Every finding on record at Mont Marie Rehabilitation & Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately coded for two Residents (#52 and #22), out of a total sample of 18 residents. Specifically, the facility failed to:1. For Resident #52, accurately code a pressure injury that was present during the observation look back period and to identify the Resident as being at risk for developing pressure injury.2. For Resident #22, accurately code an identified pressure injury present on admission, when the pressure injury was coded as Stage 3 pressure ulcer and the admission nursing assessment indicated MASD (moisture associated skin disorder) to the sacrum. Findings include:1. Resident # 52 was admitted to the facility in March 2026 with diagnoses including Spinal Stenosis, Protein Calorie Malnutrition, Congestive Heart Failure, and delirium. Review of the admission Nursing Assessment indicated Resident #52 had a pressure area (unstaged) on his/her sacrum upon admission to the facility. Review of the admission Weekly Skin check indicated Resident #52 had a Stage 2 Pressure Ulcer on his/her sacrum upon admission. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52: -had no unhealed pressure ulcers/injuries present upon admission. -was not at risk for developing pressure ulcers. During an interview on 5/18/26 at 8:09 A.M., the MDS Nurse said she uses the medical record to accurately complete the MDS which includes the admission assessments and weekly skin checks. The MDS Nurse said when the Resident record was reviewed, she did not see that Resident #52 had any identified pressure ulcers during the lookback period for his/her MDS. During a follow-up interview on 5/18/26 at 11:22 A.M., the MDS nurse said that she did not see the pressure area that was documented on Nursing admission Assessment during the lookback period, but she should have seen it. The MDS said if she had seen it, she would have staff clarify the proper [pressure injury] stage to ensure accurate coding on the MDS assessment, but this did not happen. During an interview on 5/18/26 at 12:40 P.M., the Regional MDS Nurse said that Resident #52 should have been coded as having a pressure ulcer upon admission on the 3/21/26 MDS assessment. The Regional MDS Nurse said the facility follows the RAI (Resident Assessment Instrument) guidelines to ensure accurate documentation. 2. Resident #22 was admitted to the facility in April 2026 with diagnoses including Anorexia, muscle wasting and atrophy and Protein Calorie Malnutrition, FTT (Failure to Thrive). Review of the MDS Assessment, dated 5/7/26, indicated Resident #22: -had one Stage 3 Pressure area. -the Stage 3 pressure area was present upon admission. Review of the admission Nursing Assessment indicated Resident #22 had MASD (moisture associated skin disorder) to his/her sacrum. Review of the admission Skin Check assessment for Resident #22 indicated he/she had MASD to the Sacrum. Review of Resident #22's Initial Wound Consultation dated 5/6/26 indicated: -consultation for first evaluation of wound on Sacrum, Stage 3 Pressure Ulcer/injury - full thickness skin loss. During an interview on 5/18/26 at 8:09 A.M., the MDS Nurse said she uses the entire medical record including the admission assessments and weekly skin checks to accurately complete the MDS. The MDS Nurse said Resident #22 had MASD on the admission screen, so she coded the Resident as having a pressure injury on admission. During an interview on 5/18/26 at 10:06 A.M., the MDS Nurse said that after further review, the Resident did not have a pressure injury documented on admission so his/her Stage 3 pressure injury that was identified on 5/6/26 should not have coded on the MDS as 'present' on admission. During an interview on 5/18/26 at 12:42 P.M., the Regional MDS Nurse said the MDS Nurse should have clarified what skin alteration was present upon Resident #22's admission. The Regional MDS Nurse further said the MDS Nurse should not have coded the Resident's Stage 3 pressure ulcer as 'present' on admission because he/she had MASD documented and the facility follows RAI guidelines. Please Refer to F686

Based on observations, interviews, and records reviewed, the facility failed to provide care consistent with professional standards of practice relative to pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for two Residents (#52 and #22), out of a total sample of 26 residents. Specifically, the facility failed to:1. for Resident #52, appropriately identify and communicate a sacral wound observed on admission to the Wound Provider timely, and also failed to implement the Wound Provider interventions for treatment and air mattress use pertaining to the Resident's sacral wound in a timely manner resulting in the sacral wound further deteriorating. 2. for Resident #22, identify the type of wound present on admission, and also failed to implement the Wound Provider recommendations for an air mattress in a timely manner to prevent worsening of the Resident's sacral wound. Findings include: Review of the Prevention of Pressure Injuries Policy titled April 2020, indicated: -The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -Assess the resident on admission (within eight hours) for existing pressure injury risk factors. -Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Review of the Pressure Ulcer/Skin Breakdown- Clinical Protocol, dated March 2014, indicated: -the nurse shall describe and document/report the following: description/assessment of skin alteration including location, length, width and depth, presence of exudates or necrotic tissue. current treatments, including support surfaces. -The physician will assist the staff to determine etiology (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, stages/status of wound bed, etc.) of the skin alteration. -The physician will help clarify relevant medical issues. the impact of comorbid conditions on wound healing, etc. 1. Resident # 52 was admitted to the facility in March 2026 with diagnoses including Spinal Stenosis, Protein Calorie Malnutrition, Congestive Heart Failure, and delirium. Review of the Nursing admission Assessment indicated Resident #52 had a pressure area (undetermined stage) on his/her sacrum upon admission. Review of the admission Skin Check indicated Resident #52 had a Stage 2 Pressure Ulcer on his/her sacrum on admission. Further Review of Resident #52's Weekly Skin checks indicated:-3/31/26: the Resident had MASD (moisture associated skin damage [location unspecified]) that was different from the pressure ulcer identified at admission. -4/8/26: indicated the Resident had MASD with an area on his/her sacrum measuring 4.5 x 7.5 cm. (centimeters), described as open and red. Review of the Skin Care Plan, initiated 3/20/26, indicated Resident #52: -had a potential for pressure ulcer development related to impaired mobility and incontinence. -Goal: Resident will have intact skin, free of redness, blisters or discoloration. -Interventions included: >follow facility policies/protocols for the prevention and treatment of skin breakdowns. >low air mattress on bed. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #52: -had a moderate cognitive impairment as evidenced by a score of eight out of 15 on the Brief Interview of Mental Status (BIMS) examination. -required maximum assistance from staff for the completion of Activities of Daily Living (ADLS- eating, bathing, hygiene, bed mobility, transfers). -was frequently incontinent of urine. -was not at risk for developing pressure ulcers. -had no unhealed pressure ulcers/injuries present. Review of Resident #52's March 2026 Treatment Administration Record (TAR) indicated: -Vashe Wound External Solution (wound cleansers) applied to affected area topically one time a day for dermatologicals, location of administration - both buttocks; initiated 3/19/26 and discontinued 3/31/26 -Bilateral buttocks: cleanse w/(with) normal saline, pat dry, apply zinc oxide. Leave open to air (LOTA) one time a day, initiated 3/28/26 and discontinued 4/15/26. -Skin checks weekly on Tuesday 3-11 [evening] shift. Review of Resident #52's Medical Record indicated he/she was seen by the Wound Provider on 4/1/26 and 4/8/26 for a right arm skin tear.Further review of the medical record failed to indicate any evidence that Resident #52's sacral wound was evaluated on 4/1/26 and 4/8/26 by the Wound Provider. Review of the TAR for April 2026 indicated: -Sacrum: Cleanse with normal saline solution. Apply Calcium Alginate to wound bed. Cover with Silicone Bordered Foam dressing one time a day for wound care; initiated 4/9/26 and discontinued 4/15/26. -Sacrum: Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite). Apply to Sacrum topically one time a day for wound care. Sacrum: cleanse with Dakins Solution. Pat dry. Apply Santyl to wound bed. Followed by Calcium Alginate. Cover with Silicone bordered foam dressing; initiated 4/16/26 and discontinued 5/14/26. -Right Heel: Cleanse with Normal saline solution. Pat dry. Apply Calcium Alginate to wound bed. Cover with Dry clean dressing one time a day for wound care, initiated 4/16/26. Review of the Wound Provider Consultation on 4/15/26 (27 days after the sacral wound was identified by facility staff) for Resident #52 indicated: -New Stage 3 Pressure Ulcer to the Sacrum -New Stage 3 Pressure Ulcer to the Right Heel -Recommend Air Mattress Review of the Impaired Skin Integrity Care Plan, initiated on 4/20/26, indicated Resident #52 had: -impaired skin integrity.-Right heel Pressure Stage 3.-Sacrum Pressure Unstageable. On 5/13/26 at 8:58 A.M. and 2:30 P.M., the surveyor observed Resident #52 lying in bed and did not observe an air mattress in place on the bed. During an interview on 5/14/26 at 8:48 A.M., Nurse #2 said Resident #52 received an air mattress on 5/13/26 (28 days after the Wound Provider recommendation). Nurse #2 said the Wound Provider said that the Resident's sacral wounds were worsening. During an interview on 5/14/26 at 11:18 A.M., the Wound Nurse said she completed weekly rounds every Wednesday with the Wound Provider and the facility followed the recommendations of the Wound Provider after each visit. The Wound Nurse said that if the Wound Provider recommended an intervention such as an air mattress, those are available in-house and should be started right away. The Wound Nurse said she was not aware the Wound Provider had requested an air mattress for Resident #52 on 4/15/26, and the air mattress should have been implemented right away but was not put into place until 5/13/26. During an interview on 5/14/26 at 2:30 P.M., the Wound Nurse said she was not notified that Resident #52 had a pressure ulcer on his/her admission and was first notified of the pressure ulcer on 4/8/26. The Wound Nurse said she notified the Wound Provider and obtained new orders on 4/9/26. The Wound Nurse said that if she had been notified that Resident #52 had a pressure ulcer present on admission, she would have evaluated the sacral wound right away and initiated visits with the Wound Provider. The Wound Nurse said Resident #52 was seen by the Wound Provider for his/her sacral wound on 4/15/26 and at the same time, both the Wound Nurse and Wound Provider discovered Resident #52 had a newly developed Stage 3 Pressure Ulcer on his/her right heel. The Wound Nurse said that she had been having issues with other Nurses incorrectly staging wounds, and she thought the sacral wound was incorrectly staged on the Resident's admission. During an interview on 5/18/26 at 9:32 A.M., Nurse #1 said that she had often provided care to Resident #52 since his/her admission. Nurse #1 said she was aware that Resident #52 had some MASD to the sacrum, about the size of a quarter and she was now questioning whether it was MASD or pressure associated. Nurse #1 said she was told to continue putting the ordered treatment (Zinc Cream) to the area as ordered. Nurse #1 said that she was told Resident #52's wounds were worsening and was surprised to see he/she did not have an air mattress in place. On 5/13/26, she requested [sic] the facility place an air mattress for the Resident. Nurse #1 said she felt Resident #52 should have had an air mattress since admission because of the diagnosis of FTT (Failure to Thrive) and difficulties tolerating position changes and out of bed attempts. During an interview on 5/18/26 at 11:00 A.M., the Facility Provider said that he was not aware Resident #52 was admitted with a pressure ulcer to the sacrum. The Facility Provider said that he expected himself or the Wound Provider to be notified about any skin issue so the area of concern could be properly evaluated and treated. The Provider said that depending on how the wound was presented, he potentially would have made different treatment recommendations. The Facility Provider further said that he was unsure why the Vashe cleanser was being used and was not sure if that was something the Resident had used in the hospital and got carried over to the current orders. The Facility Provider said that anytime he or the Wound Provider recommended an air mattress, it should be put into place within a day or two. During an interview on 5/18/26 at 11:30 A.M., the Director of Nursing (DON) said according to Resident #52's admission Skin Check he/she had a sacral pressure ulcer. The DON said that the Resident's wound should have been evaluated by the Facility Provider or Wound Provider for proper recommendations. The DON said that the Wound Nurse was never told the Resident had a pressure ulcer until 4/8/26, approximately 2 weeks after admission to the facility, but the Wound Nurse should have been told right away, and Resident #52 would have been referred to the Wound Provider immediately. The DON said that Resident #52 should have had an air mattress initiated upon admission and again on 4/15/26 when the Wound Provider suggested, but it was not done until 5/13/26. During an interview on 5/18/26 at 1:00 P.M., the Wound Provider said that he followed all residents with wounds except surgical wounds and any referrals to him are made by the facility Wound Nurse. The Wound Provider said he was first asked to evaluate Resident #52 on 4/1/26 for a skin tear but was not told he/she had a pressure ulcer until 4/15/26. The Wound Provider said that if he had he been told Resident #52 was admitted with a sacral wound, he would have seen him/her in March 2026 and would have recommended offloading conditions such as an air mattress. The Wound Provider said he expected the facility to obtain air mattresses within a few days of a recommendation being made. The Wound Provider said Resident #52 would benefit from an air mattress because of his/her multiple comorbidities and lack of mobility. The Wound Provider said the air mattress was softer and offloads pressure significantly better than a regular house provided mattress. 2. Resident #22 was admitted to the facility in April 2026 with diagnoses including Anorexia, Muscle Wasting and Atrophy and Protein Calorie Malnutrition, FTT. Review of the MDS Assessment, dated 5/7/26, indicated Resident #22: -was cognitively intact as indicated by a score of 15 out of 15 on the BIMS exam. -had one Stage 3 Pressure area. -the Stage 3 pressure area was present on admission [sic]. Review of the Preadmission Hospital paperwork indicated Resident #22: -had a sacral area pressure injury with wound tissue layer/thickness- full, dated 4/13/26 -had a deep tissue injury to lower back and sacrum, dated 4/17/26. -had a sacral area pressure injury (unstaged), cleansed with soap and water, described as having edges separated, no drainage, foam wound dressing changed, dated 4/27/26 Review of the admission Screener Assessment indicated Resident #22 had MASD to his/her sacrum. Review of the admission Skin check for Resident #22 indicated he/she had MASD to the Sacrum Review of Resident #22's May 2026 TAR indicated: -Phytoplex Z-Guard Paste 57-17% (petrolatum-zinc oxide), apply to buttocks topically every day and evening for excoriation. Wash with soap and water. Pat dry and apply to buttocks, initiated on 5/1/26 and discontinued on 5/6/26. -Low air loss mattress when in bed for pressure ulcer management, every shift for pressure ulcer, FTT (Failure to Thrive), start 5/7/26 (was not implemented until 5/13/26). Discontinued on 5/15/26.-Low Air loss mattress, check placement and function every shift for prevention. Setting to residents' comfort, initiated 5/13/26. -Weekly skin checks, weekly on Thursday 7-3 shift [Day], initiated 5/7/26. -Sacrum: Cleanse with Normal Saline Solution. Pat dry. Apply Honey gel to wound bed. Cover with silicone bordered dressing one time a day for wound care, initiated 5/7/26 and discontinued on 5/14/26. -Santyl Ointment 250 Unit/GM (gram) Collagenase apply to sacrum topically one time a day for wound care. Sacrum: Cleanse with Normal Saline Solution. Pat Dry. Apply Santyl to wound bed. Followed by Calcium Alginate. Cover with Dry clean dressing, initiated 5/14/26. Review of Resident #22's Initial Wound Consultation dated 5/6/26 indicated: -consultation for first evaluation of wound on sacrum, Stage 3 pressure ulcer/injury- full thickness skin loss. -cleanse wound, apply honey gel to base of wound. Secure with dry clean dressing daily. -Recommendation: Mattress with pump [sic] Review of Resident #22's Wound Consultation Note, dated 5/13/26, indicated: -Stage 3 Sacrum Ulcer status is worsening. -continue treatment. -air mattress arrived today. On 5/13/26 at 9:08 A.M., the surveyor observed Resident #22 lying in bed with no air mattress present on the bed and/or in use. During an interview on 5/14/26 at 9:01 A.M., Nurse #2 said that Resident #22 had an area on his/her bottom and was followed by the Wound Provider. Nurse #2 said that according to the admission assessment, Resident #22 had MASD upon admission. During an interview on 5/14/26 at 10:35 A.M., CNA #1 said that Resident #22 received an air mattress for his/her bed yesterday (5/13/26 - 7 days after the Wound Provider recommendation). CNA #1 said that the Resident has had a skin issue on his/her buttocks since admission and the buttocks area was covered with a dressing. The surveyor observed that Resident #22 had an air mattress on his/her bed at the time. During an interview on 5/14/26 at 10:54 A.M., CNA #2 said she provided care to Resident #22 on the day of admission, CNA #2 said Resident #22's buttocks area had a reddened area that was not open. During an interview on 5/14/26 at 3:17 P.M., the Wound Nurse said she was not notified that Resident #22 had MASD or any other wound on his/her sacrum upon admission. The Wound Nurse said on 5/5/26 she saw Resident #22 had a Physician's order for a cream to his/her buttocks and requested the Wound Provider to assess the area. The Wound Nurse said she assessed the area with the Wound Provider on 5/6/26 and it was a Stage 3 pressure ulcer. The Wound Nurse said she thought the wound assessment that occurred on admission may have been documented incorrectly. The Wound Nurse said that she was not aware Resident #22 had a history of a pressure injury to his/her sacrum while at the hospital and would have evaluated him/her sooner. The Wound Nurse further said when the Wound Provider requested an air mattress on 5/6/26, it should have been initiated within a day, but she did not see the recommendation in the note. The Wound Nurse also said the air mattress did not get implemented until 5/13/26 (one week later) and when the wound was evaluated by the Wound Provider on 5/13/26, it appeared worsened. During an interview on 5/18/26 at 9:01 A.M., Nurse #1 said she completed a full skin check on Resident #22 the day of admission and the Resident had a bandage on his/her coccyx area. Nurse #1 said when she removed the bandage, the Resident had had a small irregular shaped open area on the coccyx and felt like it was MASD. Nurse #1 said the area appeared like it was from shearing or MASD and there was a molelike, pea sized area above the open area that could have been from a previous skin issue, she was unsure. Nurse #1 said she was not sure if the Resident had a history of pressure areas and did not know where she would find that information. Nurse #1 said she documented the MASD in the admission paperwork, told her supervisor (Nurse #3) but was unsure of how this information got relayed to the Wound Nurse or Wound Provider. During an interview on 5/18/26 at 10:52 A.M., the Facility Provider said he remembered being told that Resident #22 had some shearing to the sacrum area and Zinc was ordered. The Facility Provider said he was not aware the Resident had a history of pressure areas. The Facility Provider said that an air mattress should have been initiated on admission due to his/her history of pressure areas and then again on 5/6/26 when recommended by the Wound Provider. During an interview on 5/18/26 at 11:48 A.M., the DON said the Wound Nurse should have been notified when the Resident was admitted to the facility with any skin impairments, but this did not happen. The DON said if the Wound Nurse had been notified appropriately, the facility would have had the Wound Nurse complete an evaluation earlier, reach out to the Wound Provider for consultation earlier, and would have implemented an air mattress sooner. The DON said that she was unaware the Resident had a history of pressure ulcers prior to admission. During an interview on 5/18/26 at 1:07 P.M., the Wound Provider said if he had been told that Resident #22 had MASD upon admission, he would have had the Wound Nurse evaluate the area and made recommendations for offloading with an air mattress earlier. The Wound Provider said that if the air mattress was implemented earlier, it would have slowed the wound from deteriorating because Resident #22 was at very high risk for wound development due to his/her complex medical condition. The Wound Provider said that a resident with MASD or history of wounds is at higher risk for developing pressure injuries. The Wound Provider further said since the hospital had evaluated the sacrum as a pressure ulcer, and he had evaluated the wound as a Stage 3 on 5/6/26, then it was most likely that Resident #22 had this area upon admission. During an interview on 5/18/26 at 1:20 P.M., Nurse #3 said she was the supervisor working the evening Resident #22 was admitted . Nurse #3 said she did not do a skin check but remembered being told the Resident had redness on his/her buttocks. Nurse #3 said she did not notify the Wound Nurse of any skin alteration at that time. Nurse #3 said when a resident was admitted with skin alterations, a Physician's order was initiated which alerted the Wound Nurse that the resident should be further evaluated.

Based on observations, interviews, and records reviewed, the facility failed to ensure that dialysis care consistent with professional standards of practice was provided for one Resident (#11) out of a total sample of 18 residents. Specifically, for Resident #11, the facility failed to:-accurately update the change in access site from the PermCath to the left upper arm fistula (when the Resident had a right chest PermCath and left upper arm fistula [vascular access that is created surgically by connecting an artery and a vein]) for dialysis treatments.-provide ongoing assessment of the patency of the Resident's left upper arm fistula vascular access for thrill (vibration felt) and bruit (swishing sound), to prevent complications related to the vascular access site. Findings include:Review of the Long-Term Care Facility Information for Dialysis Residents: Tips and Best Practices for End Stage Renal Disease (ESRD) - Specific Patient Care published by Health Services Advisory Group, undated, indicated but was not limited to:-The vascular access should be assessed daily.>Check for a thrill (vibration felt) and bruit (swishing sound). Review of the facility policy titled Hemodialysis Catheters - Access and Care of, dated 2001 and revised February 2023, indicated but was not limited to the following:-Care of Arterio-Venous Fistulas (AVFs).:>After placement of the fistula.the site cannot be accessed until it matures. This may take.six to 12 weeks for a fistula.>Care involves the primary goals of .maintaining patency of the catheter (preventing clots).>To prevent.clotting.check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit or blood flow through the access.-Documentation:>The nurse should document in the resident's medical record every shift as follows: Location of catheter. Resident #11 admitted to the facility in September 2025, with diagnoses including ESRD and dependence on renal dialysis. Review of the Minimum Data Set (MDS) Assessment, dated 5/13/26, indicated Resident #11:-scored an 11 out of a possible 15 points on the Brief Interview for Mental Status (BIMS) exam, indicating the Resident was moderately cognitively impaired.-was receiving dialysis services.-did not have intravenous (IV) access within the last 14 days. During an interview on 5/14/26 at 8:35 A.M., Resident #11 said his/her dialysis access site was a fistula on his/her left upper arm and at that time the Resident showed the surveyor the fistula site. Review of Resident #11's Hospital Discharge summary dated [DATE] indicated:-The Resident developed Acute Kidney Injury (AKI).now requiring hemodialysis.-Hemodialysis started as of 9/16/25.-A PermCath was placed on 9/18/25 for hemodialysis. Review of Resident #11's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated March 2026 indicated:-The Resident received dialysis in-house [sic]: Days: Monday-Wednesday-Friday. Chair time: 10:00 [sic] one time a day every Monday, Wednesday, Friday. Start date 2/4/26.-The Resident's right chest PermCath (a tunneled central venous catheter used for dialysis access) was monitored for signs and symptoms of infection/infiltration every shift. Start date 9/23/25, end date 5/3/26.-Review of the medical record failed to indicate the presence of a fistula nor monitoring of the Resident's fistula for thrill and bruit. Review of Resident #11's MAR and TAR dated April 2026 indicated:-The Resident received dialysis in-house [sic]: Days: Monday-Wednesday-Friday. Chair time: 10:00 [sic] one time a day every Monday, Wednesday, Friday. Start date 2/4/26.-The Resident's right chest PermCath was monitored for signs and symptoms of infection/infiltration every shift. Start date 9/23/25, end date 5/3/26.-Review of the medical record failed to indicate the presence of a left upper arm fistula or monitoring of the Resident's fistula for thrill and bruit. Review of Resident #11's MAR and TAR dated May 2026 indicated:-The Resident received dialysis in-house [sic]: Days: Monday-Wednesday-Friday. Chair time: 10:00 [sic] one time a day every Monday, Wednesday, Friday. Start date 2/4/26.-The Resident's right chest PermCath was monitored for signs and symptoms of infection/infiltration every shift. Start date 9/23/25, end date 5/3/26.-Review of the medical record failed to indicate the presence of a left upper arm fistula or monitoring of the Resident's fistula for thrill and bruit. Review of Resident #11's Progress Notes from 3/1/26 through 5/15/26 indicated:-On 3/17/26 at 9:44 P.M.: Patient returned from appointments is ok to use left arm fistula no new order.-Review of the medical record failed to indicate monitoring of the Resident's left upper arm fistula for thrill and bruit. Review of Resident #11's Nursing Home Communication Forms for dialysis care provided between 5/1/26 and 5/15/26 failed to indicate evidence of the facility's monitoring of the Resident's left upper arm fistula access site. The surveyor requested on 5/15/26 (prior to survey exit) and on 5/19/26 (after survey exit), evidence of Resident #11's plan of care and Physician's orders relative to dialysis access site and monitoring that were active at the time of the surveyor's observation on 5/14/26 at 8:35 A.M. The accurate requested information was not provided by the facility. During an interview on 5/15/26 at 9:53 A.M., Unit Manager (UM) #2 said Resident #11 had a left upper arm AV fistula for dialysis access. She said that residents with a fistula should be monitored every shift for thrill and bruit. UM #2 said there should be a Physician's order for the monitoring for thrill and bruit, and she said she did not see evidence of this monitoring order in the Resident's medical record. UM #2 said she would continue to look through the Resident's clinical record to determine whether there was any evidence that the Resident's fistula was being monitored for thrill and bruit, as she was not able to locate evidence in the Resident's Physician's orders, care plan or progress notes at that time.UM #2 said the importance of monitoring a fistula for thrill and bruit was to ensure the access was patent for dialysis. UM #2 said the Resident's dialysis access was changed from a PermCath to a fistula. During a follow-up interview on 5/15/26 at 11:29 A.M., UM #2 said Resident #11's PermCath was removed on 4/14/26. UM #2 said that the fistula was approved for use on 3/17/26. UM #2 said it was the facility's policy to assess for thrill and bruit of a dialysis fistula every shift. During an interview on 5/15/26 at 1:44 P.M., the Director of Nursing (DON) said she expected that residents with a dialysis fistula would be assessed for thrill and bruit daily, or as indicated by the facility policy. The DON said Resident #11 should have a Physician's order for the monitoring of thrill and bruit and this order would indicate the access site for dialysis. The DON said the importance of monitoring a fistula for thrill and bruit was to verify patency of the fistula and to identify a potential clot. The DON said Resident #11 did not have a Physician's order for the monitoring for thrill and bruit of the fistula.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who experienced an acute onset of shortness of breath, and required the administration of supplemental oxygen, the Facility failed to ensure that nursing staff were competent in how to set-up and operate a portable oxygen tank, when nursing were unaware they needed to use a key to open the tanks valve in order to access and administer the oxygen.Findings include:Review of the facility's policy titled, Oxygen Administration, dated August 2021 indicated the following:-Assemble the equipment and supplies as needed, such as a portable oxygen cylinder, and regulator.-Turn on the oxygen-Place appropriate device on the resident (i.e., mask, nasal cannula, and/or nasal catheter).Resident #1 was admitted to the Facility in November 2025, diagnoses included Congestive Heart Failure, Chronic Kidney Disease, and Diabetes.Review of Resident #1's Nursing Progress Note, dated 12/29/25 at 11:30 A.M., indicated Resident #1 was alert and breathing on room air (without supplemental oxygen) at 10:18 P.M. and said he/she could not breathe. Resident #1 was assisted to the chair and assessed by Nursing to have had a low oxygen saturation level (the percentage of red blood cells carrying oxygen in the body) and the portable oxygen tank on hand as well as the portable oxygen tank from the second floor were empty.During an interview on 01/20/26 at 12:05 P.M., Nurse #1 said she wrote the Progress Note dated 12/25/25 at 11:32 P.M. Nurse #1 said Nurse #2 responded to Resident #1's call bell when he/she complained of difficulty breathing. Nurse #1 said Nurse #2 alerted her to the situation and she (Nurse #1) went to Resident #1's room, assisted him/her to the chair, assessed his/her vital signs and found his/her oxygen saturation to be low.Nurse #1 said while she was with Resident #1, she asked Nurse #2 to bring an oxygen tank to the room as soon as possible. Nurse #1 said Nurse #2 came back to Resident #1's room and told her the oxygen tank on their unit (Unit 1) as well as the oxygen tank on Unit 2 appeared to be empty.During an interview on 01/20/26 at 12:55 P.M., the Staff Development Coordinator (SDC) said she came into the facility the night of 12/25/25, said she inspected the oxygen tanks in question, and said neither of them were empty.The SDC said that if the oxygen tank valve was not fully opened by turning the key on the top of the tank, the gauge on the regulator (a device that attaches to an oxygen tank/cylinder that features a pressure gauge to show the remaining oxygen left in a tank) would not accurately reflect the amount of oxygen in the tank. The SDC said if Nurse #2 did not complete this step, the gauge would indicate the oxygen tank was empty.During an interview on 01/20/26 at 2:50 P.M., Nurse #2 said she answered Resident #1's call bell during the evening of 12/25/25 and Resident #1 told her he/she was having difficulty breathing. Nurse #2 said she alerted Nurse #1 who responded to the room with the vital signs machine.Nurse #2 said after Resident #1's oxygen saturation was assessed by Nurse #1 to have been very low, she (Nurse #2) went to obtain the oxygen tank from the code cart on the unit. Nurse #2 said the regulator attached to the oxygen tank showed the tank was empty. Nurse #2 said somebody (she could not remember who) went to Unit 2 to get their oxygen tank and told her that tank was empty too.Nurse #2 said she later learned that neither tank was empty, and that she did not know that she needed to twist the top of the oxygen tank with a metal key to turn the oxygen on, after which the gauge on the regulator would indicate the amount of oxygen that was left in the tank.During a follow up telephone interview on 01/21/26 at 12:50 P.M., the Staff Development Coordinator (SDC) said Nurse #2 completed all clinical competencies when she was hired, including all the steps needed to prepare a portable oxygen tank for usage, and should have known the key needed to be placed on the tank valve and turned in order to fully engage the oxygen tank for use, and that the reading on the gauge would not be accurate until this step was completed.During a telephone interview on 01/21/26 at 1:55 P.M., with the Assistant Director of Nursing and the Administrator, they said Nurse #2 completed all necessary competencies upon hire which included all aspects of oxygen administration and she should have known how to prepare the portable oxygen tank for usage.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated in September 2025, the Facility failed to ensure they maintained Resident #1's rights related to obtaining copies of medical record information, when his/her Health Care Agent (HCA) requested copies of documentation from his/her medical record, and did not receive those copies, in accordance with the regulation. Findings include:Review of the Facility Medical Record Reviews Policy, revised November 2009, indicated that the Facility maintained the confidentiality of each resident's personal and protected health information. The Policy indicated the resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor). The Policy indicated the resident may obtain photocopies of his or her records by providing the facility with at least 48 hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying service.Resident #1's was admitted to the Facility in August 2025 with diagnoses including Alzheimer's Disease, urinary tract infection, urinary retention, history of falling, congestive heart failure, and unspecified protein-calorie malnutrition.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 08/19/25, indicated he/she was severely cognitively impaired.Review of Resident #1's September Physician's orders indicated there was an order to invoke the Health Care Proxy, dated 09/03/25, and his/her Health Care Agent (HCA) was activated. During a telephone interview on 11/26/25, Resident #1's Health Care Agent (HCA) said that she requested copies of documentation from Resident #1's medical record in early October 2025. The HCA said she had signed a Facility release form and had given it to the receptionist. The HCA agent she had called a telephone number that had been provided by the Facility to follow-up with her request, but she never received the medical records. Review of the Facility's Medical Record Request log indicated that copies of Resident #1's medical record had been requested by his/her HCA on 10/02/25 and 10/07/25. The Log did not indicate if Resident #1's medical record documentation had been provided to the HCA.During an interview on 12/2/25 at 4:00 P.M., the Administrator said she had no documentation to support that Resident #1's medical record had been provided to his/her HCA as requested.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they offered assistance in scheduling a Podiatry appointment as requested to ensure good foot health was maintained.Findings include:Review of the Facility policy titled, Foot Care, revised October 2022, indicated that residents are provided with foot care and treatment in accordance with professional standards of practice and that residents are assisted in making appointments and with transportation to and from specialists (podiatrist, endocrinologist, etc.) as needed.During a telephone interview on 11/26/25 at 2:00 P.M., Visitor #1 said that Resident #1 had very thick and long toenails, that his/her Health Care Agent had requested Podiatry services on admission, and that podiatry services had not been scheduled or provided. Resident #1 was admitted to the Facility in August 2025, diagnoses included Alzheimer's Disease, urinary tract infection, urinary retention, history of falling, congestive heart failure, and unspecified protein-calorie malnutrition.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 08/19/25, indicated he/she was severely cognitively impaired and dependent on staff to meet his/her care needs.Review of Resident #1's Physician orders for the month of September 2025, indicated his/her Health Care Proxy had been invoked.Review of the Request for Service form, dated 8/16/25, indicated Resident #1's Health Care Agent had requested Podiatry services.Review of Resident #1's Physician's orders for the month of September 2025, indicated the following order:-May have consult with Podiatry, dated 09/03/25.Review of Resident's #1's clinical record indicated there was no documentation to support that Podiatry services had been provided.During a telephone interview on 12/04/25 at 11:45 A.M., the Customer Service Representative for the Podiatrist said a Request for Services form for Resident #1 had not been received from the facility and that Resident #1 had not been provided with podiatry services.During an interview on 12/02/25 at 3:50 P.M., the Director of Nursing (DON) said the process for a resident to obtain Podiatry services was that a Request for Services form is signed by the Resident or their representative, faxed to the Podiatrist, and the resident is added to the list for the next time the Podiatrist comes to the Facility. The DON said she was unsure when the Podiatrist had been to the facility after Resident #1's request for services. The DON was unable to provide documentation to support that the facility had provided assistance in scheduling a Podiatry appointment for Resident #1.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physician's orders included the administration of multiple medications to help manage his/her specific gastrointestinal diseases, the Facility failed to ensure Resident #1 was provided with nursing care and treatment that met professional standards when the nursing staff failed to administer his/her bowel medications and other medications timely. Findings include: Review of the Facility's Policy titled, Administering Medications, dated as last revised April 2019, indicated the following: - Medications are administered within one (1) hour of prescribed time, unless otherwise specified (for example, before and after meal orders). Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in January 2025, diagnoses included Parkinson's disease (a progressive, neurological disorder primarily affecting movement, caused by the loss of brain cells that produce dopamine, a chemical that helps control movement), ulcerative colitis (a chronic inflammatory bowel disease that primarily affects the colon and rectum, causing inflammation and ulcers in the lining of the digestive tract), and he/she has an ileostomy (a surgically-created opening, called a stoma, constructed by bringing part of the small intestine through an opening in the abdominal wall). During an interview on 04/15/25 at 12:24 P.M., Resident #1's Representative said Resident #1 suffered from excessive amounts of loose stool and required several medications to be administered at specific intervals, including before meals to alleviate this condition. Resident #1's Representative said that there were many occasions where Resident #1 did not receive these (and other) medications timely and as a result there were issues managing the consistency and volume of output from his/her ileostomy. Review of Resident #1's Physician's Orders for February 2025, indicates they included the following medication orders: - Diphenoxylate-Atropine Oral Tablet (Lomotil, used to treat severe diarrhea), 2.5-0.025 milligrams (mg), give two tablets by mouth five times per day for loose stool, scheduled for 8:00 A.M., 11:00 A.M., 3:30 P.M., and 8:00 P.M. - Loperamide HCl Oral Tablet (Imodium, a medication used to treat diarrhea and also used to decrease the amount of drainage in patients with a stoma), 2 mg, give two tablets by mouth before meals and at bedtime for diarrhea, scheduled for 8:00 A.M., 11:00 A.M., 4:00 P.M., and 9:00 P.M. - Review of the Loperamide HCL (Imodium) product information website indicated to take the medication only on an empty stomach (1 hour before or 2 hours after a meal). - Cholestyramine Oral Powder (a medication that can be used to treat diarrhea caused by excess bile acids in the intestines), 4 grams (gm) per dose, give one dose by mouth before meals and at bedtime, scheduled for 8:00 A.M., 11:00 A.M., 4:00 P.M., and 9:00 P.M. - Review of the National Library of Medicine Medline Plus web page titled, Cholestyramine Resin, last revised 08/15/17, indicated to take the medication before a meal and/or at bedtime. - Benefiber Prebiotic-Probiotic Oral Tablet Chewable (a fiber supplement that can help slow bowel movements), give one tablet by mouth before meals, scheduled for 8:00 A.M., 12:00 P.M., and 5:00 P.M. Review of the Facility's Meal Delivery Times indicated that for the unit on which Resident #1 resided, the meals were scheduled to be delivered at the following times: - Breakfast: 7:45 A.M. and 7:50 A.M. - Lunch 11:45 A.M., and 11:50 A.M. - Dinner 4:45 P.M., and 4:50 P.M. Review of Resident #1's Medication Administration Audit Report for February, 2025 indicated the following medications were administered late on the following dates and times: - 02/06/25 -3:30 P.M. dose of Diphenoxylate-Atropine Oral Tablet administered at 4:54 P.M. (over an hour late) -4:00 P.M. dose of Loperamide HCl Oral, administered at 5:49 P.M. (over an hour late and after the dinner meal) -4:00 P.M. Cholestyramine Oral Powder administered at 5:48 P.M. (over an hour late and after the dinner meal) -4:00 P.M. Carbidopa-Levodopa Oral Tablet, 25-100 mg administered at 5:45 P.M. (over an hour late) -4:30 P.M. Famotidine (reduces stomach acid) Oral Tablet administered at 5:48 P.M. (over an hour late) -7:00 P.M. Carbidopa-Levodopa Oral Tablet, 25-100 mg administered at 9:35 P.M. (over an hour late) -8:00 P.M. dose of Diphenoxylate-Atropine Oral Tablet administered at 9:35 P.M. (over an hour late) - 02/17/25 -11:00 A.M. Diphenoxylate-Atropine Oral Tablet administered at 1:58 P.M. (over an hour late) -11:00 A.M. Cholestyramine Powder administered at 1:58 P.M. (over an hour late and after the lunch meal) -11:00 A.M. Loperamide HCl Oral Tablet administered at 1:58 P.M. (over an hour late after the lunch meal) -12:00 P.M. Benefiber Prebiotic-Probiotic Oral Tablet administered at 1:59 P.M. (over an hour late and after the lunch meal) - 02/20/25 -3:30 P.M. Diphenoxylate-Atropine Oral Tablet administered at 5:23 P.M. (over an hour late) -4:00 P.M. Cholestyramine Oral Powder administered at 5:23 P.M. (over an hour late and after the dinner meal) -4:00 P.M. Loperamide HCL Oral Tablet administered at 5:23 P.M. (over an hour late and after the dinner meal) -4:00 P.M. Carbidopa-Levodopa Oral Tablet administered at 5:23 P.M. (over an hour late) - 02/24/25 -11:00 A.M. Cholestyramine Oral Powder administered at 12:31 P.M. (over an hour late and after the lunch meal) -11:00 A.M. Loperamide HCl Tablet administered at 12:31 P.M. (over an hour late and after the lunch meal) -4:00 P.M. Cholestyramine Oral Powder administered at 6:23 P.M. (over an hour late and after the dinner meal) -4:00 P.M. Loperamide HCl Tablet administered at 6:23 P.M. (over an hour late and after the dinner meal) -4:00 P.M. Carbidopa-Levodopa Oral Tablet administered at 6:25 P.M. (over an hour late) -5:00 P.M. Benefiber Prebiotic-Probiotic Oral Tablet administered at 6:23 P.M. (over an hour late and after the dinner meal) On 04/15/25 at 3:00 P.M., after reviewing Resident #1's Medication Administration Audit Report with the surveyor, the Director of Nursing said all of these medications were administered late, and not according to the Physician's Orders.

Based on record reviews and interviews for one of three sampled residents (Resident #1), whose physician's orders included the administration of a medication to manage his/her movement disorder, the Facility failed to ensure he/she was free from significant medication errors, when upon admission, the medication was inaccurately reconciled from his/her Hospital Discharge Summary by nursing and he/she was administered incorrect dosages of the medication for multiple days. Findings include: Review of the Facility's Policy titled, Medication Reconciliation, dated as last revised [DATE], indicated that the medication reconciliation procedure is to ensure medication safety by accurately accounting for resident's medications, routes and dosages upon admission or readmission to the facility. The Policy further indicated that: - Medication reconciliation is a process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. - Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and the care team. Resident #1 was admitted to the Facility in [DATE], with a diagnosis of Parkinson's disease (a progressive, neurological disorder primarily affecting movement, caused by the loss of brain cells that produce dopamine, a chemical that helps control movement). During a telephone interview on [DATE] at 12:24 P.M., Resident #1's Representative said Resident #1 told her that he/she could not keep his/her eyes open and wanted to see a doctor. Resident #1's Representative said she inquired about Resident #1's medications to see if he/she was receiving anything new and learned Resident #1 was receiving the incorrect dose of Carbidopa-Levodopa (a medication used to alleviate the symptoms of Parkinson's disease) since he/she was admitted . Review of Resident #1's Hospital Discharge Medication List, dated [DATE], indicated his/her orders included the following: - Carbidopa-Levodopa, oral tablet, ,d+[DATE] milligrams (mg), administer two tablets (,d+[DATE] mg) orally five times per day (for a total of ,d+[DATE] mg daily) - Carbidopa-Levodopa, ,d+[DATE] mg extended release oral tablet, administer two tablets (for a total of ,d+[DATE] mg) orally daily at bedtime. Review of Resident #1's [DATE] Physician Order Summary Report indicated the following: - Carbidopa-Levodopa oral tablet, ,d+[DATE] mg, administer one tablet by mouth five times per day (for a total of only ,d+[DATE] mg daily) - Carbidopa-Levodopa extended release tablet, ,d+[DATE] mg, administer one tablet by mouth at bedtime, (for a total of only ,d+[DATE] mg at bedtime). Review of Resident #1's Medication Administration Record (MAR) indicated he/she received only one tablet (instead of the two tablets he/she was supposed to receive) of the following: - Carbidopa-Levodopa ,d+[DATE] mg five times daily ( received one tablet only) for a total of 14 times - Carbidopa-Levodopa ER ,d+[DATE] (received one tablet only) for a total of four times Therefore, Resident #1 received half the amount of medication that he/she had been receiving in the Hospital, to manage his/her movement disorder. Review of an article in MedCentral.com related to the administration of Carbidopa-Levidopa, indicated this medication must be carefully adjusted according to individual requirements, response and tolerance. The risk of precipitating (to happen suddenly) a system complex resembling neuroleptic malignant syndrome (rare but potentially fatal reaction to certain drugs, characterized by symptoms such as fever, muscle rigidity, and altered mental status, triggered by increasing or stopping a dose) patients should be watched closely if carbidopa- levodopa dose is reduced abruptly. During an interview on [DATE] at 1:55 P.M., Nurse #1 said there is a process to reconcile medications when a resident is admitted or readmitted to the Facility. Nurse #1 said it is the responsibility of the nurse performing the admission to review the medication list supplied by the hospital (if the resident is being admitted from the hospital). Nurse #1 said the process was to carefully go through the list, go over the list with the Facility Provider so they can approve the orders or make any necessary changes, and after verifying the orders with the Provider, the nurse enters the orders into the computer. During an interview on [DATE] at 2:03 P.M., the Nursing Supervisor said when reconciling admission medications, the preferred hospital documentation is within the Hospital Discharge Summary, titled Discharge Medications. The Nursing Supervisor said the Discharge Medication List contains details such as which medications were newly prescribed, which medications were changed, and which medications were unchanged or discontinued at the hospital. The Nursing Supervisor reviewed Resident #'1's Discharge Medication List with the surveyor, and said Resident #1 had been receiving two tablets of Carbidopa-Levodopa both immediate release (,d+[DATE] mg) and extended release (,d+[DATE] mg) while in the hospital. The Nursing Supervisor and the surveyor then reviewed a Physician Assistant (PA) Visit Note, dated [DATE], where the PA indicated Resident #1's Carbidopa-Levodopa order was ,d+[DATE] mg, two tablets five times per day and ,d+[DATE] mg extended release, two tablets at bedtime. The Nursing Supervisor said Resident #1 should have been receiving two tablets of each Carbidopa-Levodopa formulations since admission, and the nurse had entered the admission orders incorrectly. During an interview on [DATE] at 3:00 P.M., the Director of Nursing (DON) said when Resident #1 was admitted , the Nurse transcribed and obtained orders for the incorrect dose of Carbidopa-Levodopa (both immediate release and extended release tablets), and Resident #1 was administered the incorrect dose until it was remedied on [DATE]. On [DATE], the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) On [DATE], The Physician Assistant assessed Resident #1 and his/her physician's orders were immediately corrected. B) On [DATE], the Director of Nursing (DON) conducted a Medication Administration Review with the Nurse who reconciled Resident #1's medications incorrectly with education provided on the Five Rights of Medication Administration and Admission Process for Medication Reconciliation along with a competency evaluation administered by the Staff Development Coordinator. C) From [DATE] through [DATE] the DON provided in-person education to Licensed Nursing staff, titled Admission Medication Reconciliation and the Five Rights of Medication Administration with competencies. D) On [DATE], the DON immediately audited all new admissions starting from [DATE] to ensure admission medication orders were reconciled correctly. E) Weekly audits continue to be conducted by the DON to ensure admission medication orders were reconciled correctly. F) On [DATE] an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. The Facility leadership team developed a plan of correction related to the deficient practice. I) Effectiveness of this plan will be reviewed during Monthly QAPI meetings until further notice. J) The Director of Nursing and/or designee will be responsible for overall compliance.

Based on interviews, and records reviews, the facility failed to provide appropriate notice of discharge for a facility-initiated discharge, when the Resident did not initiate a request of discharge for one Resident (#72) out of three closed records. Specifically, the facility failed to provide appropriate notice of discharge to Resident #72 when: -the facility determined that the Resident was acting Against Medical Advice (AMA) by driving his/her personal vehicle to a scheduled eye surgery appointment. -the facility notified the Resident he/she was discharged upon return to the facility from the scheduled eye surgery appointment. -the Resident's personal belongings were packed without his/her participation and he/she was discharged with personal belongings to his/her vehicle, resulting in emotional distress when the Resident expected to return to the facility after the eye surgery appointment. Findings include: Review of the facility policy titled Transfer or Discharge Resident-Initiated, revised October 2022, indicated the following: -Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. -Discharge refers to the movement of a resident from one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. -Resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home .) a. Therapeutic Leave is a type of resident-initiated transfer. However if the facility makes a determination to not allow the resident to return, the transfer becomes a facility-initiated discharge. b. A resident's lack of objection to a facility-initiated transfer or discharge is not considered resident-initiated. c. A resident verbal or written notice of intent to leave against medical advice is considered a resident-initiated discharge. -Documentation: 1. For resident-initiated discharges, the medical record contains: a. Documentation of evidence the resident's or resident representative's verbal or written notice of intent to leave the facility; b. a discharge care plan; and c. documented discussions with the resident, or if appropriate, his/her representative containing details of discharge planning and arrangements for post-discharge care. 2. The comprehensive care plan contains the resident's goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident initiated. Resident #72 was admitted to the facility in October 2024 with diagnoses including Peripheral Vascular Disease (PVD), Chronic Kidney Disease (CKD) Stage 4, Depression, and Anxiety. Review of a recent Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #72: -was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 15 out of a total possible 15. Review of the Discharge MDS assessment dated [DATE], indicated Resident #72: -BIMS assessment was not conducted. -was assessed as Independent for making decisions regarding tasks of daily life and there was no acute mental status change. -MDS was a discharge assessment with return not anticipated. -Discharge was unplanned. -Discharge location was to home/community. Review of Resident #72's Comprehensive Plan of Care for Discharge Potential, initiated 10/9/24, indicated the following goal and interventions: >I plan to discharge to community alone, community with family, ALF (Assisted Living Facility), LTC (Long term care) placement, other - Undecided at current time. Pending outcome of therapy sessions, clinical medical stability progress reviewed weekly, initiated 11/29/24. >Encourage patient and family to be involved in planning of care and discharge planning, initiated 10/9/24. >Notify MD (Medical Doctor) of discharge plans, ensure all required discharge documentation is complete including Orders, and prescriptions are available at time of discharge, initiated 10/9/24. >Nursing, Care Navigator (Social Work), Clinical Nurse Navigator, and therapy shall discuss progress and discharge plan weekly and as needed, initiated 10/9/24. Further review of the Comprehensive Plan of Care for Discharge Potential failed to indicate any interventions relative to driving or coordination with any specific community support services. Review of Resident #72's Physician's orders, discontinued 3/13/25, indicated the following: -May go out for appointments, initiated 10/6/24, with no end date. -discharged AMA (against medical advice) with personal belongings, ordered 3/7/25, with no end date. Review of the Nurse Practitioner (NP) Encounter Note dated 3/6/25, indicated: -[Resident] reports he/she has [Lasik eye] surgery tomorrow and a friend will be bringing him/her. Further review of Resident #72's NP Encounter Note dated 3/6/25, indicated an addendum on 3/8/25 at 7:03 A.M. with the following: -[Resident] left the facility today to go to Lasik appointment. -He/she was not cleared to drive but ended up taking his/her car him/herself anyways. -Due to this he/she was advised to go to hospital for re-evaluation and not able to return. Review of the Leaving Against Medical Advice (AMA) Form, dated 3/7/25, indicated: -I, [Resident #72], am leaving against the advice of my Physician and the facility. -Documented as refused in Resident signature section. -Signed by DON (Director of Nursing) and Administrator as facility representative and witness, respectively. -Comments section on the Leaving Against Medical Advice (AMA) Form was blank. Review of Resident #72's Nursing Progress Note dated 3/7/25 at 15:17 (3:17 P.M.) indicated: -[Resident] left the facility prior to being formally discharged and was seen driving their personal vehicle to a scheduled appointment. -The [Resident] chose to leave the facility against medical advice (AMA). Further review of the Nursing Progress Note dated 3/7/25, failed to indicate that any notice of discharge was provided to Resident #72 at the time of discharge or that the Resident consented to an AMA discharge. Review of Resident #72's Social Service Progress Note dated 3/7/25 at 18:02 (6:02 P.M.) indicated: -Social Worker (SW) #2 was made aware during morning meeting that [Resident] was driving to an appointment by him/herself and had just left the facility. -Social Worker informed management that [Resident] was not given the approval to drive by the Medical Doctor. -[Resident] was informed that if he/she went out and drove . it would be considered him/her leaving against medical advice. -When [Resident] returned to the building DON and Administrator met with [Resident] and helped him/her put his/her belongings into the vehicle. -[Resident] was discharged AMA and Elder Protective [report] will be submitted. Further review of the Social Service Progress Note dated 3/7/25, failed to indicate that any notice of discharge was provided to the Resident or that the Resident consented to an AMA discharge. During an interview on 4/3/25 at 3:01 P.M., with surveyor #1, the Director of Nursing (DON), and the Administrator, the DON said that on 3/7/25, the Resident had planned eye surgery that day and the facility had booked transportation. The DON further said that the transportation company had arrived that day to pick up Resident #72 as observed by the Receptionist and Nurse #1, and Resident #72 turned the transportation away. The DON said that around noontime, Resident #72 and Resident Representative (RR) #1 arrived back at the facility and the DON said she witnessed the Resident and RR #1 arrive in separate vehicles and the Resident was wearing specialty glasses at the time. The DON said she spoke with Resident #72 privately and said to the Resident that he/she had left the facility and driven his/her vehicle which was considered against medical advice. The DON said she provided Resident #72 with information about going to the hospital. The DON said that Resident was out of the facility (away) on 3/7/25 from around 8:00 A.M. to noon. The DON said she left phone messages for the Resident and RR #2 informing them of the concern of leaving against medical advice. During an interview on 4/3/25 at 3:03 P.M., with surveyor #2 and Social Worker (SW) #1, SW #1 said that Resident #72 had been working with Social Worker (SW) #2 and that SW #2 was no longer employed at the facility. SW #1 said that Resident #72 had his/her personal vehicle on admission to the facility, was homeless, and had nowhere to store the vehicle. SW #1 said the Resident told staff that he/she was going to a medical appointment and he/she was told it was not in the Resident's best interest to drive due to the nature of the appointment. SW #1 said that she was not in the facility when the Resident left on 3/7/25, but the facility had transportation arranged for the Resident's appointment and SW #1 said she believed the Resident cancelled the transportation. SW #1 said the facility's process for Against Medical Advice (AMA) discharge is to educate the Resident regarding the risks of AMA, attempt to get them a Visiting Nurse Agency, and file a protective services report. SW #1 said the facility does not provide a notice of transfer or discharge to residents that leave AMA but the Ombudsman is notified of AMA discharges. During a telephone interview on 4/4/25 at 8:33 A.M., the Resident was contacted by surveyor #2 as he/she is no longer residing at this facility. Resident #72 said that he/she was admitted to the facility after hospitalization and was a Resident at the facility from October 2024. Resident #72 said he/she had Lasik eye surgery planned on 2/21/25, and waited for transportation which had been arranged by the facility for 2/21/25 but transportation did not show. Resident #72 said he/she was frustrated with the transportation process, had re-scheduled the eye surgery him/herself, and indicated to staff that he/she wanted to make his/her own arrangements for transportation to the new appointment. Resident #72 said he/she communicated the new eye surgery appointment to RR #2 who planned to drive him/her to the appointment. Resident #72 said on the morning of the re-scheduled appointment (3/7/25), he/she notified Nurse #1 of the eye surgery appointment, RR #2 arrived to the facility and drove the Resident in his/her own vehicle to the appointment. Resident #72 further said that RR #2 dropped him/her off at the appointment, RR #2 then returned the Resident's vehicle to the facility, and RR #2 left the facility in their own vehicle. Resident #72 said he/she made arrangements with RR #1 to pick him/her up after the eye surgery appointment and RR #1 was the person who drove him/her back to the facility in RR#1's vehicle. Resident #72 said when he/she and RR #1 returned to the facility and went to his/her room, there was none of his/her personal belongings in the room at that time. Resident #72 said after that he/she was approached by a Staff Member, whom he/she thought was the Administrator, who told him/her that he/she was outta here, I saw you drive to the appointment. Resident #72 said that he/she was not provided with any AMA paperwork and/or medications at that time. Resident #72 said he/she tried to explain to the Staff Member that RR #2 drove the Resident's vehicle to the appointment that morning and the Staff Member did not see him/her switch cars with RR #2. Resident #72 said he/she knew that he/she was not supposed to drive to the appointment as it was planned eye surgery. Resident #72 said that the Maintenance Director placed big green bags of his/her belongings in the back of the Resident's and RR #1's vehicle. Resident #72 said that he/she felt terrible with a total emptiness inside and that he/she thought what did I do wrong? Resident #72 further said they went through all of my personal belongings without me being there which I felt was the wrong way to do it. Resident #72 said after he/she spoke with the Staff Member and his/her belongings were loaded in his/her vehicle, the Resident and RR #1 sat in his/her vehicle for about 30 minutes to see if anyone would ask them to leave the property. Resident #72 said I was not sure what I would do. Resident #72 said that he/she then called RR #2 to discuss his/her options and he/she decided to go to the hospital from the facility. Resident #72 said he/she was admitted to a local area hospital the same day he/she left the facility and that the local area hospital was unable to place him/her in another local nursing home after about a week. During a telephone interview on 4/4/25 at 9:16 A.M., with surveyor #2, Resident Representative (RR) #1 said that he/she picked up the Resident around noon from the eye surgery appointment and returned to the facility with the Resident in RR #1's vehicle. RR #1 said when he/she and the Resident entered the facility and went to the Resident's room, none of Resident #72's personal belongings were in the room. RR #1 said that Resident # 72 met with one of the facility staff privately and the Resident told RR #1 They kicked me out, I have to leave. RR#1 said that he/she checked the Resident's room again to locate any belongings left behind, and found the Resident's car keys in the nightstand drawer. RR #1 said that RR #2 had driven Resident #72 to the eye surgery appointment, and drove his/her vehicle back from the appointment and dropped the car keys off to the facility. RR #1 further said the Resident was very upset that he/she had no place to go and just had an operation. RR #1 said the whole thing was a traumatic experience for me and Resident #72. They had all of his/her stuff packed already and then loaded it into the Resident and my cars. During an interview on 4/4/25 at 10:34 A.M., the Maintenance Director (MD) said that the Resident had their vehicle on the property since his/her admission to the facility. The MD said that he had been out of the facility on the morning of 3/7/25 and returned to the facility around midday and observed several large full travel bags that the facility used for residents that were discharging on a flatbed cart. The MD said the Administrator told him the travel bags were Resident #72's items and the MD was instructed by the Administrator to bring the bags outside to the Resident. The MD said that he brought the bags out to the Resident's car and put one bag in the Resident's friend's vehicle as well. During an interview on 4/4/25 at 10:56 A.M., with surveyor #2, the DON, Nurse #1, and CNA #2, Nurse #1 said that she and CNA #2 packed up the Resident's belongings as instructed by the DON. Nurse #1 said that she attempted to call the Resident and RR #2 without success and left voicemails indicating the Resident had left the facility against medical advice, that his/her belongings were packed by staff, and that the belongings would be given to him/her in the lobby when he/she returned. Nurse #1 further said the Resident returned to the facility around noon accompanied by a friend, came back up to the floor and back to his/her room. The DON said that she was the Staff Member who spoke with the Resident on 3/7/25, but she did not document the conversation when he/she provided the Resident with AMA paperwork. The DON said that she provided education to the Resident that he/she could go to two of [local area hospital] emergency rooms and the Resident left in their own vehicle and was ambulating with a cane at the time. The DON said that a notice of discharge was not provided to the Resident as Resident #72 had left against medical advice. During an interview on 4/4/25 at 11:45 A.M., SW #1 said that there was no documentation of any discharge paperwork provided to Resident #72. During a telephone interview on 4/4/25 at 11:46 A.M., Resident Representative (RR) #2 said that he/she arrived to the facility on 3/7/25 around 9:20 A.M., the Resident had his/her vehicle started and running when he/she arrived, and RR #2 drove Resident #72 to the eye surgery appointment in the Resident's vehicle. RR #2 said that he/she returned to the facility around mid-morning after dropping off the Resident at the eye surgery appointment. RR#2 said that he/she saw CNA #3 in the lobby when he/she returned and asked CNA #3 if the CNA would bring the Resident's car keys back to his/her room. RR #2 said CNA #3 took the car keys and RR #2 left the facility. During a telephone interview on 4/4/25 at 12:17 P.M., CNA #3 said on 3/7/25 around 10:30 A.M., she was returning from her morning break and was approached in the facility lobby by RR #2. CNA #3 said that she recognized RR #2 as Resident #72's relative, that they knew each other, and RR #2 handed CNA #3 a set of keys and asked CNA #3 to put them in Resident #72's nightstand drawer. CNA #3 said that she put the keys in the Resident's nightstand drawer as requested and returned to her scheduled shift assignment. Please Refer to F623

Based on record review, and interview, the facility failed to provide a written Notice of Intent to Transfer and Discharge to the Resident and/or Resident Representative (RR) and notify the Office of the State Long-Term Care Ombudsman at the time of discharge or shortly thereafter for two Residents (#72 and #34) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #72, provide a written Notice of Intent to Transfer and Discharge and statement of appeal rights as required to the Resident and/or Resident Representative for an unplanned discharge when the facility notified the Resident of the discharge upon his/her return to the facility from a scheduled eye surgery appointment. 2. For Resident #34, provide a written Notice of Intent to Transfer and Discharge to the Resident and/or Resident Representative and notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred to the hospital. Findings include: Review of the facility policy titled Transfer or Discharge, Facility-Initiated, revised October 2022, indicated the following: -Notice of Transfer is provided to the resident and representative as soon as practicable and to the long term care (LTC) ombudsman when practicable . 1. Resident #72 was admitted to the facility in October 2024 with diagnoses including Peripheral Vascular Disease, Chronic Kidney Disease Stage 4, Depression, and Anxiety. Review of the most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #72: -Resident was cognitively intact as evidenced by Brief Interview for Mental Status Score of 15 out of a total possible 15. Review of the Discharge MDS assessment dated [DATE], indicated Resident #72: -was assessed as Independent for making decisions regarding tasks of daily life and there was no acute mental status change. -MDS was a discharge assessment with return not anticipated. -Discharge was unplanned. -Discharge location was to home/community. Review of Resident #72's Physician's orders, discontinued 3/13/25, indicated: -May go out for appointments, ordered 10/6/24, with no end date. -discharged AMA (against medical advice) with personal belongings, ordered 3/7/25, with no end date. Review of Resident #72's Nursing Progress Note dated 3/7/25 at 15:17 indicated: -[Resident] left the facility prior to being formally discharged and was seen driving their personal vehicle to a scheduled appointment. -The [Resident] chose to leave the facility against medical advice (AMA). Review of the Nurse Practitioner (NP) Encounter Note dated 3/6/25 indicated: -[Resident] reports he/she has [Lasik eye] surgery tomorrow and a friend will be bringing him/her. Further review of Resident #72's NP Encounter Note dated 3/6/25, indicated the following addendum on 3/8/25 at 7:03 A.M.: -[Resident] left the facility today to go to Lasik appointment. -He/she was not cleared to drive but ended up taking his/her car him/herself anyways. -Due to this he/she was advised to go to hospital for re-evaluation and not able to return. Review of the Leaving Against Medical Advice form, dated 3/7/25, indicated: -I, [Resident #72], am leaving against the advice of my Physician and the facility. -Documented as refused in Resident signature section. -Signed by the Director of Nursing (DON) and Administrator as facility representative and witness, respectively. -The comments section on Leaving Against Medical Advice Form was blank. During an interview on 4/4/25 at 10:56 A.M., with surveyor #2, the DON, Nurse #1, and CNA #2, Nurse #1 said that she and CNA #2 packed up the Resident's belongings as instructed by the DON on 3/7/25. Nurse #1 said that she attempted to call the Resident and his/her Representative without success and left voicemails indicating the Resident had left the facility against medical advice, that his/her belongings were packed by staff, and that the belongings would be given to him/her in the lobby when he/she returned. Nurse #1 further said the Resident returned to the facility around noon accompanied by a friend, came back up to the floor and back to his/her room. The DON said that she spoke with the Resident on 3/7/25, but she did not document the conversation between the DON and the Resident when the Resident was provided with the AMA paperwork. The DON said that she provided education to the Resident that he/she could go to two local area hospital emergency rooms and the Resident left the facility in their own vehicle. The DON said that a Notice of Intent to Transfer and Discharge was not provided to the Resident as Resident #72 had left against medical advice. 2. Resident #34 was admitted to the facility in November 2024. Review of the Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form, dated 1/13/25, indicated Resident #34 was transferred from the facility to the hospital on 1/13/25. Further review of Resident 34's medical record failed to indicate documentation that a written Notice of Intent to Transfer, and Discharge was provided to the Resident and/or Resident Representative at the time of discharge or shortly thereafter or that the Office of the State Long-Term Care Ombudsman had been notified of the Resident's transfer to the hospital. During an interview on 4/3/25 at 10:37 A.M., the Social Worker (SW) said she was unable to provide documentation to show that a Notice of Intent to Transfer or Discharge was provided in writing to the Resident and/or the Resident's Representative or that the Office of the State Long-Term Care Ombudsman had been notified when Resident #34 was transferred to the hospital on 1/13/25.

Based on interview, and record review, the facility failed to ensure recommendations made by the Behavioral Health Care Team were implemented for one Resident (#53), out of a total sample of 18 residents. Specifically, for Resident #53, the facility failed to ensure an Electrocardiogram (EKG-noninvasive medical test that records the electrical activity of the heart) was completed every six months as recommended by the Behavioral Health Nurse Practitioner. Findings include: Resident #53 was admitted to the facility in February 2024 with diagnoses including Parkinson's Disease, Obsessive Compulsive Disorder, and Dementia with psychotic disturbance. Review of the Nurse Practitione(NP) from the Behavioral Health Provider Notes, dated 4/3/24, 7/22/24, 9/30/24, 1/27/25, and 3/10/25, indicated the following: >Current Medication -Seroquel (antipsychotic medication that has potential to cause heart arrhythmias) >Plan/Recommendations -Medication Monitoring: EKG for QTc (test that checks for a change in the QTc interval [a part of the heart rhythm] which could indicate potentially dangerous arrhythmias). Review of Resident #53's medical record indicated Resident #53 had a baseline EKG completed on 1/27/24, prior to his/her admission to the facility. Further review of Resident #53's medical record indicated the next EKG for Resident #53 was performed on 3/3/25, (14 months after the baseline EKG was completed). During an interview on 4/3/25 at 12:52 P.M., the Director of Nursing (DON) said she would expect a recommendation made by the Behavioral Health Provider to be put into place shortly after the recommendation had been made. The DON said a Physician order should have been put into place for a follow-up EKG to be performed six months after the baseline EKG was performed on 1/27/24, as the Resident was administered Seroquel medication daily.

Based on observation, record review, and interview, the facility failed to maintain appropriate hygiene practices while serving meals in the dining room, on one (3rd Floor Unit) out of three Units observed. Specifically, the facility failed to ensure that nursing staff who were distributing food during the breakfast meal 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 Food Preparation and Service, revised 2001, indicated: -Food distribution means the processes involved in getting food to the resident. This may include .dispensing food portions for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas to be distributed . -Food service means the process involved in actively serving food to the resident. When actively serving residents in dining room or outside a resident's room where trained staff are serving food/beverage choices from a mobile food cart or steam table, there is not need for food to be covered. -Food Distribution and Service: >Food and nutrition services staff, including nursing personnel, wash their hands before serving food to residents. >Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. On 4/2/25 from 7:46 A.M. through 8:06 A.M., during the breakfast meal observation in the 3rd Floor Dining Room, the surveyor observed: -7 Staff members (2 Nurses, 4 Certified Nurses Aides [CNAs], 1 Dietary Aide) were in the dining room and assisting with the meal service. -The 2 Nurses and 4 CNA's were serving meal trays which were plated by the Dietary Aide who was at the steam table. -10 residents were seated in the dining room and being served meals by the staff. -Staff were observed serving residents, pouring and serving beverages, and clearing plates, cups, and other dirty utensils and items for the residents in the dining room. -1 CNA cleared the used tableware and placed the dirty plates, cups and utensils in the dirty utensil bins with bare hands, and did not perform hand hygiene between handling dirty tableware and serving other residents meal items. -A hand washing sink was located behind the steam table, but was not observed used by staff for hand hygiene. -No staff were observed performing hand hygiene between distributing the residents meals and after removing dirty plates, cups, and utensils. During an interview on 4/2/25 at 8:49 A.M., Nurse #2 who assisted with the dining room meal service said that the staff should perform hand hygiene between serving residents, Nurse #2 said she would use the Alcohol Hand Sanitizer dispensers in the hallway for hand hygiene. Nurse #2 said that there was no Hand Sanitizer dispenser in the Dining Room. During an interview on 4/2/25 at 9:21 A.M., the Director of Nursing (DON) said the expectation is that staff should wash their hands or perform hand hygiene between serving each resident. The DON said that staff have been educated on appropriate hand hygiene practices in the past.

Based on record review and interview the facility failed to accurately complete Minimum Data Set (MDS) Assessments for two Residents (#52 and #60) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #52, accurately code for dental status when the Resident had full upper and lower dentures that were loose fitting. 2. For Resident #60, accurately code for two unhealed pressure ulcers present during the MDS observation period. Findings include: 1. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual version 1.19.1 dated October 2024, indicated the following: -Poor oral health has a negative impact on: - quality of life - overall health - nutritional status -Ask the resident, family, or significant other whether the resident has or recently had dentures or partials. (If resident or family/significant other reports that the resident recently had dentures or partials, but they do not have them at the facility, ask for a reason.) -Check L0200A, broken or loosely fitting full or partial denture: if the denture or partial is chipped, cracked, uncleanable, or loose. A denture is coded as loose if the resident complains that it is loose, the denture visibly moves when the resident opens their mouth, or the denture moves when the resident tries to talk. -Many residents have dentures or partials that fit well and work properly. However, for individualized care planning purposes, consideration should be taken for these residents to make sure that they are in possession of their dentures or partials and that they are being utilized properly for meals, snacks, medication pass, and social activities. -Additionally, the dentures or partials should be properly cared for with regular cleaning and by assuring that they continue to fit properly throughout the resident's stay. Resident #52 was admitted to the facility in February 2024 with diagnoses including Cachexia, Dysphagia Oropharyngeal Phase, and Malignant Neoplasm Unspecified. Review of Resident #52's Dental Consult dated 7/16/24, indicated: -Resident was alert, oriented, calm, and cooperative. -Full upper and full lower Dentures were present. -Resident wore the upper dentures sometimes, and the lower dentures never. -The upper and lower dentures were loose. -There were no natural teeth present. Review of the MDS dated [DATE], indicated Resident #52: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. -had no dentures, no missing or broken teeth, or any other dental concerns. On 4/1/25 at 10:46 A.M., the surveyor observed a full upper denture plate in Resident 52's mouth, and no teeth or dentures were present on the bottom gum. During an interview at the time, Resident #52 said that he/she has had full upper and lower dentures for years. Resident #52 also said that the dentures were loose and that he/she only wore the upper dentures for eating, but never wore the lower dentures because they were too large. During an interview on 4/3/25 at 9:59 A.M., Nurse #3 said Resident #52 had no (natural) teeth. Nurse #3 said that the Resident was wearing full upper dentures, and he/she told Nurse #3 that the full lower dentures were in the bedside drawer. Nurse #3 said that Resident #52 did not care to wear the bottom dentures because they were too loose. During an interview on 4/3/25 at 10:15 A.M., with the Regional Director of Case Management and the MDS Coordinator, the Regional Director of Case Management said that the MDS dated [DATE], should have reflected that Resident #52 was edentulous (without natural teeth) since his/her admission to the facility, and that the Resident's dentures were noted as loose in the clinical record. The Regional Director of Case Management also said that each comprehensive MDS completed since Resident #52 was admitted to the facility was incorrectly coded for dental status. The Regional Director of Case Management said that the MDS dated [DATE], should have been coded for edentulous and for loose fitting dentures, but was not coded accurately. 50320 2. Review of the Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 (RAI) User's Manual Version 1.19.1, Dated October 2024 indicated: -Coding instructions for pressure ulcer/injury, code yes if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look back period. Resident #60 was admitted to the facility in December 2024 with diagnoses including Diabetes Mellitus Type II, Acute Kidney Failure Unspecified, dependance on Renal Dialysis. Review of Resident #60's Care Plan for Pressure Ulcer Development indicated: -right heel wound unstageable and Stage 2 of left foot, initiated 1/16/25. Review of Resident #60's February 2025 Treatment Administration Record (TAR) indicated the Resident: >was receiving wound care treatments for the right heel, initiated 2/5/25 >wound care treatments were completed as ordered by the Physician, 2/5/25 through 2/26/25 >was also receiving treatments to the left lateral foot, initiated 2/17/25 >left lateral foot treatments were completed as ordered by the Physician, 2/17/25 through 2/26/25 Review of the Wound Assessment Report dated 2/25/25, indicated Resident #60: -had an unstageable right heel pressure injury and a Stage 2 pressure injury of the left lateral foot. Review of Resident #60's most recent Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD - the last day of the seven day look back observation period) of 2/26/25, indicated Resident #60: -had no unhealed pressure ulcers. During an interview on 4/2/25 at 2:38 P.M., the MDS Coordinator said Resident #60's MDS assessment dated [DATE], should have been coded yes for pressure ulcer/injury for the left foot and right heel pressure ulcers present during the 7-day look back period. The MDS Coordinator said the MDS was not coded for the left foot and right heel pressure ulcers and would need to be corrected.

Based on interview and record review the facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded for three Residents (#16, #45, #61) out of a total sample of 19 residents and for one Resident (#71) out of three sampled closed records. Specifically, the facility failed to ensure the MDS Assessment: 1. For Resident #16, was accurately coded relative to the use of a feeding tube. 2. For Resident #45, was accurately coded relative to the use of Oxygen. 3.For Resident #61, was accurately coded relative to pressure ulcers (injury to the skin resulting from prolonged pressure) when the Resident had no pressure ulcers. 4. For Resident #74, was accurately coded relative to the discharge destination when the Resident discharged from the facility. Findings include: 1. Resident #16 was admitted to the facility in November 2023 with diagnoses including severe malnutrition. Review of Resident#16's nutrition care plan, last revised 12/18/23, indicated that the Resident required enteral (passing through the intestine through an artificial opening) tube feeding due to a diagnosis of severe malnutrition. Review of Resident #16's MDS dated [DATE], indicated that the Resident did not have a feeding tube. Review of Resident #16's Physician's orders for March 2024 indicated the following: -Enteral Feed in the evening for tube feeding starting at 6 pm: Osmolite (liquid formula for tube feeding) 1.2 Cal liquid via feeding tube, feeding pump set at 80 milliliters (ml)/hour (hr) for 12 hours, total volume 960 ml, start date 12/21/23 -Tube feeding down at 6 am in the morning, start date 2/4/24 -Elevate head of bed at 30 - 45 degrees during enteral feeding, flushing, medication administration, and for 1-hour after feeding every shift, start date 11/22/23 On 3/21/23 at 9:35 A.M, the surveyor observed Resident #16 lying in bed. He/she said showed the surveyor that a feeding tube was in place by means of lifting their shirt. During an interview on 3/25/23 at 3:09 P.M., the [NAME] President (VP) of Case Management said that Resident #16's MDS had been inaccurately coded and should have been coded as having a feeding tube. 42741 2. Resident #45 was admitted to the facility in February 2024, with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of the most recent comprehensive MDS Assessment, dated 2/15/24, indicated Resident #45 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 and that Resident #45 did not use utilize Oxygen (O2) while a resident in the facility. During an observation and interview on 3/21/24 at 9:31 A.M., the surveyor observed Resident #45 to be seated on his/her bed receiving supplemental O2 via nasal cannula (tubing placed in the base of the nostrils that delivers supplemental oxygen via an oxygen concentrator). Resident #45 said he/she had been using O2 daily since his/her admission to the facility. Review of the Admission/Readmission Screener (a form utilized by the facility to medically assess a resident upon admission to the facility), effective date 2/10/24, indicated that Resident #45 utilized O2 at the time of admission. During an interview on 3/25/24 at 1:21 P.M., the VP of Case Management (who oversaw the MDS Assessment process at the facility) said Resident #45 had utilized O2 since his/her admission to the facility, and that the MDS assessment dated [DATE], was coded incorrectly and needed to be modified. 3. Resident #61 was admitted to the facility in January 2024, with diagnoses including Diabetes with diabetic neuropathy (nerve damage that occurs in someone with diabetes) and chronic venous Hypertension with bilateral lower extremity ulcers (increase in blood pressure within the lower legs that causes ulcers to form). Review of the most recent comprehensive MDS assessment dated [DATE], indicated Resident #61 had one Stage One pressure ulcer (localized damage to the skin and/or underling soft tissue as a result of prolonged pressure that presents as intact skin with an area of redness that remains reddened when pressed). Review of the Weekly Skin Assessment (a form utilized by the facility to assess a resident's skin), effective date 1/16/24, indicated the Resident did not have any pressure ulcers. During an interview on 3/25/24 at 1:22 P.M., the VP of Case Management said Resident #61 did not have any pressure ulcers at the time the 1/22/24 MDS Assessment was completed, that the MDS assessment dated [DATE], was coded incorrectly and needed to be modified. 4. Resident #74 was admitted to the facility in December 2023, with a diagnosis of End Stage Renal Disease (ESRD-a condition in which the kidneys lose the ability to remove waste and balance fluids in the body). Review of the discharge MDS assessment dated [DATE], indicated the Resident was discharged from the facility to a short-term hospital (acute care hospital). Review of the Nursing Progress Note dated 12/30/23, indicated the Resident was discharged from the facility to home. During an interview on 3/26/24 at 12:46 P.M., the MDS Nurse said Resident #74 discharged to the community, and that the MDS assessment dated [DATE], was coded incorrectly and needed to be modified.

Based on observation, record and policy review, and interview, the facility failed to provide care and services for a suprapubic catheter (an indwelling urinary catheter placed directly into the bladder through the abdomen) for one Resident (#30) out of a total sample of 19 residents, to prevent catheter related complications. Specifically, for Resident #30, the facility staff failed to obtain verification of the Physician's order for the correct size of a suprapubic urinary catheter and ensure that the verified size catheter was in place. Findings include: Review of the facility policy for Catheter Care, last revised August 2022, indicated to review the Resident's care plan to assess for any special needs of the Resident to prevent urinary catheter associated complications. Resident #30 was admitted to the facility in March 2020, with diagnoses including malignant neoplasm (a cancerous tumor that spreads), neuromuscular dysfunction (a condition that affects the communication between the muscle and the nerves) of the bladder and obstructive and reflux (conditions that affect the urinary tract due to blockage or backward flow of urine) uropathy. Review of Resident #30's suprapubic catheter care plan, last revised 2/29/24, indicated: -that the catheter size was 22 Fr (French scale or system used to size catheters) with a Balloon (retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from dislodging and sliding out of the body) size of 10 milliliters (ml). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #30 was cognitively impaired due to a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS Assessment indicated that the Resident had an indwelling urinary catheter and a diagnosis of neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly). Review of the March 2024 Physician's orders for Resident #30 indicated: -a different size catheter order (than the 22 Fr size on the suprapubic catheter care plan, revised 2/29/24) with no balloon size: >change 18 Fr catheter monthly, one time a day, every 28 days, start date 10/30/23 Review of Resident #30's Treatment Administration Records (TAR) indicated that the catheter had been changed monthly to an 18 Fr catheter on the following dates: -10/30/23 -11/27/23 -12/25/23 -1/22/24 -2/19/24 -3/18/24 During an observation of the suprapubic catheter on 3/25/24 at 11:11 P.M. with Nurse #1, Nurse #1 verified the current suprapubic catheter that was in place for Resident #30 was a size 20 Fr/10 ml catheter (which was different from the March 2024 Physician order for 18 Fr [no balloon] and suprapubic catheter care plan, revised 2/29/24 for 22 Fr/10 ml balloon). Nurse #1 said that she was not certain what the correct urinary catheter size should be for Resident #30. During an interview on 3/26/24 at 7:51 A.M., the Assistant Director of Nurses (ADON) said that the Nurses should check the Physician's orders and the care plan before changing the urinary catheter. The ADON said the Physician's orders and the care plan would indicate the sizes of the urinary catheter. The ADON also said that there should have been a balloon size on the Physician's orders and there was none documented. During an interview on 3/26/24 at 9:02 A.M., the ADON said that the Physician's order should have been in place for the correct urinary catheter size and that both Resident #30's care plan and Physician's orders had incorrect catheter sizes. The facility staff did not provide documentation as requested on what the correct size of the urinary catheter should have been for Resident #30 through the time of the survey exit.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two Residents (#45 and #278) out of a total sample of 19 residents. Specifically, the facility staff failed to ensure: 1. For Resident #45, that Physician's orders were in place for the use of Oxygen (O2). 2. For Resident #278, that Physician's orders were in place for the use of O2 on admission, and that the appropriate liter per minute (LPM- the amount of supplemental Oxygen someone received through an oxygen delivery device) of Oxygen was administered as ordered by the Physician. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with physicians' orders or inadequate instruction for oxygen therapy. -Equipment maintenance and supervision: All oxygen delivery equipment should be checked at least once daily Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. Review of the facility policy titled Oxygen Administration, revised October 2010, indicated the following: -Verify that there is a Physician's order for this procedure (safe oxygen administration). -Review the Physician's orders or facility protocol for oxygen administration. 1. Resident #45 was admitted to the facility in February 2024, with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated the Residents was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. During an observation and interview on 3/21/24 at 9:31 A.M., the surveyor observed Resident #45 seated in bed and utilizing supplemental O2 set at 3 LPM via nasal cannula (a device that delivers oxygen through a tube and into your nose). Resident #45 said he/she had been using supplemental O2 since 2023. During an interview on 3/21/24 at 2:34 P.M., Nurse #2 said the Resident who utilized O2 should have Physician's orders in place for the use of O2. Nurse #2 further said those orders should include the LPM needed to maintain the Residents' O2 saturations (SpO2- measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) to be equal to or greater than 90%, and the ability to titrate (increase or decrease the LPM) if the Resident needed their LPM changed to maintain 90% or greater SpO2. Review of the Physician's History and Physical dated 2/13/24, indicated the Resident had a diagnosis of COPD and utilized supplemental O2 since August 2023. Review of the March 2024 Physician's Order Summary Report, indicated the following order: -O2 at 3 LPM via nasal cannula to keep SpO2 equal to or above 90%, every shift for COPD, start date 3/19/24 Further review of the Physician's orders indicated no Oxygen orders that corresponded with the Resident's admission on 2/9/24 were in place until the current order from 3/19/24. On 3/25/24 at 9:16 A.M., the surveyor observed Resident #45 seated in bed receiving O2 via nasal cannula, set at 3 LPM. During an interview on 3/25/24 at 10:11 A.M., the Assistant Director of Nurses (ADON) said Physician's orders for the use of O2 for Resident #45 should have been obtained at the time of his/her admission because he/she was utilizing O2 when he/she was admitted to the facility, and it did not appear that O2 orders were in place until 3/19/23. 2. Resident #278 was admitted to the facility in March 2024 with a diagnosis of Pneumonia (infection in the lungs). Review of the Social Services Assessment, effective 3/19/24, indicated that the Resident was cognitively intact as evidenced by a BIMS score of 15 out of 15. During an observation and interview on 3/21/24 at 10:26 A.M., the surveyor observed Resident #278 lying in bed receiving O2 via nasal cannula set at 2.5 LPM. Resident #278 said he/she utilized the O2 all day and had only been using O2 since he/she was hospitalized for Pneumonia. Resident #278 further said he/she was unsure what LPM his/her O2 should be set at. Review of the Admission/Readmission Screener (a form used by the facility to medically evaluate a resident on admission), effective date 3/17/24, indicated the Resident required O2 and he/she utilized O2 via nasal cannula. Review of the March 2024 Physician Order Summary Report, indicated the following order: -O2 at 2 LPM via nasal cannula, to keep SpO2 equal to or above 90% every shift , start date 3/19/24 Further review of the Physician's orders indicated no orders that corresponded with the Resident's admission on 3/16/24 until the current order from 3/19/24. On 3/25/24 at 8:26 A.M., the surveyor observed Resident #278 lying in bed receiving O2 via nasal cannula set to 3 LPM. On 3/26/24 at 7:58 A.M., the surveyor and Nurse #2 observed Resident #278 lying in bed receiving O2 via nasal cannula set at 3 LPM. During an interview following the observation, Nurse #2 said Resident #278's O2 Physician's order was for 2 LPM and his/her O2 LPM should not have been set on 3 LPM. Nurse #2 further said if the Resident needed their O2 titrated to maintain their SpO2 at or above 90% then there should be an order in place for nursing staff to titrate the O2 and Resident #278 did not have an order for titration. On 3/26/24 at 8:03 A.M., the Nurse Supervisor said if the Resident requires a higher liter flow of O2 than what the Physician ordered, staff should be updating the Physician of the increased O2 use and should get an order to titrate the O2 to maintain the Resident SpO2 at 90% or greater. The Nurse Supervisor said Resident #278 currently did not have an order to titrate his/her O2. On 3/26/24 at 9:04 A.M., the ADON said Resident #278 was on O2 at the time of his/her admission to the facility and she was unable to provide evidence that the Physician's orders were in place for the use of O2 prior to 3/19/24.

Based on record review, and interview, the facility failed to maintain accurate medical records for one Resident (#26) out of a total sample of 19 residents, relative to identifying and documenting the Resident as a falls risk. Specifically, the facility staff failed to ensure that Resident #26's care plan accurately reflected that the Resident was at risk of falling, when the falls care plan was marked as resolved and rendered inactive. Findings include: Review of the facility policy titled Fall Risk Assessment, undated, indicated the following: -The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document resident fall risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Resident #26 was admitted to the facility in October 2017, with diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), Syncope (fainting), and a history of repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #26 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of a score of 15. Review of the facility fall investigations for Resident #26 indicated the following fall incidents: -2/25/23 Resident fell while ambulating out of his/her room. -3/2/23 Resident fell while attempting to exit his/her bed. -6/7/23 Resident fell from chair to floor. -8/13/23 Resident fell from a chair in the dayroom of the nursing unit. -9/14/23 Resident fell while attempting to stand from a wheelchair. -1/24/24 Resident fell out of bed. -1/29/24 Resident fell while ambulating in the hallway. Review of the current care plans for Resident #26 indicated that there was no comprehensive Resident centered fall prevention care plan. During an interview on 3/26/24 at 12:23 P.M., the Assistant Director of Nurses (ADON) said that resident care plans are reviewed periodically but Resident #26's care plan had not been reviewed recently. The ADON said Resident #26's fall care plan had been marked resolved in February 2024 in error and that if a care plan is marked resolved it indicated the care plan was no longer active. The ADON said she did not know how or why Resident #26's fall care plan was marked resolved but it should not have been resolved because the Resident was at risk of falling.

Based on observation, interview, and record review, the facility failed to ensure that its staff providing direct care and services to residents were assessed for the required competencies. Specifically, the facility failed to ensure that its staff provided evidence that licensed nursing staff competencies were assessed for care and services provided to residents who received hemodialysis ([CONDITION(S)] - mechanical process of purifying the blood for a person whose kidneys do not work normally), as required, according to the facility's policy for nursing staff competency and the Annual Facility Assessment, directly impacting Resident #25. Findings include: Review of the facility's Hemodialysis Access Care Competency assessment checklist, dated April 2018, included that if there was major bleeding from the [CONDITION(S)] access site post-[CONDITION(S)] treatment, staff were to apply pressure to the insertion site, contact emergency services and the [CONDITION(S)] center .this would be a medical emergency .do not leave resident alone until emergency services arrive. Review of the facility policy, titled Hemodialysis Access Emergency Care, dated March 2022, included the following: - In the event of bleeding from a hemodialysis access site, nursing staff would provide emergency care. - Emergency care, in the event that bleeding occurred from a resident's arteriovenous fistula (AV fistula: surgical connection made between an artery and a vein to create a [CONDITION(S)] access point), staff were to immediately apply firm manual pressure directly to the site of bleeding ., maintain that pressure for at least 10 minutes ., have another nurse notify the [CONDITION(S)] center or physician of the bleeding and obtain instructions ., if bleeding was major or uncontrolled, staff were to continue applying direct pressure to the site and have another staff member call emergency services ., and that staff were not to leave the resident alone or stop the application of pressure until instructed by emergency services. Review of the facility's policy, titled Competency of Nursing Staff, undated, included the following: - All nursing staff were required to meet the specific competency requirement of their respective licensure and certification requirements defined by State law. - Licensed nurses .employed (or contracted) by the facility would .demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care. - The Facility Assessment would include an evaluation of the staff competencies necessary to provide the level of care and types of care specific to the resident population. - Facility and resident specific competency evaluations would be conducted upon hire, annually, and as deemed necessary. - Competency demonstrations would be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which would be evaluated by staff already deemed competent in that skill or knowledge. Review of the document, titled Facility Assessment, dated 8/1/22, included the following: - Staff competency evaluations would be conducted for new employees, throughout employment, and annually to ensure staff ability to safely and competently provide the levels and types of care required by the resident population. - The resident population included residents that received hemodialysis services. Resident #25 was admitted to the facility in August 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) Assessment, dated 8/8/21, included the following: -The Resident was cognitively intact as demonstrated by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. -The Resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Matrix on 8/30/22 indicated that 12 residents in the facility, including Resident #25, received hemodialysis services. During an interview on 8/30/22 at 11:34 A.M., Resident #25 said that he/she attended [CONDITION(S)]. On 9/1/22 at 10:20 A.M., the surveyor observed Resident #25 in his/her room after he/she had returned from [CONDITION(S)] treatment. The Resident had two bandages that were secured over his/her left upper extremity AV fistula site. At this time, Nurse #1 said that he/she was responsible for Resident #25's care that day. Nurse #1 said that if the Resident's AV fistula started to bleed, he/she would notify the supervisor and would get a large gauze dressing (ABD) pad from the storage unit down the hall to stop the bleeding. During an interview on 9/1/22 at 2:20 P.M., the Staff Development Coordinator (SDC) said that if a resident experienced bleeding from their AV fistula, the Nurse would be required to immediately provide pressure to the site, maintain that pressure for at least 10 minutes, and have another staff member contact emergency services. She also said that the staff member applying pressure should not leave the Resident. The SDC said that notifying the supervisor of a Resident with bleeding from an AV fistula, then going to collect supplies before applying pressure to the site was not an appropriate intervention to control a Resident's bleeding. The SDC further said that there was no evidence that licensed nurses working at the facility were assessed for competency relative to the care of Residents who received hemodialysis services. During a follow-up interview on 9/6/22 at 4:00 P.M., the Regional Nurse provided a list of 13 Residents in the facility that were receiving hemodialysis as of 9/6/22 and said that six of those residents' [CONDITION(S)] access sites were via the use of AV fistulas.

Based on record review and interview, the facility failed to ensure that its staff completed the Minimum Data Set (MDS) assessment accurately for three Residents (#33, #20, #61) out of a total sample of 18 residents. Specifically: 1) The facility failed to accurately assess vision status for Resident #33, 2) The nutritional status on three consecutive MDS assessments for Resident #20, and 3) Ambulation and eating status for Resident #61. Findings include: 1. Resident #33 was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/1/22 at 9:54 A.M., CNA (Certified Nursing Assistant) #2 said that Resident #33 needs a lot of assistance because he/she is blind. CNA #2 also said the Resident told her that he/she can only see shadows. Review of the MDS assessment dated [DATE], section B Vision, indicated the Resident had adequate vision and was able to see fine detail including regular print in newspapers/books. During an interview on 9/1/22 at 12:50 P.M., the MDS Nurse said that the MDS dated [DATE] was coded incorrectly for Resident #33 with regards to vision and that the documentation in the Resident's record supported that the Resident is blind. 2. For Resident #20, the facility failed to ensure that its staff accurately coded the Resident's nutritional status on three consecutive MDS Assessments. Resident #20 was admitted to the facility in July 2021. Review of the clinical record included the following: - three consecutive MDS Assessments, dated 3/29/22, 4/18/22, and 6/21/22 that indicated Resident #20 had received a therapeutic diet (a meal plan used to control the intake of certain foods or nutrients and is used as part of the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] - a Nutrition Assessment, dated 6/17/22, that indicated the Resident received a regular diet. Review of the September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/1/22 at 8:36 A.M., the MDS Nurse said that Resident #20 had been on a therapeutic diet but that it was discontinued in September 2021. The MDS Nurse said that the MDS Assessments dated 3/29/22, 4/18/22, and 6/21/22 should not have been coded to indicate that the Resident received a therapeutic diet and that this was an error. 3. For Resident #61 the facility's staff failed to accurately code two MDS assessments relative to the Resident's ability to ambulate (walk) and eat. Resident #61 was admitted to the facility in November 2021. Review of the CNA Documentation Survey Report for November 2021 indicated the Resident ambulated on 11/2/21 during the evening and night shift and ate independently for all three meals on 11/2/21 - 11/6/21. Review of the CNA Documentation Survey Report for July 2022 indicated the Resident ambulated on 7/2/22 during the day shift, 7/3/22 during the evening shift, 7/4/22 during the day and evening shifts and ate independently for all meals on 7/1/22 - 7/4/22. Review of the MDS Assessments, dated 11/7/21 and 7/5/22 indicated the Resident did not ambulate in his/her room or in the corridor and required supervision with meals during the assessment periods. During an interview on 8/31/22 at 9:08 A.M., the Director of Rehabilitation said the Resident met his/her rehabilitation goals and was able to ambulate to the rehabilitation gym independently with his/her walker to utilize the exercise equipment if therapy staff were present. During an interview on 8/31/22 5:00 P.M., the MMQ (Management Minutes Questionnaire) Nurse said the MDS assessments dated 11/7/21 and 7/5/22 were coded incorrectly relative to the Resident's ambulation and eating and needed to be modified to indicate the Resident ambulated and ate independently.

Based on observation interview and record review, the facility failed to ensure that its staff developed and implemented a comprehensive person-centered care plan for four Residents (#33, #3, #15 and #44) out of a total sample of 18 residents. Specifically: 1) The facility failed to ensure that its staff developed and implemented a plan of care relative to vision for Resident #33, 2) Personal preference for activities for Resident #3, 3) Update and implement new wound care orders for Resident #15, and 4) Follow the care plan to obtain weights on Resident #44. Findings include: 1. Resident #33 was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimal Data Set (MDS) assessment dated [DATE], section B Vision, indicated the Resident had adequate vision and was able to see fine detail including regular print in newspapers/books. Review of the Resident's current care plan indicated no comprehensive plan of care for visual impairment or [CONDITION(S)]. During an interview on 9/1/22 at 9:54 A.M., Certified Nursing Assistant (CNA) #2 said that Resident #33 needs a lot of help because he/she is blind, and the Resident told CNA #2 that he/she can only see shadows. CNA #2 also said that she doesn't provide care differently for the Resident because of his/her [CONDITION(S)]. During an interview on 9/1/22 at 9:59 A.M., Nurse #2 said that Resident #33 is blind and cannot do much for himself/herself. Nurse #2 said that sometimes when the Resident is eating, he/she will tell her where the food is on his/her plate. During an interview on 9/1/22 at 12:50 P.M., the MDS Nurse said that the MDS assessment dated [DATE] was coded incorrectly for Resident #33 with regards to vision status and that the documentation in the Resident's record supported that the Resident is blind. 2. For Resident #3 the facility's staff failed to follow a care plan relative to the Resident's personal preference for activities. Resident #3 was admitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Activities care plan, initiated on 7/7/21, indicated the following: -Dependent on staff for activities, cognitive stimulation, social interaction related to [CONDITION(S)] and [CONDITION(S)] following a cerebral infarction (stroke) affecting the right, dominant side. -Preferred activities are watching television, especially science-fiction and Red Sox games, listening to rock music, 1:1 visits, and family visits. -When I choose not to participate in organized activities, turn on the television to a Red Sox game, the Science Fiction channel, or rock music on television in the room to provide sensory stimulation. Additionally, the care plan identified activity staff, CNAs, and nursing staff, to be responsible for ensuring the interventions are completed. On 8/30/22 at 9:34 A.M., the surveyor observed Resident #3 lying in bed in his/her room. The television was not on nor was there any music playing. The Resident was slightly restless, trying to pull off a bootie that was on one foot as well as the sheets that were tangled around his/her feet. During an interview immediately following the observation, Nurse #4 said that the Resident is was able to make his/her basic needs known and will talk a little if he/she is up to it. On 8/31/22 at 11:48 A.M., the surveyor observed Resident #3 awake in bed wearing a hospital gown. Both the room lights and the television were switched off and there was no music playing. On 8/31/22 at 2:10 P.M., the surveyor Observed Resident #3 awake in bed, uncovered, wearing a hospital gown. When the surveyor asked the Resident if the Red Sox were his/her favorite team, he/she smiled back. When asked if he/she was able to watch any of the games on the television, he/she shook his/her head no and pointed at the television. During an interview on 8/31/22 at 2:20 P.M. Nurse #3 said that there was no television or music on in his/her room and it was very quiet. She said that she was unaware of the Resident's personal preferences. 3. For Resident #15 the facility failed to update and implement new wound care orders relative to the frequency of a wound dressing change. Resident #15 was admitted to the facility in January 2022. Review of the Wound Care Specialist note, dated 8/30/22, indicated the following: -Change dressing DAILY - Oil emulsion (type of treatment used for healing wounds) apply once daily for 23 days -Gauze island with border (type of adhesive dressing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the current Physician's Order indicated the following: -Left hip - normal saline wash and pat dry. Skin area - apply oil emulsion to area followed by bordered gauze, three times a week and as needed when soiled, ordered on 8/25/22. -Review wound orders and update when applicable weekly until wound healed one time a day every Wednesday, start on 8/31/22. Review of the August 2022 Medical Administration Record (MAR) indicated that the order to review wound orders and update when applicable, was initialed on 8/31/22, indicating that it had been reviewed and updated. During an interview and document review on 9/6/22 at 10:40 A.M., Unit Manager (UM) #1 said that it is the facility's process to review the new orders/recommendations and make appropriate updates to the Resident's orders/care plans every Wednesday, following the Wound Care Specialist scheduled visits every Tuesday. UM #1 and the surveyor together reviewed the following documents: -Current Physician orders indicating that the dressing be changed three times weekly -Wound doctor note on 8/30/22 indicating new recommendations for dressing changes to be completed DAILY. -August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . UM #1 said that someone should have updated the wound order on 8/31/22, to reflect the dressings being changed daily, and they did not as required. 4. For Resident #44 the facility's staff failed to follow the care plan to routinely obtain the Resident's weights. Review of the facility policy titled, Weight Assessment and Interventions, undated, indicated the following in part: -Resident weights are monitored for undesirable or unintended weight loss or gain. -Weights are recorded in each unit's weight record chart and in the individual's medical record. -Unless notified of significant weight change, the Dietician will review the unit weight record monthly to follow individual weight trends over time. Resident #44 was admitted to the facility in March 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Nutritional note dated 2/13/22, indicated that the Resident experienced significant weight loss of seven pounds (lbs.), a -5.8% weight loss over the past month. The note further indicated to trial 237 milliliters (mls) of Ensure Plus (a nutritional supplement) and continue to monitor weight. Review of the medical record indicated no weights had been recorded in the months of March 2022 (after a significant weight loss was noted) or July 2022. During an interview on 8/31/22 at 11:07 A.M., UM #1 and the surveyor together reviewed the Resident's weight summary. UM #1 said that weights were missing for the months of March 2022 and July 2022 and should have been obtained. She further said that it is the facility's policy to obtain a Resident's weight monthly unless otherwise indicated by a Physician.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls, resulting in significant injury in four of nine falls, for one resident (#70) out of a total sample of 18 residents. Findings include: Resident #70 was admitted to the facility in August of 2016. On 1/14/20 at 8:48 A.M., Resident #70 was observed in his/her room, seated in a recliner chair facing the hall with a bed side table in front of him/her. Resident #70 told the surveyor he/she had no idea what was going on with anyone or anything. Resident #70 had a bandage over their left eye. Review of the clinical record indicated Resident #70 sustained nine falls between May and December of 2019. Seven of the nine falls were unwitnessed, three of them resulted in significant injury. Two of the nine falls were witnessed, one of them resulted in significant injury. Review of the care plan for Activities of Daily Living (ADL's), with goal date of 3/27/20, included the following interventions both dated 6/20/17: -One person assist for walking -One person assist for transfers Review of the Annual Minimum Data Set (MDS) Assessment, dated 7/16/19, indicated Resident #70 had impaired long and short term memory and severely impaired decision making ability, required extensive assist of two for transfers and ambulation in room and corridor. Review of the facility incident report, dated 8/16/19 at 12:30 P.M., indicated Resident #70 was witnessed to be ambulating unassisted with a wheeled walker in the hallway when he/she fell and landed on his/her left side, striking the left side of his/her head, arm and hip against the floor. Resident #70 sustained a laceration to the left side forehead, was sent to the emergency room (ER) and required three staples to close the wound. Review of the Significant Change MDS Assessment, dated 10/8/19, indicated Resident #70 had impaired long and short term memory and severely impaired decision making ability, required extensive assist of two for transfers and ambulation in room and corridor. Review of the facility incident report, dated 10/10/19 at 4:09 A.M., indicated Resident #70 sustained an unwitnessed fall in his/her room which resulted in a right shoulder dislocation. Resident #70 was sent to the ER for realignment. Review of the facility incident report, dated 11/1/19 at 2:15 P.M., indicated Resident #70 sustained an unwitnessed fall in his/her room and sustained a [MEDICAL CONDITION] thumb, and a laceration to the forehead and left elbow. Review of the facility incident report, dated 12/13/19 at 12:30 P.M., indicated Resident #70 sustained an unwitnessed fall in his/her room and sustained a head injury. Resident #70 was sent to the ER for evaluation and required sutures to close the [MEDICAL CONDITION] and was diagnosed with [REDACTED]. During review of Resident #70's care plan, no new interventions had been identified. On 1/14/20 at 11:55 A.M., Resident #70 was observed seated in a wheelchair in his/her room with the bedside table in front of him/her, non-skid socks were twisted upwards with the grips on the top, call light within reach, feet out of his/her shoes. On 1/14/20 at 3:48 P.M., Resident #70 was observed to be seated in a recliner in his/her room with the bedside table in front of him/her, facing the door to the hall. On 1/15/20 at 12:15 P.M., Resident #70 was observed to be seated in a recliner in his/her room, with the bedside table in front of him/her, looking out to the hallway. On 1/16/20 at 10:14 A.M., Resident #70 was observed to be seated in a recliner in his/her room, with the bedside table in front of him/her, looking out to the hallway. During an interview on 1/15/20 at 3:14 P.M., the Director of Nurses (DON) said that they have tried everything, but she can't prevent these falls from happening. She said they have made medication changes and involved rehab, but Resident #70 liked his/her independence. She said that the resident does need assistance for transfers and ambulation per the care plan, but it wasn't always provided. The DON said the staff checks in on the resident frequently. The DON said there was no specified time frame to check in on Resident #70 and that check-ins were not documented.

Based on interview and record review the facility staff failed to ensure adequate assistance was provided to prevent a fall with major injury for one Resident (#11) out of 18 sampled residents. Findings include: Resident #11 was admitted to the facility in 6/2014 with [DIAGNOSES REDACTED]. Review of the fall risk assessment, dated 7/19/18, indicated the resident was at moderate risk as evidenced by a score of 13. Review of the Significant Change of Status Minimum Data Set assessment (MDS), dated [DATE], indicated the resident had severely impaired cognition as evidenced by a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS), was dependent on two for transfers, non-ambulatory, and required extensive assist of two for bed mobility. Review of a progress note, dated 8/16/18, indicated the resident sustained [REDACTED]. Review of the incident report, dated 8/16/18, indicated the resident sustained [REDACTED]. The corrective measure was to revise the plan of care to require two staff for personal care to ensure the resident didn't have a risk for falls when being turned for incontinence care when in bed. Review of the care plan for Activities of Daily Living (ADL), initiated 6/7/15 with goal date of 4/5/19, indicated the following intervention, initiated 4/16/16; I am totally dependent on two staff for repositioning, turning in bed, bathing, dressing, and grooming . During an interview on 1/16/19 at 11:38 A.M., with the Director of Nurses (DON) and the Administrator, the DON reviewed the care plan and incident report and said the intervention put in place after the fall was to use two people for bed mobility. We continued to review the entire care plan and the intervention to use two people for bed mobility was on the ADL care plan. The DON said that she had not seen that when she reviewed the care plan after the fall. She said she must have missed it and the staff should have used two assist for bed mobility and didn't.

Based on records reviewed and interviews, for 1 out of 5 sampled Residents (Resident #1), who was assessed as being at increased risk for falls, the Facility failed to ensure they developed, reviewed and implemented an individualized plan of care for falls with appropriate interventions, to maintain Resident #1's safety. Resident #1's plan of care was updated on [DATE] to include the use of personal alarms at all times. Although Resident #1 was known to remove his/her alarms and ambulate without assistance from staff, he/she experienced two falls from [DATE] to [DATE], and no alternative interventions were attempted. On [DATE], Resident #1, who required bed and chair pads alarms at all times for safety, experienced an unwitnessed fall, was found face down on the floor, unresponsive, with bleeding from his/her head and it was determined Resident #1's chair pad alarm was not in place or functioning at the time of the fall. -On [DATE] at approximately 4:00 P.M., Resident #1 was found on the floor, unresponsive by Family Member. -On [DATE] Resident #1 was transferred to the hospital where he/she was diagnosed [MEDICATION NAME] fracture on sternal body, T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Resident #1 transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M. Findings include: The Policy titled Comprehensive Care Plans, dated [DATE], indicated the following; comprehensive care plan is based on a through assessment, each Resident's comprehensive care plan is designed to incorporate identified problem areas and risk factors associated with identified problems, reflect treatment goals and measurable outcomes, aid in preventing or reducing declines in functional status/or functional levels, enhance the optimal functioning of rehabilitative programs and areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan, assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Policy titled, Assessing Falls and Their Cause, dated [DATE], indicated identifying causes of a fall or fall risk includes the following; for each individual staff will distinguish the root cause of the fall, the Unit Manger or DON should consult with the attending Physician or Medical Director to confirm specific causes from multiple possibilities, the Physician will examine the resident or initiate testing to try to identify causes, if the cause is unknown but no additional evaluation is done, the Physician or nursing should note why, if the resident continues to fall despite attempted interventions the nursing staff will discuss the situation with the Physician or Medical Director. The Policy titled, Fall Risk Assessment, dated [DATE], indicated the Nursing staff and the Physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The staff will look for evidence of a possible link between the onset of falling or an increase in falling episodes. The staff with the support of the attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The staff and attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1's medical history included the following; Diabetes Mellitus ([MEDICATION NAME] unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Ataxia (abnormalities of gait and mobility), muscle weakness, repeated falls, long term use of Anticoagulants (blood thinners). The MDS indicated Resident #1 Brief Interview for Mental Status (BIMS) Score was 12 out of 15 ( a score of ,[DATE] indicates cognitively intact and a score of 9 to 12 indicates moderate cognitive impairment). The MDS indicated Resident #1 was unsteady during transfers and walking and was only able to stabilize his/her balance with staff assistance. A Fall Risk Assessment, dated [DATE], indicated Resident #1's was scored as a moderate risk for falls. A Fall Risk Assessment, dated [DATE], indicated Resident #1's was scored as a high risk of falls. A Fall Risk Plan of Care, updated [DATE], indicated Resident #1 required bed and chair pad alarms at all times and Resident #1 to wear non skid socks at night. A Fall Risk Plan of Care, updated [DATE], indicated additional safety interventions included Resident #1 required hands on assistance to move from place to place, he/she was confused and attempts to get up on his/her own, keep Resident #1 in activities as much as possible to provide a diversion to reduce risk of getting up unassisted and educate Resident #1 to always request assistance. Although Resident #1 was known to remove his/her alarms and ambulate without assistance from staff, he/she experienced two falls from [DATE] to [DATE], and no alternative interventions were attempted. A Physician Order, dated [DATE], indicated Nursing to check placement and function of Resident #1's bed and chair pad alarm every shift. A Facility's Occurrence Report, dated [DATE], indicated Resident #1's call light was not sounding, call light was off and Resident #1 was last seen on [DATE] at 1:00 P.M. A Nurse Progress Note, dated [DATE], indicated Resident #1's alarm was not sounding because he/she shuts it off and ambulates about room unassisted, even though he/she has been reminded not to turn off the alarm because, it is for his/her safety and to ask for help when ambulating even with the walker. Review of Resident #1's Treatment Administration Record (TAR), dated [DATE] for the 3:00 P.M. to 11:00 P.M. shift, indicated (at the time of Resident #1 unwitnessed fall in his/her room) that there was no documentation to support Resident #1's bed and or chair pad alarm was checked for placement and functioning. Surveyor #1 interviewed Nurse #1 at 2:52 P.M. on [DATE]. Nurse #1 said Resident #1 required alarms at all times when in bed or in the chair. Nurse #1 said Resident #1 was forgetful, liked to keep his/her door closed, would take his/her alarm off and hide the alarm in his/her room. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 2:03 P.M. on [DATE]. Nurse #2 said CNA's check for placement and functioning of personal alarms for all Resident's at the start of each shift. Nurse #2 said it is the Nurses responsibility to check placement of bed and chairs alarms and functioning at the start of each shift. Surveyor #1 interviewed Unit Manger #2 at 1:50 P.M. on [DATE]. Unit Manger #2 said Resident #1 had a chair pad alarm and she witnessed him/her disconnecting the alarm and placing the alarm in the draw. Unit Manger #2 said a resident would be able to reset the alarm themselves by pressing the alarm button 3 times and the alarm would automatically turn off. Unit Manger #2 said Resident #1 was able to figure out how to turn off his/her alarm and was able to reach it easily on his/her chair. Unit Manger #2 said Resident #1 liked his/her door closed for privacy and said it is hard to hear the alarm when the door was closed. Unit Manger #2 said she was unable to explain why Resident #1's Plan of Care of personal alarms were not reevaluated. Surveyor #2 interviewed the Former Medical Director at 6:00 P.M. on [DATE]. The Former Medical Director said he/she did not review the quality of care issues related to Resident #1 on [DATE] nor his/her past falls. The Former Medical Director said there was inadequate communication and inadequate staffing at the facility for the delivery of patient care.

Based on records reviewed and interviews for 1 of 5 sampled Residents (Resident #1), who was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing), the Facility failed to meet the following; -Failed to ensure a thorough Clinical assessment was performed when Resident #1 (Full Code) was found unresponsive in a prone position (face down) in a pool of blood for unknown length of time at approximately at 4:00 P.M. on [DATE]. -Failed to ensure a first responder certified in Cardiopulmonary Resuscitation (CPR, lifesaving technique to restore [MEDICATION NAME] blood flow to body organs when person stops breathing or heart stops breathing) stayed with Resident #1 and instructed another staff member to announce Code Blue (emergency response) over intercom system, gather emergency equipment and call 911 in accordance with Facility's Emergency Procedure-Cardiopulmonary Resuscitation. -Failed to assess Resident #1's breathing pattern, heart rate, oxygen level, blood glucose level and blood pressure after Resident #1 was found unresponsive at approximately 4:00 P.M., and or prior to Emergency Medical Services (EMS) arrival to the Facility at 4:12 P.M. When EMS arrived Resident #1 was unresponsive with agonal respirations (abnormal breathing characterized by gasping labored breathing) and had a pulse. EMS applied a non-rebreather mask and oxygen to Resident #1 to assist with breathing. Resident #1's blood glucose level was 20 mg/dl (normal adult range ,[DATE] mg/dl). During transport to the Hospital Resident #1 sustained a [MEDICAL CONDITION], CPR was initiated, Resident #1's breathing and pulse were recovered on transport. -Resident #1 sustained, [MEDICATION NAME] fracture on sternal body, T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). -Resident #1 was transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. The Massachusetts Board of Registration in Nursing (BORN) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws (M.G.L.), chapter 30A, section 8, and chapter 112, section 80B, dated [DATE], the nurse licensed by the Massachusetts Board of Registration in Nursing (BORN) is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's current position that these standards, in the context of practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, require the initiation of CPR when a patient or resident has experienced a [MEDICAL CONDITION] except when the patient or resident has a current, valid Do Not Resuscitate (DNR) order OR Signs of irreversible death. In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a [MEDICAL CONDITION]. According to the American Heart Association Chain of Survival, dated 2015, survival chances decline with every minute that passes by ,[DATE]%, within ,[DATE] minutes brain damage and permanent death start to occur, and after 10 minutes few attempts at resuscitation succeed. The Policy titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated revised [DATE], indicated if a resident is found unresponsive and not breathing normally, (briefly assess for abnormal or absence of breathing) a licensed staff member who is certified in CPR/BLS shall initiate CPR, (if sudden [MEDICAL CONDITION] is likely) and the following: Instruct a staff member to activate the emergency response system (Code) and call 911; Instruct a staff member to retrieve the Automated External Defibrillators (AED); Verify or instruct a staff member to verify the code status of the individual and initiate the basic life support (BLS) (level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at the hospital) sequence of events. The Policy indicated personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of sudden [MEDICAL CONDITION]. The Policy indicated training in BLS includes recognizing presentations of sudden [MEDICAL CONDITION] such as victims may initially have gasping respirations. The Policy indicated the Facility shall staff at least one licensed nurse with current CPR/BLS certification on each shift. The Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], indicated Resident #1 was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing). The MOLST indicated to attempt resuscitation, intubate and ventilate, use non-invasive ventilation (breathing mask to support breathing) and transfer to the hospital. The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1's medical history included the following; Diabetes Mellitus ([MEDICATION NAME] unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Hypertension, repeated falls, and long term use of anticoagulants (blood thinners). A Nurse Progress Note, dated [DATE], indicated Resident #1's Family Member reported to Nurse #1 that Resident #1 was on the floor. The Note indicated, Nurse #1 entered Resident #1's room and Resident #1 was lying face down on the floor with his/her head towards the bed, feet pointing to the door and he/she was bleeding from the head. The Note indicated Resident #1's chair pad alarm was not sounding. The Note indicated Resident #1 was unresponsive, 911 was called and Resident #1 was not assessed until EMS arrived. The Note indicated Resident #1 was transferred to hospital and covering Physician was notified. Surveyor #1 interviewed Family Member #1 at 11:55 A.M. on [DATE]. Family Member #1 said she went to visit Resident #1 on [DATE] around 4:00 P.M., when she arrived to his/her room the door was closed and Resident #1 did not respond when she knocked on the door. Family Member #1 said she went into Resident's #1 room, saw Resident #1 on the floor, face down with blood on his/her face, blood around his/her head on the floor, and sent another family member to get the nurse. The Fire Department Report, dated [DATE] indicated, the Fire Department arrived at the Facility prior to EMS, found Resident #1 lying face down next to his/her bed, with a pool of dried blood around his/her head, and he/she was unresponsive with snoring respirations (sound due to an obstructed air movement during breathing). The Report indicated the Fire Department stabilized Resident #1's cervical spine (held head) and rolled him/her onto his back and EMS arrived to assist. The American Medical Response (AMR) Patient Care Report, dated [DATE], indicated the following: -At 3:59 P.M. a call was received from the Facility indicating Resident #1 fell and was not alert. -At 4:02 P.M. EMS was dispatched, arrived at the Facility at 4:09 P.M. -At 4:12 P.M. EMS were with Resident #1, he/she was unresponsive with agonal respirations and had a pulse. EMS applied a non-rebreather mask and oxygen to Resident #1 to assist with breathing. Resident #1's skin was cyanotic (bluish or purplish color) and clammy (cold, damp moisture) to the touch. -At 4:14 P.M. EMS assessed Resident #1's blood glucose level, reading indicated low at 20 mg/dl, and at this time arrival Advanced Life Support (ALS) arrived at bedside to assist with Resident #1's care. -At 4:15 P.M. EMS assessed Resident #1's radial pulse at 80 (normal adult pulse range ,[DATE] beats per minute) and respiratory rate level of 6 (normal adult respiratory rate level of ,[DATE] breaths per minute) with agonal breathing continued. The EMS assessed Resident #1 who continued to be unresponsive to tactile and verbal stimuli. -The EMS Report indicated, after ten minutes of chest compressions and treatments Resident #1 regained strong radial and carotid pulses, prior to arrival to the hospital emergency room . Family Member #1 said Resident #1 was making snoring noises like he/she was sleeping. Family Member #1 said she stayed in Resident #1's room until EMS arrived, and said facility nursing staff did not do any type of assessments on Resident #1 including; checking his/her blood pressure or blood glucose level, and did not apply oxygen. Family Member #1 said EMS assessed Resident #1 after they arrived at the facility. Surveyor #1 interviewed Nurse #1 at 2:52 P.M., on [DATE], and re-interviewed Nurse #1 at 3:05 P.M. on [DATE], with Surveyor #2. Nurse #1 said she went to check on Resident #1, found him/her face down on the floor, unresponsive, bleeding from his/her head, instructed CNA #1 to stay with Resident #1, and left the room to call 911. Nurse #1 said she called Nurse #2 to inform him that Resident #1 was on the floor and said she called the Physician. Nurse #1 said she only did a visual assessment of Resident #1 because she did not want to move him/her and said she knew Resident #1 was breathing because she watched Resident #1's back rise and fall. Nurse #1 said she did not obtain Resident #1's vital signs (heart rate, respirations, blood pressure, oxygen level or blood glucose level) because of the position Resident #1 was lying in, and said she did not want to move Resident #1 because she did not want to cause him/her any further injuries. Nurse #1 said because Resident #1 was bleeding from the head she was unable to give him/her breaths. Nurse #1 said she did not call a Code Blue since Resident #1 was already down and she did not need to know his/her code status since Resident #1 was not safe to turn over. Nurse #1 said she did not obtain Resident #1's blood glucose level and said she did not apply oxygen. Surveyor #1 interviewed Certified Nursing Assistant (CNA) #1 at 4:05 P.M. on [DATE]. CNA #1 said on [DATE] she was instructed to stay in the room with Resident #1 after a fall while Nurse #1 left the room to call 911. CNA #1 said she heard Resident #1 make gurgling noises and said Resident #1 started making snoring type noises prior to the EMS arrival. Surveyor #1 interviewed Nurse #2 at 5:40 P.M. on [DATE], and re-interviewed Nurse #2 at 2:03 P.M. on [DATE], with Surveyor #2. Nurse #2 said on [DATE] he went to assist Nurse #1 after she informed him Resident #1 was on the floor. Nurse #2 said he asked Nurse #1 about Resident #1's vital signs and said Nurse #1 told him she did not do vital signs. Nurse #2 said he did not take Resident #1's vital signs. Nurse #2 said he did not do an assessment or move Resident #1 because he felt it was not safe to move him/her and his job was to stay with Resident #1 to make sure Resident #1 stayed awake. Nurse #2 said Resident #1 was making a mumbling sound and said when he asked Resident #1 if he/she was okay, Resident #1 did not answer. Nurse #2 said he left CNA #1 with Resident #1 to let the EMS into the Facility. Surveyor #1 interviewed Director of Nursing #1 (DON) at 12:53 A.M. on [DATE]. DON #1 said on [DATE] Nurse #2 informed her Resident #1 was found face down on the floor, unresponsive and was sent to the hospital. DON #1 said she does not know what type of assessments were done by nursing staff on Resident #1 after he/she was found on the floor. Surveyor #1 interviewed EMS Crew Member #1 at 10:20 A.M. on [DATE]. Crew Member #1 said upon arrival Resident #1 was unresponsive with agonal breathing and Resident #1 was turned from a prone position to recovery position (side) to open Resident #1's airway. Crew Member #1 said Resident #1 had blood in his mouth, needed assistance with recovery position (maintaining spine precautions), suctioning to prevent Resident #1 from aspiration (liquid going into airway or lungs) was needed and blood was visibly seen on Resident #1 and on the floor. Crew Member #1 said Resident #1 had bruising on his/her forehead, face and skin tears. Crew Member #1 said he did not receive report from Nursing Staff. Crew Member #1 said the Facility did not obtain vital signs including oxygen level or a blood glucose level prior to arrival. Crew Member #1 said Resident #1's Blood Glucose Level was 20 mg/dl, color of skin was pale/bluish, and Resident #1's body skin was clammy to the touch.

Based on records reviewed and interviews, for 1 out of 5 sampled Residents (Resident #1), who was assessed at high risk for falls, the Facility failed to ensure that safety interventions in his/her plan of care were implemented by direct care staff. Resident #1's plan of care was updated on [DATE] to include the use of personal alarms at all times. Although Resident #1 was known to remove his/her alarms and ambulate without assistance from staff, he/she experienced two falls from [DATE] to [DATE], and no alternative interventions were attempted. On [DATE], Resident #1 sustained an unwitnessed fall and was found face down, unresponsive on the floor with bleeding and it was determined Resident #1's chair pad alarm was not in place or functioning at the time of the fall. -On [DATE] at approximately 4:00 P.M., Resident #1 was found on the floor, unresponsive by a family member, Resident #1 was transferred to the hospital where he/she was diagnosed [MEDICATION NAME] fracture on sternal body, T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Resident #1 transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M. Findings include: The Policy titled, Assessing Falls and Their Cause, dated [DATE], indicated identifying causes of a fall or fall risk includes the following; for each individual staff will distinguish the root cause of the fall, the Unit Manger or DON should consult with the attending Physician or Medical Director to confirm specific causes from multiple possibilities, the Physician will examine the resident or initiate testing to try to identify causes, if the cause is unknown but no additional evaluation is done, the Physician or nursing should note why, if the resident continues to fall despite attempted interventions the nursing staff will discuss the situation with the Physician or Medical Director. The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1's medical history included the following; Diabetes Mellitus ([MEDICATION NAME] unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Ataxia (abnormalities of gait and mobility), muscle weakness, repeated falls, long term use of Anticoagulants (blood thinners). The MDS indicated Resident #1 Brief Interview for Mental Status (BIMS) Score was 12 out of 15 ( a score of ,[DATE] indicates cognitively intact and a score of 9 to 12 indicates moderate cognitive impairment). The MDS indicated Resident #1 was unsteady during transfers and walking and was only able to stabilize his/her balance with staff assistance. A Fall Risk Assessment, dated [DATE], indicated Resident #1's was scored as a moderate risk for falls. A Fall Risk Assessment, dated [DATE], indicated Resident #1's was scored as a high risk of falls. A Fall Risk Plan of Care, updated [DATE], indicated Resident #1's required bed and chair pad alarm at all times and Resident #1 to wear non skid socks at night. A Fall Risk Plan of Care, updated [DATE], indicated additional safety interventions included Resident #1 required hands on assistance to move from place to place, he/she was confused and attempts to get up on his/her own, keep Resident #1 in activities as much as possible to provide a diversion to reduce risk of getting up unassisted and educate Resident #1 to always request assistance. A Physician Order, dated [DATE], indicated Nursing to check placement and function of Resident #1's bed and chair pad alarm every shift. A Nurse Progress Note, dated [DATE], indicated Resident #1's alarm was not sounding because he/she shuts it off and ambulates about room unassisted, even though he/she has been reminded not to turn off the alarm because, it is for his/her safety and to ask for help when ambulating even with the walker. An Occurrence Report, dated [DATE], indicated Resident #1's call light was not sounding, call light was off and Resident #1 was last seen on [DATE] at 1:00 P.M. Review of Resident #1's Treatment Administration Record (TAR), dated [DATE] for the 3:00 P.M. to 11:00 P.M. shift, indicated (at the time of Resident #1 unwitnessed fall in his/her room) there was no documentation to support Resident #1's bed and or chair pad alarms was checked for placement and functioning. The Hospital Discharge Summary, dated [DATE], indicated Resident #1's readmission to Facility revealed rib fractures (bones in the rib cage cracks), [MEDICATION NAME] fracture on sternal body ([MEDICATION NAME] chest trauma), T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back) with widening concerning for hyperextension (extending of a limb or part beyond the normal limit) injury and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Surveyor #1 interviewed Nurse #1 at 2:52 P.M. on [DATE]. Nurse #1 said Resident #1 required alarms at all times when in bed or in the chair. Nurse #1 said was forgetful, liked to keep his/her door closed, would take his/her alarm off and hide the alarm in his/her room. Nurse #1 said if Resident #1's alarm was found unattached, Nursing would replace the alarm. Nurse #1 said after staff left Resident #1 room he/she would take it off. Nurse #1 said because we knew Resident #1 could remove his/her alarms we would check on him/her more often. Nurse #1 said upon entering Resident #1's room on [DATE] the alarm on the chair pad was not sounding and the alarm box was disconnected in the draw. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 2:03 P.M. on [DATE]. Nurse #2 said CNA's check for placement and functioning of personal alarms for all Resident's at the start of each shift. Nurse #2 said it is the Nurses responsibility to check placement of bed and chairs alarms and functioning at the start of each shift. Surveyor #1 interviewed Unit Manger #2 at 1:50 P.M. on [DATE]. Unit Manger #2 said Resident #1 had a chair pad alarm and she witnessed him/her disconnecting the alarm and placing the alarm in the draw. Unit Manger #2 said a resident would be able to reset the alarm themselves by pressing the alarm button 3 times and the alarm would automatically turn off. Unit Manger #2 said Resident #1 was able to figure out how to turn off his/her alarm and was able to reach it easily on his/her chair. Unit Manger #2 said Resident #1 liked his/her door closed for privacy and said it is hard to hear the alarm when the door was closed. Unit Manger #2 said she was unable to explain why Resident #1's Plan of Care of personal alarms were not re-evaluated.

Based on records reviewed and interviews for 1 of 5 sampled residents (Resident #1) identified as a Full Code (in the event of cardiac or [MEDICAL CONDITION]) and an insulin dependent diabetic, the Facility failed to accurately assess, failed to obtain a blood glucose level, failed to implement their Emergency Procedure-Cardiopulmonary Resuscitation (Code Blue) policy, failed to deliver oxygen via an appropriate delivery source, when on [DATE] Resident #1 was found down face first on the floor, bleeding from the head and was unresponsive to verbal and tactile stimuli. When the Fire Department arrived crew members found Resident #1 lying prone (face down) next to his/her bed, with a pool of dried blood around his/her head, and he/she was unresponsive with snoring respirations. The Fire Department stabilized Resident #1's cervical spine, rolled Resident #1 onto his/her back, applied a cervical collar, and applied oxygen via a non-rebreather mask, at which point EMS arrived and assumed care. When Emergency Medical Services (EMS) Responders arrived crew members assessed Resident #1 as unresponsive with agonal respirations (abnormal breathing characterized by gasping labored breathing) and he/she had a pulse. EMS assisted Resident #1 with breathing via a bi-valve mask with 15 liters (LPM) per minute of oxygen. Nursing staff stated Resident #1 was a diabetic, blood glucose level indicated Resident #1 was hypoglycemic (low blood glucose) with a blood glucose level of 20 mg/dl (normal adult range ,[DATE] mg/dl). EMS noted Resident #1 had multiple lacerations, swelling and deformity to his/her face and left eye resulting from the fall. Advanced Life Support (ALS) crew arrived and took over care with EMS. When ALS Responders arrived crew members assessed Resident #1, [DIAGNOSES REDACTED] was confirmed, intravenous started with 12.5 milligrams (mg) of D50 ([MEDICATION NAME] 50%, used in emergency care to treat [DIAGNOSES REDACTED]), breathing pattern more sporadic, SPO2 (blood oxygen saturation level, normal range 94% to 99%) level in the low 90's, Resident #1 went apneic (suspension of breathing), went into [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) initiated, Resident #1 was intubated (insertion of tube into the trachea (windpipe) for ventilation), after approximately 10 minutes of CPR Resident #1 was noted to have strong carotid and radial pulses and was transported to the Hospital Emergency Department. The Hospital Discharge Summary indicated Resident #1 sustained, [MEDICATION NAME] fracture on sternal body, T11-T12 acute fracture (bottom part of the [MEDICATION NAME] spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Resident #1 was transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. The Massachusetts Board of Registration in Nursing (BORN) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws (M.G.L.), chapter 30A, section 8, and chapter 112, section 80B, dated [DATE], the nurse licensed by the Massachusetts Board of Registration in Nursing (BORN) is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's current position that these standards, in the context of practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, require the initiation of CPR when a patient or resident has experienced a [MEDICAL CONDITION] except when the patient or resident has a current, valid Do Not Resuscitate (DNR) order OR Signs of irreversible death. In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a [MEDICAL CONDITION]. According to the American Heart Association Chain of Survival, dated 2015, survival chances decline with every minute that passes by ,[DATE]%, within ,[DATE] minutes brain damage and permanent death start to occur, and after 10 minutes few attempts at resuscitation succeed. The Policy titled Emergency Procedure-Cardiopulmonary Resuscitation, dated revised [DATE], indicated if a resident is found unresponsive and not breathing normally, (briefly assess for abnormal or absence of breathing) a licensed staff member who is certified in CPR/BLS shall initiate CPR, (if sudden [MEDICAL CONDITION] is likely) and the following: Instruct a staff member to activate the emergency response system (Code) and call 911; Instruct a staff member to retrieve the Automated External Defibrillators (AED); Verify or instruct a staff member to verify the code status of the individual and initiate the basic life support (BLS) (level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at the hospital) sequence of events. The Policy indicated personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of sudden [MEDICAL CONDITION]. The Policy indicates training in BLS includes recognizing presentations of sudden [MEDICAL CONDITION] such as victims may initially have gasping respirations. The Policy indicates the Facility shall staff at least one licensed nurse with current CPR/BLS certification on each shift. The Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], indicated Resident #1 was a Full Code (Facility to interceded if a patient's heart stops beating or if the patient stops breathing). The MOLST indicated to attempt resuscitation, intubate and ventilate, use non-invasive ventilation (breathing mask to support breathing) and transfer to the hospital. The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1's medical history included the following; Diabetes Mellitus ([MEDICATION NAME] unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Ataxia (abnormalities of gait and mobility), muscle weakness, repeated falls, long term use of Anticoagulants (blood thinners). The MDS indicated Resident #1 Brief Interview for Mental Status (BIMS) Score was 12 out of 15 ( a score of ,[DATE] indicates cognitively intact and a score of 9 to 12 indicates moderate cognitive impairment). The Fire Department Report, dated [DATE] indicated, the Fire Department arrived at the Facility prior to EMS, found Resident #1 lying face down next to his/her bed, with a pool of dried blood around his/her head, and he/she unresponsive with snoring respirations (sound due to an obstructed air movement during breathing). The Report indicated the Fire Department stabilized Resident #1's cervical spine (held head) and rolled him/her onto his back and EMS arrived to assist. The American Medical Response (AMR) Patient Care Report, dated [DATE], indicated the following: -At 3:59 P.M. a call was received from the Facility indicating Resident #1 fell and was not alert. -At 4:02 P.M. EMS was dispatched, arrived at the Facility at 4:09 P.M. -At 4:12 P.M. EMS were with Resident #1, he/she was unresponsive with agonal respirations and had a pulse. EMS applied a non-rebreather mask and oxygen to Resident #1 to assist with breathing. Resident #1's skin was cyanotic (bluish or purplish color) and clammy (cold, damp moisture) to the touch. -At 4:14 P.M. EMS assessed Resident #1's blood glucose level, reading indicated low at 20 mg/dl , and at this time arrival Advanced Life Support (ALS) arrived at bedside to assist with Resident #1's care. -At 4:15 P.M. EMS assessed Resident #1's radial (feeling/hearing artery) pulse at 80 (normal adult pulse range ,[DATE] beats per minute) and respiratory rate level of 6 (normal adult respiratory rate level of ,[DATE] breaths per minute) with agonal breathing continued. The EMS assessed Resident #1 who continued to be unresponsive to tactile and verbal stimuli. -The EMS Report indicated, after ten minutes of chest compressions and treatments Resident #1 regained strong radial and carotid pulses (heartbeat), prior to arrival to the hospital emergency room . A Nurse Progress Note, dated [DATE], indicated Resident #1's Family Member reported to Nurse #1 that Resident #1 was on the floor. The Note indicated, Nurse #1 entered Resident #1's room and Resident #1 was lying face down on the floor with his/her head towards the bed, feet pointing to the door and he/she was bleeding from the head. The Note indicated Resident #1's chair pad alarm was not sounding. The Note indicated Resident #1 was unresponsive, 911 was called and Resident #1 was not assessed until EMS's arrived due to possible potential head trauma to prevent further injuries. The Note indicated Resident #1 was transferred to hospital and covering Physician was notified. Surveyor #1 interviewed Family Member #1 at 11:55 A.M. on [DATE]. Family Member #1 said she went to visit Resident #1 on [DATE] around 4:00 P.M., when she arrived to his/her room the door was closed and Resident #1 did not respond when she knocked on the door. Family Member #1 said she went into Resident's #1 room, saw Resident #1 on the floor, face down with blood on his/her face, blood around his/her head on the floor, and sent another family member to get the nurse. Family Member #1 said Resident #1 was making snoring noises like he/she was sleeping. Family Member #1 said she stayed in Resident #1's room until EMS arrived, and said facility nursing staff did not do any type of assessments on Resident #1 including; checking his/her blood pressure or blood glucose level, and did not apply oxygen. Family Member #1 said EMS assessed Resident #1 after they arrived at the facility. Surveyor #1 interviewed Nurse #1 at 2:52 P.M., on [DATE], and re-interviewed Nurse #1 at 3:05 P.M. on [DATE], with Surveyor #2. Nurse #1 said she went to check on Resident #1, found him/her face down on the floor, unresponsive, bleeding from his/her head, instructed CNA #1 to stay with Resident #1, and left the room to call 911. Nurse #1 said she called Nurse #2 to inform him that Resident #1 was on the floor and said she called the Physician. Nurse #1 said she only did a visual assessment of Resident #1 because she did not want to move and said she knew Resident #1 was breathing because she watched Resident #1's back rise and fall. Nurse #1 said she did not obtain Resident #1's vital signs (heart rate, respirations, blood pressure, oxygen level or blood glucose level) because of the position Resident #1 was lying in, and said she did not want to move Resident #1 because she did not want to cause him her any further injuries. Nurse #1 said because Resident #1 was bleeding from the head she was unable to give him/her breaths. Nurse #1 said she did not call a Code Blue since Resident #1 was already down and she did not need to know his/her code status since Resident #1 was not safe to turn over. Surveyor #1 interviewed Certified Nursing Assistant (CNA) #1 at 4:05 P.M. on [DATE]. CNA #1 said on [DATE] she was instructed to stay in the room with Resident #1 after a fall while Nurse #1 left the room to call 911. CNA #1 said she heard Resident #1 make a gurgling noises and said Resident #1 started making snoring type noises prior to the EMS's arrival. Surveyor #1 interviewed Nurse #2 at 5:40 P.M. on [DATE], and re-interviewed Nurse #2 at 2:03 P.M. on [DATE], with Surveyor #2. Nurse #2 said that on [DATE] he went to assist Nurse #1 after she informed him Resident #1 was on the floor. Nurse #2 said he asked Nurse #1 about Resident #1's vital signs and said Nurse #1 told him she did not do vital signs. Nurse #2 said he did not take Resident #1's vital signs. Nurse #2 said he did not do an assessment or move Resident #1 because he felt it was not safe to move him/her and his job was to stay with Resident #1 to make sure Resident #1 stayed awake. Nurse #2 said Resident #1 was making a mumbling sound and said when he asked Resident #1 if he/she was okay, Resident #1 did not answer. Nurse #2 said he left CNA #1 with Resident #1 to let the EMS into the Facility. Surveyor #1 interviewed Director of Nursing #1 (DON) at 12:53 A.M. on [DATE]. DON #1 said on [DATE] Nurse #2 informed her Resident #1 was found face down on the floor, unresponsive and was sent to the hospital. DON #1 said she does not know what type of assessments were done by nursing staff on Resident #1 after he/she was found on the floor. Surveyor #1 interviewed EMS Crew Member #1 at 10:20 A.M. on [DATE]. Crew Member #1 said upon arrival Resident #1 was unresponsive with agonal breathing and Resident #1 was turned from a prone position to recovery position (side) to open Resident #1's airway by Fire Crew Member. Crew Member #1 said Resident #1 had blood in his mouth, needed assistance with recovery position (maintaining spine precautions), suctioning to prevent Resident #1 from aspiration (liquid going into airway or lungs) was needed and blood was visibly seen on Resident #1 and on the floor. Crew Member #1 said Resident #1's Blood Glucose Level was 20 mg/dl, color of skin was pale/bluish, and Resident #1's body skin was clammy to the touch. Crew Member #1 said Resident #1 had bruising on his/her forehead, face and skin tears. Crew Member #1 said he did not receive report from Facility nursing staff and said the Facility did not obtain vital signs including oxygen level or a blood glucose level prior to their arrival.

Based on records reviewed and interviews, for 1 out of 5 sampled Residents (Resident #1), who received anticoagulation medication daily and was at increase risk for bleeding, the Facility failed to maintain his/her Resident safety, failed to ensure bed or chair alarms where in place and functioning correctly and as a result Resident #1 experience an unwitnessed fall, and was found unresponsive on the floor by a family member. Although Resident #1 was known to remove his/her alarms and ambulate without assistance from staff, he/she experienced two falls from [DATE] to [DATE], and no alternative interventions were attempted. -On [DATE] at approximately 4:00 P.M., Resident #1 was found face down on the floor of his/her room, bleeding from his/her head and unresponsive by a family member. Resident #1 was transferred to a hospital where he/she was diagnosed transverse fracture on sternal body, T11-T12 acute fracture (bottom part of the thoracic spine-back), bilateral first rib fractures, right third and forth rib fractures, left second through fifth fractures and aspiration pneumonitis (lung disease develops after you inhale food, liquid or vomit into your lungs). Resident #1 transferred back to the facility on [DATE] on hospice care. Resident #1 died on [DATE] at 1:20 A.M. Findings include: The Policy titled, Safety and Supervision of Resident's, dated [DATE], indicated Facility-oriented approach to safety addresses safety and accident hazards for individual Residents. The Policy indicated the care team shall target interventions to reduce the potential for accidents as well as monitoring the effectiveness of interventions. The Policy indicated monitoring shall include ensuring interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions. The Policy titled, Assessing Falls and Their Cause, dated [DATE], indicated the following; if a resident has fallen nursing staff will record vitals and evaluate for possible injury and provide appropriate first aid, an incident report must be completed for resident falls and should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing (DON) no later than 24 hours after the fall occurs. The Policy indicated identifying causes of a fall or fall risk includes the following; for each individual staff will distinguish the root cause of the fall, the Unit Manger or DON should consult with the attending Physician or Medical Director to confirm specific causes from multiple possibilities, the Physician will examine the resident or initiate testing to try to identify causes, if the cause is unknown but no additional evaluation is done, the Physician or nursing should note why, if the resident continues to fall despite attempted interventions the nursing staff will discuss the situation with the Physician or Medical Director. The Policy titled Fall Risk Assessment, dated [DATE], indicated nursing staff and the Physician will review the resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The policy indicated the staff will look for evidence of a possible link between the onset of falling or increasing in falling episodes. The Policy indicated the staff will seek to identify environmental factors that may contribute to falls. The Policy indicated for resident's with reoccurring falls staff will implement additional or different interventions or indicate why the current approach remains relevant. The Policy indicated that staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. The Policy titled, Falls and Fall Risk Managing, dated [DATE], indicated if falls recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant and if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The Policy indicated, as needed the attending Physician will help staff reconsider possible causes that may not previously have been identified. The Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1's medical history included the following; Diabetes Mellitus (pancreases unable to produce enough insulin), Arthritis (joint swelling), Dementia (memory disorder), Ataxia (abnormalities of gait and mobility), muscle weakness, repeated falls, long term use of Anticoagulants (blood thinners). The MDS indicated Resident #1 Brief Interview for Mental Status (BIMS) Score was 12 out of 15 ( a score of ,[DATE] indicates cognitively intact and a score of 9 to 12 indicates moderate cognitive impairment). The MDS indicated Resident #1 was unsteady during transfers and walking and was only able to stabilize his/her balance with staff assistance. Review of Resident #1's medical record indicated he/she experienced several falls in the Facility since his/her admission on [DATE]. Documentation indicated Resident #1 experienced a witnessed fall on [DATE]; and unwitnessed falls on [DATE]; [DATE]; [DATE] and [DATE]. The Occurrence Report, dated [DATE], indicated Resident #1 experienced a witness fall in the dining room, was found lying on his/her left side, Resident #1 sustained a skin tear below his/her left elbow, complained of a small amount of discomfort to the left elbow, and no other injuries were noted. A Nurse's Note at 4:35 P.M. on [DATE], indicated Resident #1 fell after eating breakfast, stood up and lost his/her balance and it was a witnessed fall. The Fall Risk Assessment, dated [DATE], indicated Resident #1 was at moderate risk for falls due to history of falls. An Occurrence Report, dated [DATE], indicated Resident #1 experienced an unwitnessed fall in his/her room, was found by a certified nursing assistant, sitting on the floor with his/her back near the chair and Resident #1 denied pain. Review of Resident #1's medical record after the fall on [DATE], indicated Licensed Nursing staff did not complete all the documentation required per the Facility's Fall Documentation Packet protocol and the Facility was unable to provide the Fall Documentation Packet and documentation to support Resident #1's plan of care was reviewed for fall interventions. A Nurse Note, dated [DATE], indicated contributing factor to Resident #1's fall included the soles of his/her slippers were noted to be worn, Resident #1 required assistance for ambulation and transfer and required reminders to use the call light for assistance. The Note indicated Resident #1 agreed to the use of Chair and bed pad alarms for safety A Falls At Risk Plan of Care, updated [DATE], indicated Resident #1's required bed and chair pad alarms at all times. A Fall Risk Assessment, dated on [DATE], indicated Resident #1's was at high risk of falls and additional triggers included uses short discontinuous steps and/or shuffling steps and decrease muscle coordination. A Physical Therapy (PT) Screen/Referral Form, dated on [DATE], indicated factors that contributed to Resident #1's fall on [DATE] included, poor safety awareness, decline in ambulation and mobility status and cognitive decline. Review of Resident #1's medical record indicated he/she experienced an unwitnessed fall on [DATE], he/she was found on the floor in his/her room lying on his/her back, and Resident #1 stated he/she lost his/her balance. Review of Resident #1's medical record after the fall on [DATE], indicated licensed nursing staff did not complete all the documentation required per the Facility's Fall Documentation Packet protocol. The Facility was unable to provide the Fall Documentation Packet to support Resident #1's plan of care was reviewed for fall interventions. A Nurse's Note at 7:00 A.M. on [DATE], indicated Resident #1 was found sitting on the floor with his/her back against the bed at 12:30 A.M. and stated he/she was trying to go to the bathroom. The Nurse Note indicated Resident #1 did not have a bed alarm and the Nurse attached the bed alarm to Resident #1's bed. A physician's orders [REDACTED].#1's bed and chair pad alarm where to be checked for placement and functioning every shift. A Nurse's Note, dated [DATE], indicated Resident #1 alarm was sounding , upon entering his/her room Resident #1 chair alarm was not sounding and it was determined that Resident #1 had disconnected the chair alarm. A Care Plan Meeting held in the Facility on [DATE], indicated Resident #1 and his/her family member where in attendance. The Care Plan meeting worksheet indicated family members expressed concerns Resident #1 was confused, but there was no indication that family members were informed Resident #1 was removing his/her bed or chair pad alarms. An Occurrence Report, dated [DATE], indicated Resident #1 experienced an unwitnessed fall in his/her room, was found on the floor in a face down bleeding from the head, and his/her chair pad alarm was not sounding. The Fire Department report, dated [DATE], indicated crew members arrived found Resident #1 lying prone (face down) next to his/her bed, with a pool of dried blood around his/her head, and he/she was unresponsive with snoring respirations. The Fire Department stabilized Resident #1's cervical spine, rolled Resident #1 onto his/her back, applied a cervical collar, and applied oxygen via a non-rebreather mask, at which point EMS arrived and assumed care. The Fall Review Assessment, dated [DATE], indicated Resident #1 remained at high risk for falls and additional triggers included he/she is confined to a chair and disoriented and exhibits loss of balance when standing. Review of Resident #1's Treatment Administration Record (TAR), dated [DATE] for the 3:00 P.M. to 11:00 P.M. shift, indicated (at the time of Resident #1 unwitnessed fall in his/her room) that there was no documentation to support Resident #1's bed and/or chair pad alarm was checked for placement and functioning. Review of Resident #1 medical record after the fall on [DATE], indicated Licensed Nursing staff did not complete all the documentation required per the Facility's Fall Documentation Packet protocol and the Facility was unable to provide the Fall Documentation Packet. Surveyor #1 interviewed CNA #4 at 12:14 P.M. on [DATE]. CNA #4 said Resident #1 did not like his/her alarm and staff would find him/her removing the alarm. CNA #4 said she would check on him/her more often. CNA #4 said the last time she saw Resident #1 on [DATE] was around 2:30 P.M. or 2:45 P.M. and Resident #1 was in his/her room sitting on the chair. Surveyor #1 interviewed CNA #5 at 1:10 P.M. on [DATE]. CNA #5 said the last time she saw Resident #1 on [DATE] was around 2:50 P.M. -3:00 P.M. or 3:15 P.M. and Resident #1 sitting on a chair in his/her room. Surveyor #1 interviewed Unit Manger #2 at 1:50 P.M. on [DATE]. Unit Manger #2 said Resident #1 had a chair pad alarm and she witnessed him/her disconnecting the alarm and placing the alarm in the draw. Unit Manger #2 said a resident would be able to reset the alarm themselves by pressing the alarm button 3 times and the alarm would automatically turn off. Unit Manger #2 said Resident #1 was able to figure out how to turn off his/her alarm and was able to reach it easily on his/her chair. Unit Manger #2 said Resident #1 liked his/her door closed for privacy and said it is hard to hear the alarm when the door was closed. Surveyor #1 interviewed Nurse #1 at 2:52 P.M. on [DATE]. Nurse #1 said Resident #1 was forgetful, would keep his/her door to their room closed, would take off his/her alarm off and hide the alarm in his/her room. Nurse #1 said on [DATE] at approximately 4:00 P.M., Family Member #1 informed her that Resident #1 was on the floor in his/her room, upon entering Resident #1's room the alarm was not sounding, the pad was on the chair and the alarm was in the draw. Surveyor #1 interviewed DON #1 at 12:53 P.M. on [DATE]. DON #1 said Resident #1 would walk without assistance from staff and wanted his/her door closed at all times. DON #1 said when interviewing staff about Resident #1's incident on [DATE] a common theme was Resident #1 would unattached his/her bed alarm a lot. DON #1 said she was unaware if Resident #1 turning off his/her alarm and multiple falls were discussed during the daily A.M. meetings. DON #1 said she was unaware if any interventions were in place to ensure Resident #1's safety. Surveyor #1 interviewed Family Member #1 at 9:42 A.M., on [DATE]. Family Member #1 said she had a meeting at the Facility a few days prior to the fall on [DATE]. Family Member #1 said Resident #1 was not steady on his feet and she expressed her concerns for Resident #1's safety in the care plan meeting. Family Member #1 said she was unaware Resident #1 was able to disconnect his/her bed and chair alarms. Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 2:03 P.M. on [DATE]. Nurse #2 said the nurses are responsible for completion of treatment orders for each resident, Resident #1's alarms were checked off each shift by nursing on the TAR for placement, and if the nurse does not initial the TAR it indicates the Nurse did not acknowledge the Physician order [REDACTED].

Based on record review and interview, for one of seven Sampled Residents (Resident #1), who was at high risk for falls and care planned to have a bed alarm and a floor mat in place, the Facility failed to ensure that the bed alarm and floor mat were in place when on 5/2/14, during the 11:00 P.M. to 7:00 A.M. shift, Resident #1 attempted to get out of bed unassisted, fell and was found lying on the floor and sustained a left hip fracture. Findings include: The Facility admitted Resident #1 in May, 2011 with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 2/14/14, indicated that Resident #1 had severely impaired cognition, but had clear speech, understood others and was understood by others. The MDS indicated Resident #1 required limited staff assistance with bed mobility, transfers, ambulation and toilet use. The MDS indicated Resident #1 used a walker or wheelchair for locomotion. The MDS indicated Resident #1 was continent of bowel and bladder function. The MDS indicated Resident #1 experienced one fall without injury since the last assessment. A fall risk assessment, dated 2/14/14, indicated that Resident #1 scored 13 points and according to the assessment tool used by the Facility, a score of 10 or over represented a high fall risk. A fall risk care plan, dated 2/14/14, indicated that Resident #1 was at risk for falls related to cognitive loss, immobility and the daily use of narcotic pain medication. Care plan interventions included: ensuring the call light was within reach at all times when Resident #1 was in his/her room, keeping personal and frequently used items within Resident #1's reach, ensuring that Resident #1 had proper footwear, providing a bathroom door alarm at all times, providing a bed pad alarm at night and checking the bed pad alarm for placement and function every shift. Safety Meeting Minutes, dated 3/27/14, indicated that Resident #1 experienced a fall on 3/21/14 and sustained several skin tears. The Safety Meeting Minutes indicated a chair pad alarm was added to Resident #1's plan of care. The Safety Meeting Minutes indicated that Resident #1 also experienced a fall on 3/23/14, when Resident #1 was discovered on the bathroom floor sitting next to the toilet. The Safety Meeting Minutes indicated the chair pad alarm was discontinued, Resident #1 was provided with a trial of a scoot chair and Resident #1 was moved to a room closer to the nurses' station. The Safety Meeting Minutes indicated that Resident #1 was impulsive and required supervision. The Facility's Fall Risk Identification and Alarm Management Policy indicated rounds would be completed by incoming and outgoing charge nurses on each shift to ensure all alarms were in place and functioning. The Unit Alarm List, indicated that Resident #1 required a bed alarm, a low bed, a fall mat (beside the bed) and a bathroom door alarm. The staffing schedule for Resident #1's unit indicated that Nurse #1 was on duty during the 3:00 P.M. to 11:00 P.M. shift and Nurse #2 was on duty during the 11:00 P.M. to 7:00 A.M. shift on 5/1/14 into 5/2/14. The staffing schedule also indicated that Certified Nurse Aide (CNA) #1 and CNA #2 were on duty on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift. The Alarm Census Check indicated that at 11:00 P.M. on 5/1/14 into 5/2/14, Nurse #1 signed as the offgoing nurse and Nurse #2 signed as the oncoming nurse (that alarms were in place and functioning). The Surveyor interviewed Nurse #1 at 3:50 P.M. on 6/6/14. Nurse #1 said Resident #1 was a high fall risk and was also very fast when he/she got up. Nurse #1 said Resident #1 had been trying to get up from the scoot chair all shift on 3:00 P.M. to 11:00 P.M., so she kept an eye on Resident #1. Nurse #1 said she and Nurse #2 (an Agency Nurse) physically went around and checked all alarms and Resident #1's bed alarm was in place, but was not turned on because Resident #1 was up in the scoot chair. Nurse #1 said she told Nurse #2 that Resident #1 had a bed alarm that needed to be turned on when Resident #1 was placed into bed. Nurse #1 said the CNAs were present when she told Nurse #2 about Resident #1's bed alarm. Nurse #1 said Resident #1 also had an alarm on the bathroom door and the fall mat was in the room, but not in place because Resident #1 was up in the scoot chair. Nurse #1 said she left at about 11:30 P.M. and waved bye to Resident #1, who was still in the scoot chair at that time. A nurse's note, dated 5/2/14, indicated tat at 4:15 A.M. a CNA found Resident #1 on the floor in Resident #1's bedroom. The nurse's note indicated Resident #1 moved his/her arms and legs with no issues and attempted to get up off the floor despite being told that he/she needed to be checked for injuries. The nurse's note indicated that Resident #1 had a skin tear to the left elbow and a skin tear to the pinky finger. The nurse's note indicated Resident #1 denied any pain and was assisted back into bed; however, Resident #1 then reported pain with a rating of 4 (on a scale of 1 to 10, with 10 being the worst pain) when Resident #1 walked to bed. The nurse's note indicated two calls were placed to the on-call physician to inquire about an x-ray of Resident #1's hand and left hip, but there was no call back at the time this note was completed (7:30 A.M.). There was no documentation that the Facility received a return call from the physician. The Facility's Fall Incident Report, dated 5/2/14, indicated the only alarm in use at the time of Resident #1's fall was the bathroom door alarm. The Surveyor interviewed Nurse #2 at 10:12 A.M. on 6/19/14. Nurse #2 said she worked for an Agency and this was the first time she worked at this Facility. Nurse #2 said when she did rounds with Nurse #1, they did not have a list of alarms with them and she was unaware that there was a list of alarms. Nurse #2 said she could not be sure, but she believed Resident #1 may have been in bed when they completed the rounds. Nurse #2 said she was made aware of the fall by another staff member and when she entered the room, Resident #1 was lying on the floor on his/her side, but she could not recall which side. Nurse #2 said no bed alarm was in use at the time of the fall. Nurse #2 said initially Resident #1 had no complaint of pain, but later when she and another nurse re-assessed Resident #1, he/she complained of hip pain. Nurse #2 said she called the on-call physician twice, but there was no call back before she left. Nurse #2 said after the fall, someone produced a list of alarms and she then was aware that Resident #1 should have had a bed alarm. Nurse #2 said she also discovered that Resident #1 had a history of [REDACTED]. Nurse #2 said she was never made aware that Resident #1 required a bed alarm until after the fall. The Surveyor interviewed CNA #1 at 5:20 P.M. on 6/17/14. CNA #1 said Resident #1 was up in a recliner chair on the 3:00 P.M. to 11:00 P.M. shift and she and CNA #2 were asked to assist Resident #1 into bed. CNA #1 said she started to help CNA #2, but then had to go answer a call light, so CNA #2 put Resident #1 into bed alone. CNA #1 said she knew that Resident #1 usually had a bed alarm, but Nurse #2 told them that Nurse #1 told her Resident #1 only had a bathroom door alarm. CNA #1 said she then believed that the bed alarm must have been discontinued. CNA #1 said sometime between 4:00 A.M. and 5:00 A.M. she was walking down the hallway and heard Resident #1 yelling for help. CNA #1 said she responded to the room and observed Resident #1 on the floor on his/her left side with a blanket wrapped around his/her legs. CNA #1 said there was no alarm sounding and there was no mat on the floor. CNA #1 said after the fall, she looked at the safety book and discovered that Resident #1 was supposed to have a bed alarm and a floor mat, neither of which were in place at the time of the fall. CNA #1 said she observed the bed alarm on a chair in Resident #1's room. Attempts to contact and interview CNA #2 were unsuccessful; however, a written statement completed by CNA #2 indicated Nurse #1 told them (CNAs) and Nurse #2 that the only alarm Resident #1 required was an alarm on the bathroom door. CNA #2's statement indicated that she assisted Resident #1 into bed and the bed alarm was not visible. CNA #2's statement indicated that after Resident #1's fall, she checked the green book (alarm list) and discovered that Resident #1 was supposed to have a bed alarm and floor mat, but nothing was on at the time of the fall. The Surveyor interviewed Nurse #3 at 11:00 A.M. on 6/6/14. Nurse #3 worked during the 7:00 A.M. to 3:00 P.M. shift on 5/3/14, 5/4/14 and 5/5/14. Nurse #3 said she did not observe anything out of the ordinary that would have alerted her to the fact that Resident #1 had a fractured hip; however, the following nurses' notes were in Resident #1's medical record. A nurse's note, dated 5/2/14 at 10:45 P.M., indicated that Resident #1 had increased agitation this shift, constantly yelled out and Resident #1 received scheduled Tylenol #3 and Trazodone with no effect, so prn (as needed) Tylenol #3 and Trazodone was administered to Resident #1. A nurse's note, dated 5/3/14, indicated Resident #1 was in the unit sitting room, crying my legs, my feet, pains and Resident #1 was medicated with Tylenol #3. A nurse's note, dated 5/4/14, indicated Resident #1 yelled feet, legs, pain all over and Resident #1 was medicated with Tylenol #3. A nurse's note, dated 5/5/14, indicated that when staff attempted to toilet Resident #1, he/she complained of left leg pain and was unable to weight bear on the left leg. The nurse's note indicated there was an approximately 6 centimeter x 8 centimeter purple bruise on Resident #1's left hip, shortening of the left leg and pain with palpation. The nurse's note indicated a call was placed to a covering physician and an order was obtained for a left hip x-ray and if positive, send to the emergency department. A Radiology Report, dated 5/5/14, indicated that a left hip x-ray showed Resident #1 had a left subcapital fracture with mild lateral displacement (left hip fracture). A Hospital Transfer Summary, dated 5/10/14, indicated Resident #1 was admitted to the hospital on [DATE] with a left hip fracture sustained in a mechanical fall at the Facility. The Hospital Transfer Summary indicated Resident #1 underwent a left hip hemiarthroplasty and was returned to the facility on [DATE]. Resident #1 was pronounced dead at 2:20 P.M. on 6/1/14, so was unable to be interviewed or observed.

Based on record review and interview, for one out of five sampled Residents (Resident #1), assessed to be at risk for falls, the Facility failed to ensure that a bed alarm and personal alarm functioned properly. On 1/25/14 Resident #1 got out of bed unassisted and the bed alarm failed to sound and the personal alarm had been removed (which staff said Resident #1 was able to do) and Resident #1 sustained a non-displaced oblique tuft fracture of the 2nd distal phalanx (finger). Findings include: The Facility admitted Resident #1 in January, 2013 with [DIAGNOSES REDACTED]. A fall risk predictive factors assessment, dated 12/30/13, indicated Resident #1 scored 10 points and according to the assessment tool used by the facility, a score of 10 or above was representative of a high risk for falls. A fall risk care plan, dated 12/31/13, indicated Resident #1 had a history of [REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 1/3/14, indicated Resident #1 scored 6 out of 15 possible points on a Brief Interview for Mental Status, which represented severely impaired cognition. The MDS indicated Resident #1 required limited staff assistance with transfers and ambulation, but required extensive staff assistance with toileting. The MDS indicated Resident #1 was not steady moving from a seated to a standing position or walking and was able to stabilize only with staff assistance. A nurse's note, dated 1/25/14 at 4:45 A.M., indicated staff heard Resident #1 yelling and Resident #1 was at the bathroom door with the left index finger bleeding. The nurse's note indicated Resident #1 had removed the personal alarm and the bed alarm did not sound. The nurse's note indicated Resident #1 was unable to recall what happened, but complained of pain in The Surveyor interviewed CNA #2 at 3:50 P.M. on 3/7/14. CNA #2 said she did not hear any alarm sound when Resident #1 got out of bed. CNA #2 said the bed alarms sometimes did not sound even when the alarm was turned on. CNA #1 and CNA #2 said they checked the alarms at the beginning of the shift; however, there was no documentation that the alarms were checked at the beginning of the shift or any other time. The Surveyor interviewed Resident #1 at 10:40 A.M. on 3/7/14. Resident #1 was unable to recall the incident and did not recall injuring his/her finger. A Radiology Report, dated 1/25/14, indicated a left hand x-ray showed Resident #1 had a non-displaced oblique tuft fracture of the 2nd distal phalanx (finger). the right elbow and left index finger. The nurse's note indicated the physician was notified and ordered ice to the left hand and right elbow, an x-ray of the left hand and Resident #1's condition be monitored. The Facility's staffing for 1/25/14 indicated that Nurse #1, CNA #1 and CNA #2 were on duty on Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift. The Surveyor interviewed Nurse #1 at 3:00 P.M. on 3/7/14. Nurse #1 said Resident #1 had a history of [REDACTED]. Nurse #1 said Resident #1 could unplug or turn off the personal alarm. Nurse #1 said the alarms were checked at the beginning of the shift and Resident #1's bed alarm had sounded earlier in the shift when Resident #1 changed position in bed. Nurse #1 said Resident #1 yelled and she went to the room and found Resident #1 standing by the bathroom door and Resident #1's finger was bleeding under the fingernail. Nurse #1 said the bed alarm was turned on, but did not sound when Resident #1 exited the bed. Nurse #1 said Resident #1 was not able to tell her what happened and she questioned if Resident #1 had either hit the finger on something or caught the finger in the door. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:15 P.M. on 3/7/14. CNA #1 said they heard Resident #1 call out, but she did not hear any alarms sound. CNA #1 said the bed alarm was turned on, but did not sound and Resident #1 was able to turn off the personal alarm. CNA #1 said the bed alarms did not always work properly and Resident #1 frequently got up unassisted and was very quick.

Based on observation, record review and interview, the facility failed to provide the necessary care and services for pain control for 1 resident (#1) in a total sample of 17. Findings included: Resident #1 was admitted to the facility in 10/10 with a [DIAGNOSES REDACTED]. The Initial Pain Assessment Tool of 10/21/10 was incomplete and only included: Worst pain gets: when changing dressing. The initial Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/1/10 indicated that the resident had short and long term memory loss, was bed bound, was dependent with bed mobility, eating, bathing and dressing, had a [MEDICAL CONDITION], an indwelling catheter and a stage 4 pressure ulcer, and had vocal complaints of pain and facial expressions of pain on a daily basis. The Care Area Assessment (CAA) of 11/2/10 indicated that the resident had pain with the following complicating factors: a stage 4 pressure ulcer, immobility, [MEDICAL CONDITIONS] with metastatic process, and impaired communication. The risk was for unmanaged pain issues. The Plan of Care for at risk for painful complications from medical conditions of 11/1/10 included: [MEDICAL CONDITION] with liver metastasis and no plans for further treatment, hypertension, diabetes and [MEDICAL CONDITION]. The Approach included: assess for signs/symptoms of progression [MEDICAL CONDITION] and metastasis, ascites, jaundice, change in bowel status and abdominal pain. The Plan of Care for Pain of 11/1/10 included: Resident exhibits some discomfort with pressure ulcer dressing changes and at times will moan and verbalize pain. The goal included: Will have pain management needs anticipated and met daily. Approaches included: Monitor and record complaints of pain. Monitor for and record any non verbal signs of pain, moaning, crying, restlessness, withdrawal and guarding. Administer physician ordered pain management of Tylenol 650 milligrams (mg) by mouth 4 times per day. On 12/5/10, [MEDICATION NAME] (pain medication) 15 mg was added three times per day. Tylenol was changed to as needed. On 1/21/11, [MEDICATION NAME] 15 mg was added at 8:30 A.M., before the pressure ulcer dressing change. The MDS assessment with an ARD of 1/23/11 indicated that the resident continued to have vocal complaints of pain and facial expressions of pain on a daily basis. Nurse's Notes of 2/7/11 indicated that during a care plan meeting, the family requested that the resident's pain management be reviewed. The family indicated that the resident had pained expressions and moaning. Nurse's Notes of 2/8/11 indicated that the physician was notified of the resident's pain issues. The physician gave new orders to add [MEDICATION NAME] (pain medication) 20 mg/ml (milliliter): administer 5 mg/0.25 ml sublingually every 4 hours as needed for pain. Nurse's Notes of 2/13/11 indicated that the physician was in and was made aware of the resident's difficulty with oral medications. The physician gave new orders to discontinue all [MEDICATION NAME] (ordered 4 times per day), and administer [MEDICATION NAME] 0.25 ml sublingually every 4 hours as necessary for pain. There was no regularly scheduled pain medication ordered, even though the resident had been identified as having increased pain. Review of the 2/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurse's Notes of 2/15/11, 3/1/11, 3/11/11, and 3/23/11 indicated that the resident was grimacing and moaning after the dressing change, and [MEDICATION NAME] was administered. Even though the resident had been identified as having pain during the stage 4 pressure ulcer dressing change, the resident was not premedicated. Review of Nurse's Notes, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. to 3:00 P.M. shift; 3:00 P.M. to 11:00 P.M. shift; 11:00 P.M. to 7:00 A.M. shift). Review of the 3/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Nurse's Notes, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s pain on any shift. Review of the 4/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. On 4/11/11 at 7:30 A.M., during a dressing change to the resident's stage 4 pressure ulcer on the coccyx, the following was observed by the surveyor: Treatment Nurse #1, with gloved hands, removed and discarded the old dressing and wound packing. Treatment Nurse #1 changed gloves and washed hands. Treatment Nurse #1 irrigated the wound with normal saline using a 30 ml syringe and cleansed the surrounding skin with normal saline. Treatment Nurse #1 applied Santyl to the wound bed and packed the wound with Calcium Alginate using a sterile Q-tip. Treatment Nurse #1 applied a Border Dressing. During the entire procedure, the resident grimaced, moaned, was restless, and nodded "yes" when asked if the dressing change was painful. Treatment Nurse #1 acknowledged that Resident #1 had pain during the dressing change and should have been premedicated. On 4/11/11 at 11:30 A.M., the Director of Nurses acknowledged that for Resident #1, with [MEDICAL CONDITION] and a stage 4 pressure ulcer, the facility failed to adequately assess and treat the resident's pain.

2. For Resident #11, the facility failed to provide effective interventions to prevent 10 falls and one tripping incident. Resident #11 was admitted to the facility in 12/07 and readmitted in 11/08 with a [DIAGNOSES REDACTED]. Review of nurses' notes and facility's investigation reports revealed that the resident sustained [REDACTED]. #1. On 7/23/10 at 1:40 A.M., the resident was found on the floor in the bedroom. Prior to the fall, the resident was trying to close the bedroom door. The light was dim, and the resident was not wearing appropriate footwear. On 7/29/11, during a Falls Committee Meeting, no new interventions were implemented. #2. On 8/9/10 at 9:15 A.M., the resident was found lying on the floor in the Third Floor Lounge. The resident was eating breakfast prior to the fall. On 8/12/11, during a Falls Committee Meeting, there was a question whether new shoes were needed. #3. On 9/27/10 at 1:20 P.M., the resident was found lying on back in the sitting room at the end of the corridor. A small raised area was observed on the forehead. The resident was ambulating on the unit prior to the fall. #4. On 9/28/10, the resident tripped over a walker. #5. A review of the nurses' notes of 10/4/11 revealed that the resident had eye surgery in the morning. The resident returned to the facility with an eye patch in place. At 4:45 P.M., the resident was seated in the sitting room. The resident got up, lost balance and fell . The facility's investigation report indicated that the resident was "more confused than usual, "gait unsteady," and "cluttered area." A chair alarm was put in place. The resident's Annual Minimum Data Set (MDS) Assessment of 10/8/10 identified the resident as being moderately impaired for decision-making; independent with transfer and ambulation in room and corridor; continent of bowel and bladder; having fallen (4 falls with no major injury), and receiving antianxiety and antidepressant medications. The plan of care of 10/8/10 for falls included the following: fall assessment completed on admission, reviewed quarterly to update risk factors; physical and occupational therapy screens quarterly to review function, equipment and positioning needs; keep call light in reach at all times resident is in room; keep light on in room; keep bed in lowest position and brakes locked; provide environment free of clutter; assure floor is free of glare, liquids, foreign objects; keep personal and frequently used items within reach; assure resident is wearing glasses and kept clean and in good repair, and follow-up eye appointment. A review of the nurses' notes and investigations revealed that the resident had 3 more falls: #6. On 11/5/10 at 2:00 A.M., the resident was found bending over to shut off the bed alarm, lost balance and fell . Slight bruising was noted on left knee. The facility's investigation report indicated "reinforced (resident) to call for help." #7. On 11/10/10 at 3:50 A.M., the resident was sitting on the floor near chair and bedside table. A bruise was observed on left knee. The facility's investigation report indicated that the resident fell while trying to shut off alarm. The Falls Committee Meeting minutes of 11/11/10 indicated that alarms had been removed because the resident was trying to shut them off; non-skid strips to be placed on the floor by the bed, and non-skid socks to be purchased and worn at night. The plan of care was revised on 11/11/10 to include non-skid strips on the floor, and non-skid socks at night. The plan of care indicated that all alarms were discontinued. #8. On 12/13/10 at 1:45 A.M., the resident was found lying on the floor. The resident was attempting to go to the bathroom. The facility's investigation report indicated that the resident's roommate notified staff that the resident had fallen. The plan of care was revised again on 12/15/10 to include bathroom door alarm at night to alert staff. The resident's Quarterly MDS Assessment of 1/4/11 identified the resident as requiring supervision with ambulation in room, and having fallen. The plan of care was reviewed and continued. A review of the nurses' notes and investigations revealed that the resident had 3 additional falls: #9. On 2/12/11 at 2:40 P.M., a visitor reported that the resident lost balance and fell , hitting back of head on the wall. The visitor stated, "I helped (resident) up." No new interventions were implemented. #10. On 2/19/11 at 10:00 A.M., a staff member observed the resident ambulating in the hallway, loosing balance and falling to the floor. No new interventions were implemented. #11. On 3/11/11 at 3:52 P.M., the resident was found on the floor in bedroom between beds A and B. The facility's investigation report indicated to "remind resident to ask for help." No new interventions were implemented. The resident's Quarterly MDS Assessment of 3/31/11 identified the resident as being independent with transfer and ambulation in room and corridor, and having fallen. The plan of care was reviewed and continued. On 4/11/11 at 1:45 P.M., the surveyor met with the Administrator to discuss above findings. The Administrator told the surveyor that the resident's dementia has worsened. Planned interventions were not effective in preventing falls. In eight (8) of the 11 falls/incidents, the resident was found on the floor in bedroom and/or common areas. Interventions involving reminders, reinforcement and asking for help were not effective, because the resident was unable to carry them out on a consistent basis secondary to worsening of dementia. On 4/11/11 at 10:00 A.M., the surveyor observed the resident in the bedroom sitting in a chair near the doorway. The resident was looking through a book. At 11:25 A.M., the surveyor observed the resident seated in the Day Room with other residents. At 1:18 P.M., the resident was observed wandering throughout the unit. Based on record and document reviews, observation and interviews, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 2 of 7 sampled resident (#6 and 11) with falls, accidents, and/or fractures, out of a total sample of 17 residents. Findings included: 1. For Resident #6, the facility staff failed to provide adequate supervision and effective interventions to prevent 6 falls and one accident. The last fall resulted in a fractured left hip. Resident #6 was admitted to the facility in 7/10 from another long term care facility with [DIAGNOSES REDACTED]. Review of the discharge referral form from the former facility, dated 7/1/10, indicated the resident required a Wanderguard, alarms for safety due to poor safety awareness. The resident also required assistance with ambulation due to an unsteady gait. Review of the admission nurse's note of 7/1/10 indicated the resident required assistance with ambulation and that a Wanderguard and alarms were in place. Review of the nurse's note of 7/2/10 indicated that at 6:00 P.M., the resident stood up independently and fell in the doorway of the resident's room. Review of the circumstances surrounding the fall indicated the resident was found on the floor at 6:00 P.M. This investigation indicated the resident stood up from the wheelchair and fell . This investigation indicated the resident had a personal alarm on at the time of the fall. The investigation did not indicate whether or not the alarm sounded. The nurse's note indicated the resident stood up from the wheelchair, the wheelchair rolled back, and the resident fell . (There was no indication whether the brakes were locked or not). The nurse's note of 7/2/10 indicated the resident had an abrasion to the back. A chair alarm was added. The resident was also to be assisted with ambulation in the morning and afternoon. The resident was moved to a room closer to the nurses' station. Review of the Rehabilitation Consult of 7/2/10 indicated the resident was to ambulate to all destinations with a gait belt and staff assistance. Review of the care plan dated 7/3/10 to prevent falls indicated the resident had a need for alarms (with a fall on 7/2/10). The interventions included: -Admission review at Safety/Rehabilitation meeting and after a fall, near fall, or change in status has occurred. -Bed pad alarm and personal alarm. -Ensure call light is within reach when in room. -Seating in unit day room for close observation if needed. Review of the nurse's note of 7/4/10 indicated the resident attempted to ambulate alone, had no safety awareness and had an unsteady gait. The nurse's note of 7/7/10 indicated the resident continued to attempt to ambulate alone and resisted staff assistance. The nurses' notes of 7/8/10 and 7/9/10 indicated the resident was uncooperative with staff assistance with ambulation. The physician was notified and an order was obtained for Haldol (an antipsychotic medication). Review of the resident's initial Minimum Data Set (MDS) assessment of 7/14/10 revealed that the resident had short term memory impairment with moderately impaired decision making ability. The MDS further revealed that the resident required assistance of one staff member for transfers and ambulation, had an unsteady gait, and of had experienced falls in the past 30 days. Review of the Resident Assessment Protocol (RAP) for falls dated 7/14/10 indicated the resident was at risk of falls and injury related to confusion, unsteady gait and poor safety awareness. Review of the care plan in place 7/15/10 indicated the following interventions were in place: -Admission review at Safety/Rehabilitation meeting and after a fall, near fall or change in status has occurred. -Bed pad alarm . -Ensure call light is within reach when in room. -Seating in unit day room for close observation if needed. -Rehabilitation screens at admission and quarterly. -Keep items close to resident. Nurse's note of 7/23/10 indicated the resident had become more cooperative with the addition of Haldol. This note also indicated the resident preferred to be in the resident's room. Review of the nurse's note of 7/28/10 indicated that the resident attempted independent ambulation from the bed. The alarm sounded and staff responded. Review of the nurses' notes of 8/25/10 indicated the resident was non-verbal and lethargic. The physician made a visit and indicated that the resident may have had a Transient Ischemic Attack ( TIA). The resident's unsteady gait was noted to be worse. Review of the nurse's note of 8/28/10 indicated the resident was found on the floor next to the bed. No injury was noted. Review of the circumstances surrounding the fall indicated the resident was found on the floor at 4:15 A.M. The resident did not use the call bell. The investigation indicated that a bed pad sensor alarm was in place and sounded. The resident was confused and a personal alarm was added for safety. The resident had experienced a decline in mental status, ambulation status, and had a urinary tract infection. Review of the nurses' notes of 9/2/10 to 9/5/10 indicated the resident remained confused demonstrating poor safety awareness such as attempts to exit the unit. Review of the nurse's note of 9/13/10 at 6:20 A.M. indicated the resident's alarm was sounding. Staff responding as the resident was falling out of bed. Review of the circumstances surrounding the fall indicated the resident did not use the call bell and attempted to transfer alone. No injury occurred. Review of the nurse's note of 9/27/10 indicated the resident was found on the floor. Review of the circumstances surrounding the fall indicated the resident was found on the floor at 5:50 A.M. No injuries were noted. This investigation indicated that a chair alarm, wall sensor alarm and bed sensor alarm were in place. The investigation did not indicate if the alarms sounded at the time of the fall. Review of the nurse's note of 10/13/10 indicated the resident was found alone in the resident's room at 7:30 P.M., sitting in a chair with the television, cable box, and night stand on top of the resident. Review of the investigation surrounding the accident indicated the resident had pulled the night stand, television, and cable box over on top of the resident. The night stand was described as toppling on the resident. The right forearm and inner arm was red, and ice packs were applied. The new interventions included placing the cable box under the television and providing a larger table for the television. No interventions were put in place to supervise the resident while in the resident's room. Review of the nurse's note of 10/14/10 indicated the right arm contained a small bruise post accident. Review of the nurse's note of 11/4/10 indicated the resident fell out of a chair to the floor while attempting independent ambulation. The resident sustained [REDACTED]. Review of the investigation indicated the resident fell at 3:05 P.M., alone in the resident's room. The call light was not used. Staff observed the resident stand, throw an item in the waste basket and fall. This investigation indicated the resident's chair alarm was in place. The investigation did not indicate whether or not the alarm sounded. The new interventions to prevent falls was to keep things near the resident. The investigation did not indicate if the resident was in a stationary chair or wheelchair. Review of the nurse's note of 11/25/10 indicated the resident had another episode of unresponsiveness that lasted from 7:00 A.M. to 9:30 A.M. The resident's gait was unsteady. The nurse's note of 11/26/10 indicated the resident was unsteady and needed to use a wheelchair. Further review of the nurses' notes from 12/1/10 to 12/7/10 indicated the resident had periods of lethargy and was discovered to have a urinary tract infection. Review of the nurse's note of 12/27/10 indicated the resident was found on the floor at 1:30 P.M. The staff responded to an alarm sounding, heard the wheelchair slam against the door, and found the resident on the floor. This note indicates that the wheelchair was not locked when the resident was found on the floor. The resident sustained [REDACTED]. Review of the investigation indicated the resident fell while alone in the resident's room from a wheelchair that was not locked. The intervention to prevent further falls included placing the resident in a stationary chair after lunch. Review of the nurse's note of 2/10/11 indicated the resident was found on the floor at 6:15 P.M., with the alarm on. The left leg was under the right leg and the resident was complaining of pain. Review of the circumstances surrounding the fall indicated the resident was found alone in the resident's room on the floor next to the bed. The resident was last seen sitting in a chair in the bedroom watching television. This report did not state if the resident was in a stationary chair or a wheelchair. The resident did not call for help. The resident was transferred to the hospital and admitted with a fracture of the left hip. The resident returned to the facility 2/23/11 after surgical repair of a left hip fracture. The resident's left hip contained 12 sutures and a dressing. There was a large ecchymotic area around the dressing. Review of the nurse's note of 2/26/11 indicated the resident now required a Hoyer transfer to a recliner. Review of the resident's significant change MDS of 3/1/11 indicated the resident had short and long term memory problems with impaired decision making ability. The resident was now totally dependant on staff for transfers, ambulation, dressing and eating. The resident had experienced falls with a major injury and had frequent pain. Review of the Care Area Assessment for falls indicated the resident was at risk of falls because of poor safety awareness and impaired mobility. The care plan in place for falls included the following interventions: -Falls assessment on admission, quarterly to update risk factors. -Bed pad alarm, chair alarm, wander guard, and personal alarm. -Ensure call light is within reach when in room. -Transfer with Hoyer and 2 assists. -Rehabilitation screens at admission and quarterly. -Keep items close to resident. -Ambulate with 1 assist and gait belt. Review of the nurses notes of 3/1/11 to 3/15/11 indicated the resident's sutures were out and steri strips were in place. The resident was now getting up to the wheelchair. The resident continued to have periods of confusion. Review of the nurse's note of 3/18/11 indicated the resident was now a two person transfer with a gait belt and the Hoyer was discontinued. Review of the nurse's note of 3/24/11 indicated the alarms in bed were discontinued. A personal alarm was continued only when the resident was up in a wheelchair. Observations of the resident on 4/8/11 at 3:00 P.M., was of the resident in a regular height bed. On 4/8/11 at 3:30 P.M., the Director of Nurses, Assistant Director of Nurses, and the Administrator acknowledged that the resident had experienced 6 falls and 1 incident, with the last fall resulting in a fractured hip. Observations of the resident on 4/8/11 at 4:15 P.M., was of the resident sitting up in a wheelchair in the dining room. The resident's wheelchair brakes were observed to be unlocked.