose. Monitor orthostatic blood pressures. Review of the Nurse's Note of 6/28/11 indicated the resident was found on the floor in the bathroom located off the unit hallway. Review of the Falls Investigation indicated the resident was found on the floor at 7:00 P.M. The resident was not provided with assistance to the bathroom as care planned. The resident apparently wheeled him/herself away from the common area and down the hall without being observed by staff. Review of the Nurse's Note of 7/14/11 indicated the resident was found on the floor in the resident's room, in front of wheelchair at 8:00 P.M. The Falls Investigation indicated the resident had been previously sitting in his/her wheelchair near the Nurses' Station. The resident apparently wheeled him/herself away from the common area and down to the resident's room without being observed by staff. The facility failed to keep the resident in common areas as much as possible as care planned. Review of the Nurse's Note of 7/20/11 indicated the resident was found on the floor in the resident's bathroom at 1:45 P. M. Review of the Falls Investigation indicated the resident fell while trying to get up from the toilet without assistance. The assigned CNA was in the resident's room outside the bathroom door when the resident fell . The Falls Investigation indicated a staff person left the resident on the toilet in the resident's bathroom. The care plan intervention to maintain contact guard with the resident in the bathroom was not followed. Review of the Nurse's Note of 8/26/11 indicated the resident was found on the floor in the resident's room at 4:17 A. M. Review of the Falls Investigation did not indicate if the resident had footwear on at the time of fall as this section of the investigation was blank. Review of the Nurse's Note of 9/04/11 indicated the resident was found on the floor in the resident's bathroom at 7:00 P.M. Review of the Falls Investigation indicated the resident's wheelchair seatbelt alarm and wheelchair pad alarm did not sound. Although the care plan called for the resident to be on 15 minute checks, review of 15 minute checks record (on 9/15/11) indicated the checks were not done on 9/4/11, from 6:15 P.M. until when the resident fell at 7:00 P. M. In addition, review of the alarm check documentation indicated the alarm checks were not done on the 7:00 A. M. to 3:00 P. M. shift and the 3:00 P. M. to 11:00 P. M. shift as per the care plan. Record review of the 15 minute check sheets (for August 2011 and September 1-12, 2011) revealed the 15 minute checks were frequently not done as care planned as follows: -The 7:00 A.M. to 3:00 P.M. shift 15 minute check sheets were not done on 8/1, 8/3, 8/7, 8/8, 8/12, 8/16, 8/17, 8/20, 8/21, and 8/25 to 8/31, 2011. -The 3:00 P.M. to 11:00 P.M. shift 15 minute checks were incomplete on 8/1, 8/3, 8/4, 8/5, 8/6, 8/8, 8/9, 8/10, 8/11, 8/12, 8/13, 8/15, 8/16, 8/18, 8/20, 8/21, 8/22, 8/23, 8/24, 8/26, 8/28, 8/29 and 8/30, 2011. -The 7:00 A.M. to 3:00 P.M. shift 15 minute check sheets were not done from 9/1 to 9/12/11 on the following days: 9/1 to 9/4, 9/9, and 9/12/11. -The 3:00 P.M. to 11:00 P.M. shift 15 minute checks were incomplete from September 1 to September 12 on the following days: on 9/1, 9/3, 9/4, 9/5, 9/8, 9/9, 8/9 and 9/12/11. Observations on 9/13/11 at 8:45 A.M., again at 9:20 A.M., and at 11:15 A.M., was of the resident sitting in his/her room in a wheelchair watching television. There was no effort by staff to move the resident to a common area, as planned. During interview on 9/13/11 at 2:20 P.M., CNA #1 (who was assigned to the resident from 7:00 A.M. to 3:00 P. M.) indicated that 15 minute checks were not done on the resident that day because the staff was very busy (care plan indicates 15 minute shifts all shifts). This CNA indicated the resident also was not on a 2 hour toileting plan or toileting after a meal, but would tell staff when he/she had to go to the bathroom (care plan indicated resident to be toileted every 2 hours and after all meals). This CNA indicated the resident spent most of the time in his/her room watching television (care plan stated to encourage off unit activities and keep in common area as much as able). Observation of the resident on 9/14/11 at 7:15 A.M. was of the resident sitting in a wheelchair in the resident's room. During interview on 9/14/11 at 8:55 A.M., CNA #6 (who was assigned to the resident from 7:00 A.M. to 3:00 P.M.) indicated that the resident was not on a 2 hour toileting plan or toileting after a meal because the resident would tell staff when he/she had to go to the bathroom (care plan indicated resident was to be toileted every 2 hours and after all meals). This CNA indicated the resident spent most of the time in his/her room watching television or roaming around the unit (care plan stated to encourage off unit activities and keep in common area as much as able). Observation of the resident on 9/15/11 at 11:00 A.M. to 11:30 A.M., was of the resident sitting in a wheelchair in the resident's room. The resident was banging the wheelchair into the bed, dresser and wall by rolling backward and forward in the wheelchair. Although several staff walked by the resident's room, no staff directed the resident to the common areas of the facility as care planned. Record review revealed that the wheelchair alarm checks were not always done as care planned. Review of the check sheets from September 1 to September 13, 2011 indicated the alarms were not signed as checked as follows: 9/1/11 to 9/6/11, 9/8/11 to 9/10/11, and 9/12/11 to 9/13/11 were not signed as completed by 7:00 A.M. to 3:00 P.M. shift. The 3:00 P.M. to 11:00 P.M. shift did not sign the alarm check sheets on 9/4/11, 9/6/11 and 9/11/11. During interview on 9/15/11 at 11:45 A.M., the Director of Nurses (DON) acknowledged that the resident had experienced 13 falls since November 2010, one which resulted in a [MEDICAL CONDITION] wrist. The DON acknowledged that the care plan was not always followed regarding non-skid socks, supervision in the bathroom, alarm checks and toileting schedules. Please refer to F 323, Example 1. 4. For Resident #2, the facility failed to follow the physician's orders [REDACTED]. a. Elevate feet to decrease [MEDICAL CONDITION]. b. Call bell in place/reach. c. Chair alarm when in w/c (wheelchair). Resident #2 was admitted to the facility in 2/09. The resident's [DIAGNOSES REDACTED]. During the initial tour of the resident's unit with UM #3 on 9/12/11 at 8:50 A.M., UM #3 told the surveyor that Resident #2 had fallen a few months ago, and fractured the left ankle, but the fracture was currently healed. The surveyor observed Resident #2 sitting up in a w/c. The resident was wearing black shoes and white elastic hose. The resident's feet were flat on the floor. There were no leg rests on the w/c. There was no chair alarm on the w/c. The call light cord was on the bed, but was 3 feet behind this resident and was not in reach. The resident's left ankle and lower leg were larger than the right foot and lower leg. However, both the left and right ankles/lower legs appeared to be swollen. Review of the 7/8/11 "Progress Notes" (reviewed on 9/12/11 at 12:15 P.M.) indicated a "Quarterly Note" and revealed that the resident spends most of his/her time in the resident's room, and will also sit by the elevator. On 9/12/11 at 11:30 A.M., 11:46 A.M. and 11:58 A.M., and on 9/13/11 at 1:46 P.M., the surveyor observed Resident #2 sitting up in a w/c. The resident's legs were not elevated to decrease [MEDICAL CONDITION], the call bell was not in reach/place, and the resident did not have a chair alarm on the w/c, as planned. During interview on 9/13/11 at 2:10 P.M., Unit Manager (UM) #3 acknowledged that the resident's legs were not elevated, the chair alarm was not on the w/c, and the call light was not in reach/place, as planned for Resident #2.

2. For Resident #10, the facility failed to provide effective interventions and/or supervision to prevent 4 falls with injury requiring 6 sutures. Resident #10 was admitted to the facility in 2/10. [DIAGNOSES REDACTED]. The plan of care to be free from falls/injury, (from 6/28/10 to 11/30/10), due to no safety awareness, forgetfulness to call for assistance and use of walker, decreased strength and arthritis, had the following interventions: -Use non-skid socks, -Keep personal items within reach, -Assist with toileting on rising in the "am, & before and after meals, and prn. (as needed) Q (Every) 2 hrs.", -Refer to Rehabilitation if indicated, -Bed in low position and wheels locked, -Monitor for safety during visits, -Move to dementia unit for increased supervision, -Bed Alarm, -Wheelchair alarm, -Ambulation schedule, -Add more non-skid strips at bedside, -and Medical evaluation prn. Clinical Record documentation indicated the resident's last two falls had occurred when the resident attempted to self transfer and ambulate in the bedroom (in 6/10 and 9/10). Nurse's Notes and Investigation, dated 10/29/10 at 11:30 P.M., revealed the resident had a unwitnessed fall when the resident was found sitting on the lobby floor. The resident had slid from the wheelchair onto knees. No injury was noted. Nurse's Notes of 10/31/10 (time unknown) and 11/5/10 at 6:00 A.M. indicated the resident was "alert, responsive with confusion, got out of bed without assist (to bathroom) , (and was) encouraged by staff to use the call bell...call for help." An 11/1/10 care plan update indicated check alarms daily. Nurse's Notes and Investigation of 11/9/10 at 8:30 P.M. revealed that staff noted the resident had a large ecchymotic area on the right upper inner thigh, 5 cm. (centimeter) x 4 cm. and a 2 cm. x 2 cm. ecchymotic area on the right anterior forearm. The Investigation indicated the injuries might be attributed to multiple recent falls. Nursing Notes and Investigation of 11/18/10 at 7:30 A.M. revealed the resident had an unwitnessed fall. Although alarms were activated, the resident stood up from the wheelchair, ambulated to the bathroom, and fell when attempting to open the bathroom door. No injury was noted. The care plan was updated to include a Velcro alarmed seatbelt. The Falls Risk Assessment (FRA) of 11/19/10 indicated the resident was a "high" risk for falls with a score of 20. The plan of care was re-written 11/30/10 to have no injury from falls due to the resident's no safety awareness and forgetfulness to call for assistance. The interventions included: -Have commonly used items within easy reach, -Transfer and Change Positions slowly, -Reinforce need to call for assistance, -Resident to wear proper and non-skid footwear, -Encourage resident to use handrails and assistive devices properly, -Call bell within reach in room,' -Ensure environment is free of clutter, -Monitor for Urinary Tract Infection, -Non-skid socks, -Non-skid strips at bedside and toilet, -Bed in low position with wheels locked, -Answer call light promptly, -Monitor changes in gait -Use gait belt, -Bed and Chair alarms, -Velcro alarm seat belt, -And Rehabilitation screen prn. The quarterly MDS review of 12/1/10 indicated the resident has moderate difficulty hearing and seeing, was severely impaired cognitively (BIMS score of 4/15), required limited assist for transfers, ambulation, and toilet use, supervision for ambulation in wheelchair, was unsteady in balance during transitions and walking, was occasionally incontinent of bowel and bladder, and had fallen without injury. Nurse's Notes and Investigation of 12/19/10 at 7:50 P.M. revealed that staff noted the resident on the floor in the bathroom after the resident stood up from the toilet seat and lost balance. No injury was noted, and the care plan was updated 12/20/10 to include the interventions of: Staff "not leaving the resident alone in the bathroom. Keep in common areas while awake. Needs constant supervision." Fall prevention Committee meeting notes of 12/19/10 also recommended non-skid strips in front of toilet's bathroom door. The FRA of 2/18/11 indicated the resident was a "high" risk for falls with a score of 18. The annual MDS assessment of 2/25/11 indicated the resident usually made self understood and sometimes understands others, was now an extensive assist for transfers and toilet use, and was incorrectly coded as having no falls since the prior assessment. The care plan was updated 3/3/11 with the intervention to monitor the resident for safety during "on unit activities." The quarterly MDS reviews of 6/3/11 (and 8/25/11) indicated the resident was highly impaired in hearing, had disorganized thinking, required extensive assist for ambulation in the wheelchair, and had no falls. The FRA of 8/19/11 indicated the resident was a "high" risk for falls with a score of 22.0. The resident's "Alarm Checks" sheet for working bed and chair pressure alarms, were to be completed each shift, and signed off at the beginning and end of each shift by staff. The resident's alarm checks were incomplete. For example, there were no alarm checks or signatures for the daytime and evening shifts on 8/25/11 and 8/27/11, and no evening shift alarm checks or signatures on 8/26/11. While the 8/28/11 alarm checks were checked off for all three shifts, there were no signature sign offs by staff at the end of each shift as required by the facility. Nurse's Notes and Investigation of 8/28/11 at 3:10 A.M. revealed staff heard a crash and found the resident on the right side on the floor next to the bed. The bed alarm did not sound until approximately 20 seconds after the nursing team arrived in the room. The resident had bruising and a laceration on the right orbital area, which required 6 sutures to close, after a local hospital emergency room visit. The care plan was updated 8/29/11 to have a new bed pad alarm and 15 minute checks daily. A review of the "Every 15 Minute Check Sheet" indicated incomplete checks. For example, there was no 15 minute checks done: -on 8/31/11, from 7:15 A.M. to 3:15 P.M. and from 6:45 P.M. to 10:15 P.M., -on 9/1/11, from 7:15 A.M. to 3:15 P.M., from 3:45 P.M. to 4:15 P.M. and from 5:15 P.M. to 6:00 P.M., -and on 9/3/11, from 7:15 A.M. to 2:45 P.M. Review of the resident's Alarm Checks, also noted on the CNA's Kardex ("check alarm q shift for functionality"), for example, indicated the following: -on 9/1/11, there were no alarm checks for the evening shift, and/or no signatures at the beginning or end of all three shifts, as required; -on 9/3/11, there were no alarm checks or signatures for the day and evening shifts, and no signatures for the evening shift, and no signatures for the end of all three shifts, as required; -on 9/4/11, there were no alarm checks or signatures for the daytime and evening shifts, and no signature for the day and evening shifts, and no signatures for the end of the night shift, as required; -on 9/5/11, there were no alarm checks for the evening shift, and no signatures on the evening shift and no signatures at the end of each shift, as required; -and, on 9/6/11, there were no alarm checks or signatures for the day and evening shifts, and no signature for the end of the night shift, as required. Nurse's Notes and Investigation of 9/6/11 at 9:00 A.M. revealed staff found the resident on the floor next to the bed, sitting upright with back to the bed. No injury was noted, however, staff indicated the bed pressure alarm was delayed in sounding again. Review of the "Every 15 Minute Check Sheet" on 9/7/11 indicated there was no 15 minute checks or signatures for the day and evening shifts, and no signature for the end of the night shift, as required. The resident's care plan was updated 9/7/11 to include: -one person assist for ambulation to the bathroom, -bed against the wall with floor mat on side of bed, -and scoop mattress on bed. Observation of the resident on 9/12/11 at 4:00 P.M. revealed the resident seated in the unit corridor in a wheelchair with Velcro alarmed seat belt and personal alarm, with right orbital socket bruising. On 9/13/11 at 8:08 A.M., the resident was observed in the bedroom being assisted by staff with a rolling walker and gait belt to the bathroom. There was no evidence of a floor mat next to or adjacent to the resident's bed, and no non-skid strips outside of the bathroom door as planned. On 9/13/11, from 9:00 A.M. to 10:00 A.M., the resident was observed in the unit's south activity room asleep at a table, in a wheelchair with seat belt attached. During an interview on 9/13/11 at 1:50 P.M., CNA #2 indicated that that the resident was alert and confused, agitated at times, did not seek staff assist for needs or utilize the call bell, self transferred at times, was incontinent of bowel and bladder, wore pull-ups;, and had had falls. The resident was usually up in a wheelchair throughout the day, with the exception of naps, with a Velcro seat belt attached. The CNA was unable to describe, when asked, what additional interventions were necessary besides a bed alarm, when the resident was in bed (such as a floor mat.) Review of the "Every 15 Minute Check Sheet" on 9/13/11 indicated there was no 15 minute checks or signatures for the day shift, as required. On 9/14/11 at 6:50 A.M., the resident was observed asleep in a bed against the wall, with no floor mat next to the bed as planned. Additionally, there was no non-skid floor strips in the resident's bathroom as planned. Surveyor inquired of Nurse #4 at 6:55 A.M., who acknowledged there was no floor mat next to the resident's bed and no non-skid strips outside or inside the resident's bathroom as planned. The floor mat was discovered by Nurse #4 on the other side of the privacy curtain and under the roommate's bed frame. On 9/14/11 at 2:00 P.M., the resident's falls were discussed with Unit Manager #2 and with the Director of Nurses (DON) at 4:00 P.M. Both Unit Manager #2 and the DON acknowledged that the resident's care plan had been rendered ineffective for fall prevention interventions. The resident's injury from a fall occurred because the bed alarm was not functioning, staff relied upon reminding the confused resident to remember to use the call bell for assistance, to ask for staff assistance when self-transferring from bed to bathroom, on incomplete 15 minute resident and alarm checks, on non-skid strips in and outside the bathroom that were not present, as well as the non-use of a floor mat when the resident was in bed. Please refer to F 282, Example 2. Based on record review, observation and interviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents/injuries for 2 sampled residents (#1 and #10) out of a sample of 24 residents; and 1 Non-Sampled resident (NS #4). In addition, the facility failed to ensure that arm rests were not ripped/ torn creating sharp edges for 5 sampled residents (#1, #3, #10, #12, and #17) and 15 non-sampled residents (NS #1 to #15). Findings included: 1. For Resident #1, the facility failed to provide effective interventions and provide appropriate supervision to prevent 13 falls. This resident experienced severe pain following a fall and sustained a fractured wrist in another fall. Resident #1 was admitted to the facility in April of 2010 with Osteoarthritis, Osteoporosis, Alzheimer's Disease, history of falls with a fracture, glaucoma, and anxiety. Review of the fall risk assessment (of 7/10) indicated the resident was a high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment (of 10/8/10), indicated the resident had impaired short and long term memory, required assistance with ambulation, transfers, toileting, and had a history of [REDACTED]. Review of the care plan in place 11/6/10 to prevent falls indicated the following interventions: -Use non skid footwear. Keep items in reach. -Observe for changes in transfers and ambulation. -Ambulate with contact guard. -Answer call light promptly and keep bed in low positioned and locked. -Bed pad alarm,chair pad alarm, and wheelchair alarm. Cue for safety. -Follow toileting schedule. -Monitor every 15 minutes. -Encourage off unit activities and keep in common areas as much as able. -Anti roll back device on wheelchair. -Observe for side effects of medications and give lowest possible dose. Monitor orthostatic blood pressures. Review of the Nurse's Note of 11/6/10 indicated the resident was found on the floor at 6:15 P.M. Review of the Falls Investigation indicated the resident was found on the floor near the toilet. The resident had apparently attempted self transfer and fell . Although the investigation indicated the alarm was on the chair, the investigation does not indicate that the alarm sounded. No injuries were noted. The intervention to prevent further falls was to provide more non-skid strips in front of the toilet and in front of the resident's bed. Review of the Nurse's Note of 11/22/10 indicated the resident was found on the floor at 7:00 P.M. Review of the Falls Investigation indicated the resident was found on the floor near the toilet. The resident had stood up from the toilet without assistance and fell . A staff member was in the resident's room at the time, but had left the resident in the bathroom on the toilet. The staff person was making the resident's bed at the time of the fall. No injuries were observed. The intervention to prevent further falls was to educate staff to provide contact guard while in the bathroom. Review of the quarterly MDS assessment of 1/8/11, indicated the resident had severe cognitive impairment as evidenced by a BIMS (Brief Interview for Mental Status) score of 5, needed assist with ambulation, transfers, toileting, and had a history of [REDACTED]. Review of the Nurse's Note of 1/19/11 indicated the resident was found on the floor at 1:15 A.M. Review of the Falls Investigation indicated the resident was found on the floor next to the resident's bed. No injuries were observed. The investigation indicates a bed alarm was in place but did not indicate if it sounded. The intervention to prevent further falls was to place a gray mat on the floor next to the bed. Review of the Nurse's Note of 1/23/11 of 2:00 P.M., indicated the resident was experiencing increased agitation propelling up and down the hallway stating he/she wanted to "go home". Further review of the Nurse's Note of 1/23/11 indicated that the resident was found on the floor in his/her room at 2:15 P.M. The resident's right knee was noted to be reddened. Review of the Falls Investigation indicated the resident was found on the floor in the resident's room. This investigation indicated the resident fell from the wheelchair and that the alarm sounded. The investigation does not refer to the nurse's note that described the resident as agitated prior to the fall on 1/23/11 or why the resident was left alone in the room if he/she was agitated and not in a group activity or common area as care planned. The intervention to prevent further falls was to evaluate for an alarmed self release seatbelt. This intervention was added to the care plan. Review of the Nurse's Note of 3/5/11 indicated that the resident was found on the floor at 3:30 P.M. Review of the Falls Investigation indicated the resident was found on the floor in the resident's room. This investigation indicated the resident fell from the bed and that the bed alarm did not sound. The Investigation indicated the alarm was in the off position. No injuries were observed. The intervention to prevent further falls was to educate staff to make sure the alarm was in the on position when the resident is in bed. Review of the Nurse's Note of 3/15/11 indicated that the resident was found on the floor, lying on the resident's right hip, at the foot of the resident's bed. Review of the Falls Investigation indicated the resident was found on the floor at the foot of his/her bed, at 9:10 P.M. The Falls Investigation did not indicate whether or not the alarm sounded. This investigation indicated the resident complained of right hip and back pain. The resident was sent to the hospital for x-rays of the right pelvis, spine, and hip. These x-rays were negative for fracture despite the resident's complaints of severe pain. The resident was returned to the facility and provided with pain medication. This investigation indicated the resident did not have slipper socks on at the time of the fall as care planned. The intervention to prevent further falls was to place slipper socks on feet at bedtime (already in care plan since 4/14/10) and to toilet before getting into bed for the evening. Review of the Nurse's Note of 4/8/11 indicated the resident was found on the floor in his/her room. Review of the Investigation of the fall indicated that the resident was found face down on the floor of the resident's room at 6:40 A.M.. The resident complained of left wrist pain. An X-ray of the left wrist showed a fracture of the wrist. The resident was sent to the local hospital emergency room where after Orthopedic consult, a cast was applied to the left wrist. The resident returned to the facility the same day. Further review of the Falls Investigation Report indicated that at the time of the fall the resident's bed alarm did not sound and the resident was not wearing slipper socks as required. This investigation indicated that the new interventions to prevent further falls was the use of a low bed and provide CNA (certified nursing assistant) education to ensure proper placement of bed alarm. Review of the annual MDS assessment 4/10/11 indicated a BIMS score of 6, the resident was coded as requiring assist with ambulation, transfers, toileting, and had a history of [REDACTED]. Some of the care plan interventions included: -Use non skid footwear and insure on when in bed. Keep items in reach. -Observe for changes in transfers and ambulation. -Ambulate with contact guard in the bathroom. Gray mat on floor. -Answer call light promptly and keep bed in low positioned and locked. -Self release wheelchair alarmed seatbelt, check alarm whenever resident is placed in the wheelchair. -Bed pad alarm and chair pad alarm. Check alarms for placement. Cue for safety. -Monitor every 15 minutes. -Encourage off unit activities and keep in common areas as much as able. -Anti roll back device on wheelchair. -Observe for side effects of medications and give lowest possible dose. Monitor orthostatic blood pressures. Review of the Nurses' Notes from 4/11/11 to 5/19/11 indicated the resident continued to experience pain at times in the left wrist area and experienced swelling of the fingers of the left hand. The left wrist was elevated on a pillow and the resident was provided with pain medication. Review of the Nurse's Note of 5/19/11 indicated the resident was seen by the Orthopedic surgeon and the cast was removed and replaced with a removable brace. Review of the Nurse's Note of 5/28/11 indicated the resident was found on the floor next to the resident's roommate's bed. Review of the Falls Investigation indicated that the alarm had sounded and the resident was found on the floor at 2:15 A.M. There was no apparent injuries noted. Interventions put in place to prevent further falls included: -Ambulation schedule to increase strength. -Ask the resident if he/she needs to be toileted if awake. Review of the Nurse's Note of 6/28/11 indicated the resident was found on the floor in the bathroom located off the unit hallway. Review of the Falls Investigation indicated the resident was found on the floor at 7:00 P.M.. The resident was found with her pants down and had been apparently attempting to toilet self. The alarm sounded. No injury occurred. The new intervention to prevent falls was to toilet every two hours and to offer to move to the third floor. Review of the employee statements (part of the Falls Investigation) indicated that the resident had been previously sitting in his/her wheelchair near the nurse's station. Review of the Nurse's Note of 7/14/11 indicated the resident was found on the floor in the resident's room, in front of wheelchair. The resident's alarm was sounding. Review of the Falls Investigation indicated the resident was found on the floor at 8:00 P.M. The resident's right wrist was observed to be bruised. Ice was applied to the wrist. Apparently, the resident was watching television in the common area near the Nurse's Station when the resident independently wheeled to his/her room. The resident attempted to stand, the wheelchair rolled back and the resident fell . The investigation indicated the anti-roll back device on the wheelchair failed to operate correctly. Review of the employee statements (part of the Falls Investigation) indicated that the resident had been previously sitting in his/her wheelchair near the nurse's station. The interventions to prevent further falls was to fix the anti roll device on the wheelchair and to attempt to find a room closer to the nurses station. Review of the Nurse's Note of 7/20/11 indicated the resident was found on the floor in the resident's bathroom, at 1:45 P.M. Review of the Falls Investigation indicated the resident fell while trying to get up from the toilet without assistance. The Falls Investigation indicated a staff person left the resident on the toilet in the resident's bathroom. This investigation did not address why staff did not maintain contact guard with the resident in the bathroom care planned (on 3/20/11). The interventions to prevent further falls was to leave the bathroom door ajar when the resident was on the toilet. However, the existing care plan intervention to maintain contact guard in the bathroom was also kept as an intervention on the care plan. The cause of the fall was determined to be the resident not asking for help from the staff with transfers, but did not address the staff lack of supervision in the bathroom. Review of the Nurse's Note of 8/26/11 indicated the resident was found on the floor in the resident's room, at 4:17 A.M. No injuries were noted. Review of the Falls Investigation indicated the resident's alarm sounded and staff found the resident on the floor in the resident's room. This investigation was blank in the section that described the footwear the resident was wearing at the time of the fall. This investigation did not indicate the resident had non-skid socks on at the time of the fall as care planned. This investigation also indicated the alarms were not loud enough for staff to hear and respond in a timely manner. The interventions to prevent further falls was to transfer the resident to a bed closer to the nurses station when available and to apply a wireless bed pad when available. Review of the Nurse's Note of 9/04/11 indicated the resident was found on the floor in the resident's bathroom at 7:00 P.M. The resident stated he/she hit the back of his/her head on the bathroom door. The resident sustained [REDACTED]. No other injuries were noted. Review of the Falls Investigation indicated the resident's wheel chair seatbelt alarm and wheelchair pad alarm did not sound. The resident was coming out of the bathroom alone when the staff found the resident on the floor. Although the care plan called for the resident to be on 15 minute checks, review of the 15 minute checks record on 9/4/11 indicated the checks were not done from 6:15 P.M. until the resident fell at 7:00 P.M. The resident stated he/she hit the back of the resident's head on the bathroom door. In addition, review of the alarm check documentation indicated that the alarms were not done on the 7:00 A. M to 3:00 P.M. shift and the 3:00 P.M. to 11:00 P.M. shift as per the care plan. The interventions to prevent further falls was to offer toileting after every meal (in addition to the resident's care intervention in place to toilet every 2 hours). The intervention of educating staff to ensure alarms were on when placed was also listed as a new intervention. Observation of the resident on 9/12/11 at 8:45 A.M. was of the resident eating breakfast in the dining room. The resident was observed to have a seat belt on. Observation of the resident at 9:30 A.M. was of the resident in a wheelchair in the resident's room watching television. Observation of the resident on 9/13/11 at 8:45 A.M., again at 9:20 A.M., and at 11:15 A.M. was of the resident sitting in his/her room in a wheelchair watching television. There was no observed attempt by staff to move the resident to a common area. The resident was observed to be sitting in the hallway at 1:00 P.M. and again at 2:00 P.M. During interview on 9/13/11 at 2:20 P.M., CNA #1 (who was assigned to the resident from 7:00 A.M. to 3:00 P.M.) indicated that the 15 minute checks were not done on the resident that day because the staff was very busy (care plan indicates 15 minute checks all shifts). This CNA indicated the resident also was not on a 2 hour toileting plan or toileting after a meal but would tell staff when he/she had to go to the bathroom (care plan indicated resident to be toileted every 2 hours and after all meals). This CNA indicated the resident spent most of the time in his/her room watching television (care plan stated to encourage off-unit activities and keep in common area as much as able). Observation of the resident on 9/14/11 at 7:15 A.M. was of the resident sitting in a wheelchair in the resident's room. During interview on 9/14/11 at 8:55 A.M., CNA #6 (who was assigned to the resident from 7:00 A.M. to 3:00 P.M.) indicated that the resident was not on a 2 hour toileting plan or toileting after a meal because the resident would tell staff when he/she had to go to the bathroom (care plan indicated resident to be toileted every 2 hours and after all meals). This CNA indicated the resident spent most of the time in his/her room watching television or roaming around the unit (care plan stated to encourage off unit activities and keep in common area as much as able). Observation of the resident on 9/15/11 at 11:00 A.M. to 11:30 A.M., was of the resident sitting in a wheelchair in the resident's room. The resident was banging the wheelchair into the bed, dresser and wall by rolling backward and forward in the wheelchair. Although several staff walked by the resident's room, no staff directed the resident to the common areas of the facility as care planned. During interview on 9/15/11 at 11:45 A.M., the Director of Nurses (DON) acknowledged that the resident had experienced 13 falls since November 2010, one which resulted in a fracture of the left wrist. The DON acknowledged that interventions in place were not always effective as alarms did not always sound, anti roll back devices on the wheelchair did not always work and the care plan was not always followed regarding non-skid socks, supervision in the bathroom, and toileting schedules. Please refer to F 282, Example 1. 3. For Non-Sampled (NS) Resident #4, the facility failed to ensure adequate supervision and effective interventions to prevent 10 of 11 falls in a ten month time frame (from 11/11/10 to 9/14/11). Five of the falls were with minor injury, such as hand and leg bruises, a skin tear, leg abrasions; and 1 of the falls was with major injury identified as fractures to the resident's face and arms. NS Resident #4 was admitted to the facility in 9/07. The resident's pertinent [DIAGNOSES REDACTED]. The falls prevention care plan (initiated 8/12/10) identified (reviewed on 9/15/11 at 10:30 A.M.) that the resident was at high risk for falls due to a history of falls related to dementia, bipolar disorder and chronic constipation. This care plan included that the resident received psychotropic medications, had poor impulse control, required a wheeled walker for ambulation with supervision, frequently forgot to use the walker when responding to need for toileting, and was at risk for injury from falls. The care plan interventions to prevent the resident from falling with injury included: - Pressure alarm in bed. - TV monitor when in bed for nurses' to view when at nurses' station. - Non-skid strips to exit side of bed, extended to bedside bureau. - 15 minute checks when in bed and awake. - Provide a cup of M & M candy on the nightstand. - Provide verbal cueing/reminders for safety. - Non-skid footwear to be worn at all times. - Psychotropic medication review on a regular basis and as needed, - Alarms on at all times. - and One to two assist for all transfers. The Behavioral/Mood State/Activities Care Plan (initiated 8/12/10) included the following: - Maintain accessibility of walker to provide visual cueing for use during impulsive episodes for ambulation. The 11/11/10 Annual MDS Assessment (reviewed on 9/15/11 at 10:38 A.M.) revealed that the resident scored a "00"on the BIMS (Brief Interview for Mental Status) indicating that the resident has memory problems and severely impaired cognition. This MDS revealed that the resident had problems with delusions, mood and behavior problems in the past two weeks, such as, little interest or pleasure doing things, feeling or appearing down, depressed or hopeless, trouble falling or staying asleep/sleeping too much, trouble concentrating on things; was independent for bed mobility, required limited assist for transfers, ambulation, dressing, required extensive assist with toilet use, hygiene and bathing; had problems with balance; was always continent of bladder and occasionally incontinent of bowel; sustained 2 or more falls with injury since the previous assessment; received antipsychotic and antidepressant medications. The 11/11/10 Nursing Note (reviewed on 9/15/11 at 10:28 A.M.) revealed the resident was found lying on right side, on the floor in the resident's room at 5:30 P.M. The alarm was sounding, and the privacy curtain was pulled around the resident's bed at the time of the fall and documented that the resident was "noncompliant." A new pair of non-skid slipper socks were provided as the old ones were "worn." The Investigation report (reviewed on 9/15/11 at 10:30 A.M.), relevant to the 11/11/10 fall revealed that the fall was not witnessed. The fall was from the bed. Slipper socks appeared "worn," and were personal socks from home. Non-skid socks were replaced. Follow-up action to prevent reoccurrence of falls included "TV monitor and bed pressure alarms" (interventions already in place to prevent falls). The 1/20/11 Nursing Note revealed that the resident received a suppository with results, and had difficulty ambulating to breakfast with "legs bending/weak." At 12:05 P.M., the bed alarm was sounding and the resident was yelling, "Help me." The resident was found sitting on the floor in the resident's room with no apparent injury. The Investigation report (reviewed on 9/15/11 at 10:32 A.M.) relative to the 1/20/11 fall revealed that the resident was in bed prior to fall. The fall was not witnessed. The cause of the fall indicated that the resident was impulsive, confused, agitated, and did not have his/her walker nearby (care plan identified to maintain sensibility to walker). A statement attached to the investigation report indicated that the resident got up too fast, did not take walker with him/her, and fell . The written falls care plan was updated 1/21/11 to include Psych med (medication) review requested. The 2/10/11 Nursing Note indicated that the resident fell . Review of the Investigation report (on 9/15/11 at 10:37 A.M.), revealed that the resident fell on [DATE] at 9:15 P.M., whereby, the resident was found on the floor in resident's room with a walker on top of the resident, and the fall was not witnessed. The resident sustained [REDACTED]. The report revealed that prior to the fall, the resident was in bed, walked with an unsteady gait, may have tangled night dress in walker and lost balance. The report indica