Every finding on record at Mt Greylock Extended Care Facility

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards relative to a urinary catheter for one Resident (#74), of two applicable residents, out of a total sample of 20 residents. Specifically for Resident #74, the facility failed to provide care and services consistent with professional standards of practice for a suprapubic catheter (SPC: thin, flexible tube inserted through a small incision made in the lower abdomen directly into the bladder, allowing for urine drainage) when the facility staff failed to obtain Physician orders for irrigation of the SPC, and completed irrigation of the SPC, putting the Resident at risk of urinary catheter complications, contamination of equipment and infection. Findings include: Resident #74 was admitted to the facility in October 2024, with diagnoses including bladder-neck obstruction, obstructive and reflux uropathy, infection and inflammation due to an indwelling catheter, and urinary retention. Review of the Urinary Catheter Care Plan, initiated 10/13/24, indicated Resident #74 had a SPC in place and included the following goals and interventions (initiated 10/13/24): -Goal: Resident will be free from serious complications from urinary catheterization. -Change catheter if closed system is interrupted and as needed (PRN) to maintain patency. -Notify Medical Doctor (MD) of suspected catheter complications, as needed (PRN). -Maintain sterile technique when inserting catheter. -Avoid irrigation of catheter unless specifically ordered by the MD. Review of the Physician's orders from December 2024 through June 2025 included the following: -Suprapubic Catheter change as needed (PRN), may change SPC PRN for occlusion or leakage ., initiated 10/8/24 -Further review of the Physician's orders failed to indicate instructions or orders for irrigation of the Resident's SPC. Review of the Minimum Data Set (MDS) Assessment, dated 4/7/25 indicated Resident #74: -had unclear speech, understands and was understood -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -required substantial/maximum assistance of staff with toileting needs -had an indwelling urinary catheter in place Review of the Resident's clinical record indicated the following: -Nursing Note, dated 12/2/24 at 4:34 A.M., Foley [sic] was irrigated with 60 cubic centimeters (cc: unit of measure) of normal saline -Nursing Note, dated 12/10/24 at 12:06 A.M., Resident complained of (SPC) discomfort and after irrigation it (SPC) ran better . -Nursing Note, dated 12/26/24 at 8:02 A.M., SPC clogged, attempted to irrigate with normal saline and was unable to irrigate . -Nursing Note, dated 2/17/25 at 9:44 P.M., Resident complained of SPC not draining .did attempt to flush (irrigate) catheter but was resistant . -Nursing Note, dated 2/20/25 at 10:20 P.M., Resident assessed, stated lots of pressure in abdomen, unable to flush (irrigate) . On 6/8/25 at 10:22 A.M., the surveyor observed Resident #74 dressed and seated in a wheelchair in his/her room. A urinary drainage collection bag and tubing were observed covered and positioned under the Resident's wheelchair. During an interview at the time, Resident #74 said there had been some issues with his/her urinary catheter but was unable to provide specific details to the surveyor. During an interview on 6/10/25 at 11:00 A.M., Unit Manager (UM) #1 said Resident #74's SPC should not be irrigated (flushed) unless there was a specific Physician's order to do so. UM #1 said if the Resident's SPC was blocked or occluded, then the nursing staff should be changing the Resident's catheter. During a follow-up interview on 6/10/25 at 12:01 P.M., UM #1 said she reviewed the Resident's clinical record and there were notations from the nursing staff that the Resident's SPC was irrigated, and the SPC should not have been irrigated. UM #1 said there had been issues with facility staff irrigating resident's catheters in the past, so the nursing staff had been instructed not to irrigate a resident's catheter unless there were Physician's orders to do so. UM #1 said Resident #74 did not have a Physician's order to irrigate his/her SPC, and that by doing this, there could be an increased risk of infection and potential harm to the Resident.

Based on observation, interviews and record reviews, the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately coded for four Residents (#46, #78, #24 and #87), out of a total sample of 19 residents and three closed records reviewed. Specifically, the facility failed to: 1. For Resident #46, accurately reflect range of motion (ROM) deficits. 2. For Resident #78, accurately reflect ROM deficits and the use of an antipsychotic medication (used to treat mental health problems whose symptoms include psychosis). 3. For Resident #24, accurately code Insulin (medication used to treat Diabetes) orders. 4. For Resident #87, accurately code the discharge location. Findings include: 1. Resident #46 was admitted to the facility in September 2022, with diagnoses including cerebral infarction (stroke- damage to the tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and hemiplegia (paralysis of one side of the body) affecting the left non-dominant side. Review of the Activity of Daily Living (ADL) Care Plan, initiated 9/15/22, indicated Resident #46 had an alteration in his/her ability to provide self care, and was dependent on ADLs due to left sided hemiplegia. Review of the MDS assessment dated [DATE], indicated Resident #46: -was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of a total 15 -was dependent for upper/lower body dressing -had no ROM impairments On 4/2/24 at 10:27 A.M., the surveyor observed Resident #46 lying in bed. During an interview at the time, the Resident said he/she required assistance from staff with care because the left side of his/her body was paralyzed. During an interview on 4/5/24 at 11:06 A.M., the MDS Nurse said Resident #46's MDS assessment dated [DATE], was coded incorrectly and should have reflected that the Resident had ROM impairments on one side of the body. 2. Resident #78 was admitted to the facility in September 2023, with diagnoses including Cerebral Infarction, hemiplegia, major depressive disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) and anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations). Review of the Activity of Daily Living (ADL) Care Plan, dated 10/3/23, indicated Resident #78 had alteration in ability to perform ADLs related to stroke with left sided weakness. Review of the MDS assessment dated [DATE], indicated Resident #78: -had severe cognitive impairment as evidenced by a BIMS score of 3 out of a total 15 -was dependent for ADLs -had no ROM deficits -did not receive antipsychotic medication during the assessment reference period Review of the March 2024 Medication Administration Record (MAR) indicated the Resident was administered Risperdal (antipsychotic medication) 0.25 milligrams twice daily from 3/1/24 through 3/31/24. During an interview on 4/5/24 at 11:06 A.M., the MDS Nurse said Resident #78's MDS assessment dated [DATE], should have indicated ROM deficits for upper and lower body on one side due to his/her hemiplegia and also should have indicated antipsychotic medication had been administered during the reference period. The MDS Nurse said the MDS Assessment was coded incorrectly and would need to be modified. 49422 3. Resident #24 was admitted to the facility in July 2022, with diagnoses of aftercare following joint replacement surgery and Diabetes Type 2 (DM II - chronic condition in which the body does not produce enough insulin and has trouble controlling blood sugar levels). Review of the MDS assessment dated [DATE], indicated Resident #24 received seven days of Insulin injections, and had seven Physician order changes for Insulin during the assessment reference period. Review of the January 2024 MAR indicated that Resident #24 received seven days of Insulin administration during the review period, 1/16/24 through 1/22/24, and had no new Insulin orders during the assessment reference period. During an interview on 4/5/24 at 11:12 A.M., the MDS Nurse said Resident #24's MDS assessment dated [DATE], was coded incorrectly and should have reflected that the Resident had no Insulin Physician order changes during the assessment reference period. 42761 4. Resident #87 was admitted to the facility in February 2024, with a diagnosis of Cerebral Infarction. Review of Resident #87's Nursing Progress Note dated 3/9/24, indicated that the Resident was discharged to home from the facility on 3/9/24. Review of Resident #87's MDS assessment dated [DATE], indicated the Resident was discharged to the hospital. During an interview on 4/5/24 at 11:05 A.M., the MDS Nurse said she reviewed Resident #87's MDS Assessment, dated 3/9/24, and that the MDS Assessment was coded inaccurately relative to the Resident's discharge status. The MDS Nurse further said Resident #87 was not discharged to the hospital, but was discharged to home.

Based on observation, interview, record and policy review, the facility failed to ensure that Enhanced Barrier Precautions (EBP- targeted gown and glove use during high contact resident care activities, designed to reduce transmission of infection) were implemented in order to prevent the potential spread of infection for one Resident (#47), of one applicable resident on EBP, out of a total sample of 19 residents. Specifically, the facility staff failed to ensure that the required personal protective equipment (PPE) was worn when providing high-contact feeding tube care for Resident #47 when he/she was identified as being on EBP. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, January 2023, indicated EBP: -Will be used on all residents on the unit with indwelling medical devices (e.g., . feeding tube). -Require gowns and gloves for all high contact care: .Device care or use: feeding tube. Resident #47 was admitted to the facility in September 2019, with Intracerebral hemorrhage (a type of stroke, with damage to the brain from bleeding within the brain), Apraxia (the inability to execute learned motor tasks due to brain damage or degeneration) and recurrent aspiration (frequently inhaling food and/or liquids into the airway and lungs accidentally which may cause serious health problems such as Pneumonia). On 4/3/24 at 10:30 A.M., the surveyor observed the following: -Signage posted outside the Resident's room indicating: -Stop. Enhanced Barrier Precautions: Everyone must: >Clean their hands, including before entering and when leaving the room. >Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities .Device Care or use: feeding tube. -A cart with PPE (gown, gloves) was located outside the Resident's room. On 4/3/24 at 10:45 A.M., the surveyor observed the medication and tube feeding administration process with Nurse #3 and Nurse #1 that was being provided for Resident #47. The surveyor observed that Nurse #1 entered the room wearing gloves, but no gown, and assisted Nurse #3 to turn and reposition Resident #47 in bed. The surveyor observed that Nurse #3 wore gloves to check the feeding tube placement, administer medications and provide liquid nutrition through the feeding tube. Nurse #3 did not don (put on) a gown before or during the high-contact feeding tube care as required. During an interview on 4/5/24 at 1:00 P.M., Nurse #1 said that the facility's EBP protocol included for staff to wear a gown and gloves when providing high-contact care for any resident with a feeding tube. When the surveyor asked Nurse #1 if they used EBP during the feeding tube care and medication/feeding administration with Nurse #3 on 4/3/24 at 10:45 A.M., Nurse #1 said they did not wear a gown as required.

Based on interview and record review, the facility failed to administer medication as ordered by the Physician for one Resident (#52) out of a total sample of 19 residents. Specifically, the facility staff failed to ensure that Midodrine (medication to treat low blood pressure [hypotension] by increasing the blood pressure) was administered according to the parameters ordered by the Physician. Findings include: Review of the facility policy titled Administration Procedure for All Medications, effective 9/20/13, included the following: -Purpose: to administer medications in a safe and effective manner. -Check the Medication Administration Record (MAR) for order. -Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration. Resident #52 was admitted to the facility in December 2023, with diagnoses including Acute Cerebrovascular Insufficiency (obstruction of one or more arteries that supply blood to the brain), Nonrheumatic Mitral Valve Insufficiency (form of heart disease where the mitral valve does not close properly and can leak or flow in the wrong direction), Hypertension (high blood pressure) and Occlusion and Stenosis of the Carotid Artery (blockage of the large artery on either side of the neck). Review of Resident #52's Cardiac Care Plan, initiated 12/12/23, indicated the Resident had a potential for alteration in cardiac function/status related to . hypertension, hypotension. The plan of care included the following interventions: -monitor and document vital signs as indicated. -administer medications as ordered and assess for effectiveness and adverse side effects. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #52 was severely cognitively impaired as evidenced by staff interview. Review of the January 2024 Physician's orders included the following: -Midodrine HCL 5 milligram (mg), 2 tablets (for total dose of 10 mg) orally three times daily for hypotension. -Hold (do not administer) for a Systolic Blood Pressure (SBP = pressure in the arteries when the heart beats) > (greater than) 110 [mm Hg] (measurement - millimeters of mercury), initiated 1/2/24 Review of the January 2024 MAR indicated that the Midodrine medication was administered to Resident #52, outside of the Physician's ordered parameters (SBP > 110 mm Hg) on the following dates/times: -1/2/24: SBP was 126 mm Hg at 8:00 P.M. -1/6/24 and 1/21/24: SBP was 118 mm Hg at 8:00 P.M. -1/7/24: SBP was 128 mm Hg at 8:00 P.M. -1/9/24: SBP was 111 mm Hg at 8:00 A.M. -1/20/24: SBP was 114 mm Hg at 8:00 P.M. -1/22/24: SBP was 112 mm Hg at 2:00 P.M. -1/23/24: SBP was 124 mm Hg at 8:00 P.M. Review of the February 2024 Physician's orders included the following: -Midodrine HCL 10 mg, 1 tablet orally three times daily for hypotension. Hold for a SBP > 110 [mm Hg], initiated 2/1/24 Review of the February 2024 MAR indicated Midodrine medication was administered to Resident #52, outside of the Physician's ordered parameters on the following dates/times: -2/1/24: SBP was 116 mm Hg at 8:00 P.M. -2/15/24: SBP was 118 mm Hg at 8:00 P.M. -2/20/24: SBP was 118 mm Hg at 8:00 A.M. -2/22/24: SBP was 125 mm Hg at 8:00 A.M. -2/23/24: SBP was 120 mm Hg at 8:00 P.M. -2/27/24: SBP was 113 mm Hg at 2:00 P.M. Review of the March 2024 MAR indicated Midodrine medication was administered to Resident #52, outside of the Physician's ordered parameters on the following dates/times: -3/4/24 and 3/6/24: SBP was 118 mm Hg at 8:00 P.M. -3/6/24: SBP was 118 mm Hg at 8:00 A.M. -3/9/24: SBP was 122 mm Hg at 8:00 P.M. -3/10/24: SBP was 116 mm Hg at 8:00 P.M. -3/11/24: and 3/23/24: SBP was 118 mm Hg at 8:00 P.M. -3/13/24: SBP was 111 mm Hg at 8:00 A.M. -3/19/24: SBP was 112 mm Hg at 2:00 P.M. -3/24/24: SBP was 123 mm Hg at 2:00 P.M. -3/26/24: SBP was 117 mm Hg at 8:00 A.M. On 4/3/24 at 3:23 P.M., the surveyor reviewed Resident #52's MARs with Unit Manager (UM) #1 relative to the Midodrine medication. When the surveyor UM #1 asked to define what the > symbol within the order meant, UM #1 said it meant greater than or less than. After further prompting from the surveyor, UM #1 said the > symbol meant to hold the medication if the SBP was greater than 110 mm Hg. The surveyor and UM #1 reviewed when the Midodrine was administered to Resident #52 and the documented SBP associated with the administration times, and UM #1 said she would have to look into this matter because it appeared that some of the Nurses might not understand what the > symbol within the Physician order means. During a follow-up interview on 4/3/24 at 3:59 P.M., UM #1 said that she spoke with one of the Nurses who had administered the Midodrine outside of the Physician ordered parameters, and asked what the > symbol meant. UM #1 said the Nurse indicated that the > symbol meant greater than. UM #1 further said that it appears that the Nurses may not be paying attention and/or may not understand the Physician ordered parameters of when to administer or hold the Midodrine medication. UM #1 said the Physician will have to be notified that the Midodrine medication was administered outside of the ordered parameters.

Based on record review, and interview, the facility and its staff failed to ensure that the medical record included documentation that education and the opportunity to consent to, receive, or decline pneumococcal immunization (a vaccine to prevent pneumonia: a potentially life threatening lung infection) was present for three Residents (#63, #64, and #74),out of five residents sampled for immunization review. Findings include: Review of the facility policy titled Resident Pneumococcal Immunization, revised October 2022, indicated that: - Residents will be offered immunization to protect them from pneumococcal disease unless medically contraindicated or the residents have already been immunized. -Pneumococcal immunizations will be provided as recommended by the Center for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices (ACIP). Review of the CDC document titled Pneumococcal Vaccine Timing for Adults, dated 4/22/22, indicated that: - adults who have never received a pneumococcal vaccine should receive a dose of PCV20 or PCV15 vaccination (pneumococcal conjugate vaccines that target the most common strains of pneumonia). -adults who previously received PPSV23 but who have not received PCV15 or PCV20, should receive a dose of either PCV 15 or PCV20 at least a year after the PPSV23 vaccine. 1. Resident #63 was admitted to the facility in May 2022. Review of the medical record indicated no documented evidence that the resident and/or his/her representative received education regarding the risks and benefits of the pneumococcal vaccine, nor was there evidence the vaccine was offered, received or declined. Review of the Minimum Data Set Assessment, dated 6/1/22, indicated the Resident was up to date with his/her pneumococcal vaccination. 2. Resident #64 was admitted to the facility in August 2022. Review of Resident #64's medical record indicated no documented evidence that the resident and/or his/her representative received education regarding the risks and benefits of the pneumococcal vaccine, nor was there evidence the vaccine was offered, received or declined. Review of the MDS assessment dated [DATE] indicated the pneumococcal vaccine was not up to date and the vaccine had not been offered to the resident and/or his/her representative. 3. Resident #74 was admitted to the facility in August 2022. Review of Resident #74's medical record indicated no documented evidence that the resident and/or his/her representative had received education regarding the risks and benefits of the pneumococcal vaccine, nor was there evidence the vaccine was offered, received or declined. During an interview on 10/04/22 at 2:09 P.M., Unit Manager (UM) #1 said that she reviews influenza and pneumococcal vaccines with residents and/or their representatives during flu season and she had not gotten to the pneumococcal vaccine review as yet this year. She said that the Management Minutes Questionnaire (MMQ) Nurse would review vaccination information prior to a resident being admitted , but usually only receive information about COVID-19 vaccinations. She further said that the Administrator had access to the Massachusetts Immunization Information System and looked up immunization information for the UMs, but that she was not here. She also said that if a resident comes from New York State, their immunization information is not in the Massachusetts system. During an interview on 10/04/22 at 2:31 P.M., The Minimum Data Set (MDS) Nurse said she reviewed the medical records of Residents #63, #64 and #74 and said there was no evidence of pneumococcal vaccination in the clinical or hospital records. She said that the Infection Control Nurse used to track immunization information, but she had left the facility. During a subsequent interview on 10/04/22 at 2:52 P.M., the MDS Nurse said she had located a pneumococcal vaccine record for Resident #63 that indicated he/she had received a PPSV-23 vaccination on 11/5/2012, but there was nothing to reflect that he/she had received any type of pneumococcal vaccine immunization after that date. During an interview on 10/4/22 at 3:35 P.M., with the Corporate Nurse Consultant (CNC) and the Director of Nurses (DON), the DON said that there was no evidence that Residents #63, #64 and #74 had been educated, offered, consented and received or declined the pneumococcal vaccine as required. The CNC said that Resident #63 was eligible for and should have been offered a PCV15 or PCV20 per CDC guidance, as required.

Based on observation, record review, and interview, the facility failed to ensure its staff: 1) Appropriately disposed of used personal protective equipment (PPE), in a manner that would not contaminate clean PPE on one unit (North 1) out of three units observed, and 2) Screened residents for signs and symptoms of COVID-19 every shift on a unit experiencing a COVID-19 outbreak for one Resident (#36) in a sample of three residents. Findings include: 1. On the North 1 Unit, facility staff failed to properly dispose of used PPE from an isolation room in a proper manner to prevent contamination of clean PPE. During an observation on 9/29/22 at 9:26 A.M., the surveyor observed a Certified Nurses Aide (CNA) #1 in an isolation room (a room with a resident that was on precautions due to being positive for COVID-19, that required staff to wear a gown, gloves, N95 mask, and eye protection to enter the room) on the North 1 Unit. The CNA doffed (took off) her gown, gloves, and eye protection and threw them away in a garbage can inside the resident's room. She proceeded to exit the resident's room still wearing her N95 mask. She performed hand hygiene and proceeded to take a clean mask from the clean PPE cart outside the resident's room. She doffed her used N95 mask and laid the used mask on top of a box of clean gloves that was on top of the PPE cart outside of the resident's room. During an interview following the observation CNA #1 said she had just come out of an isolation room and was required to change out her N95 mask upon exiting but there was no garbage can outside the room. She said she was unsure where to put her used N95 mask while she donned (put on) her new mask, so she placed it on the box of clean gloves. She further said that she should not have put the used N95 mask on top of the box of clean gloves on the PPE bin outside the resident's room. 2. For Resident #36, the facility failed to ensure staff screened him/her for signs and symptoms of COVID-19 every shift while the facility was experiencing a COVID-19 outbreak on the unit where the resident resided. Review of the facility policy titled COVID-19 Prevention and Outbreak Management, Revised 6/25/22, indicated the following: Residents on a unit that is undergoing quarantine must be screened for COVID-19 symptoms each shift as opposed to just once a day. Resident #36 was admitted to the facility in May 2020. Review of the Mt. Greylock COVID-19 positive residents list provided to the surveyor during the survey indicated the Unit that Resident #36 resided on started outbreak testing on 9/30/22. Review of the October 2022 Physicians Orders indicated the following: Corona (COVID-19): Assess for respiratory symptoms every shift (Q shift) .with a start date of 10/3/22. Review of the September 2022 and October 2022 Medication Administration Records (MAR) indicated from 9/30/22 through 10/2/22, Resident #36 was only being screened one time daily for symptoms of COVID-19. During an interview on 10/4/22 at 1:36 P.M., Unit Manager #1 said residents on the unit should be monitored Q shift for symptoms of COVID-19 and Q shift monitoring should have started on 9/30/22, when the outbreak on the unit was identified. She further said Resident #36 was not monitored Q shift for symptoms of COVID-19 until 10/3/22. During an interview on 10/4/22 at 1:52 P.M., the Staff Development Coordinator (SDC) said the Unit that Resident #36 resided on was under quarantine as they were currently conducting outbreak testing on that unit.

Based on an observation, interview and policy review, the facility and its staff failed to properly secure medications on one unit out of a total of three units. Specifically, the facility staff failed to ensure an unattended medication cart was locked, putting residents at risk for potential harm. Findings include: Review of the facility policy titled, Medication Storage in the Facility, dated June 2010 indicated the following: - Medications and biologicals are stored safely, securely, and properly accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. - Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. During an observation and interview on the North 1 Unit on 9/30/22 at 4:18 P.M., the surveyor observed an unattended, unlocked medication cart in the corridor with no staff present in the immediate area and a resident seated approximately 10 feet away from the cart. The surveyor observed Nurse #1 emerge from a resident's room several doors down the hall and return to the medication cart. Nurse #1 said she forgot to lock the cart after obtaining a glucometer (a piece of equipment used to measure blood sugar levels) to obtain a resident's blood sugar reading, and the cart should have been locked.

Based on observation and interview the facility and its staff failed to ensure the posting of the daily staffing information reflected the current date. Findings include: On 9/29/22 the surveyor observed the posted nurse staffing information with a date of 9/20/22, that did not provide current, accurate date and information for residents and visitors. During an interview on 10/04/22 at 8:25 A.M., the facility scheduler and surveyor reviewed a photo taken on 9/29/22 of the staffing information dated 9/20/22. The scheduler said that the nurse staffing sheet should be updated daily, and it was not done as required.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was dependent for care needs, had limited mobility, and required extensive assistance of two staff members for bed mobility and positioning, the Facility failed to ensure staff implemented and followed interventions in Resident #1's plan of care related to staff assistance during positioning and bed mobility. On 7/20/22, while attempting to remove the mechanical lift pad that had been left underneath Resident #1, Certified Nurse Aide (CNA) #1 turned and repositioned Resident #1 in bed, without another staff member present to assist her, after rolling Resident #1 onto his/her side, Resident #1 fell out of bed onto the floor. Resident #1 was transferred to the Hospital Emergency Department and found to have two acute fractures of his/her thoracic vertebrae (bones of the back bone to which the ribs are attached) a [CONDITION(S)] that required sutures to repair, and was admitted . Findings include: Review of the Facility's Policy, Care Planning, dated 6/29/19, indicated that the Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must be individualized for the resident by adding care needs, interventions and resident specific strategies based on the assessment of a resident's needs, strengths, goals and life history. Resident #1 was admitted to the Facility in May 2013, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Activities of Daily Living Care Plan, dated 4/18/22, indicated that he/she was dependent on staff for all levels of care and required two staff members with bed mobility and positioning. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 5/30/22, indicated that Resident #1 required extensive physical assistance of two staff members for bed mobility. The MDS indicated Resident #1 had functional limitations in Range of Motion in his/her upper and lower extremities on both sides. Review of Resident #1's Falls Care Plan, indicated that Resident #1 was at risk for falls due to confusion, and unsafe behaviors. Interventions included bilateral bed bolster cushions for positioning when in bed due to immobility and contractures. Safety devices included he/she was to have a low wide bed. Review of Resident #1's CNA Care Flow Sheet, dated July 2022, indicated that he/she was dependent for care and required assistance of two staff members with positioning in bed. Review of a Nurse Progress Note, dated 7/20/22, (written by Nurse #2) indicated this Nurse was called by the CNA (later identified as CNA #1) into Resident #1's room and found Resident #1 lying on his/her right side on the floor with a large amount of blood coming from a head wound. The Note indicated, per CNA #1, after removing a mechanical lift pad from underneath Resident #1, he/she then fell out on the left side of the bed, onto the floor. Review of Resident #1's Fall Investigation, dated 7/20/22 at 12:40 P.M., indicated that Resident #1 had a witnessed fall when he/she rolled out of bed from the left side of the bed and hit the right side of his/her head when landing on the floor. Resident #1 had a large amount of blood by him/her, with a [CONDITION(S)]. Prior to Resident #1's fall he/she was transferred with a mechanical lift and mechanical lift pad. Resident #1's condition before the fall was confused and nonverbal. During an interview on 8/31/22 at 9:06 A.M., Nurse #2 said that CNA #1 called her into Resident #1's room and said, I need help. Nurse #2 said she found Resident #1 lying on his/her right side on the floor on the left side of his/her bed in a pool of blood from a [CONDITION(S)]. Nurse #2 said that CNA #1 told her that she turned Resident #1 onto his/her left side to remove the mechanical lift pad, and Resident #1 rolled out of bed. Nurse #2 said that Resident #1 was completely dependent on staff for care and required assistance of two staff members with bed mobility and positioning. Review of CNA #1's Written Witness Statement, dated 7/20/22, indicated that Resident #1 was on the mechanical lift pad in bed, and when she was taking this pad out from underneath Resident #1, he/she rolled off the bed onto the floor. During an interview on 8/30/22 at 7:40 A.M. and re-interview at 12:00 P.M., Certified Nurse Aide (CNA) #1 said that on 7/20/22 after lunch, she went back to remove the mechanical lift pad out from underneath Resident #1, and said she did not get another staff member to help her. CNA #1 said first she turned Resident #1 onto his/her right side, rolled up the mechanical pad, pushed it under his/her body, and then turned Resident #1 onto his/her left side towards herself, to remove the pad. CNA #1 said when she pulled the mechanical lift pad out from underneath the left side of Resident #1's body, he/she fell on to the floor (the bed was in the high position, approximately 4 feet from the bed to the floor). CNA #1 said at the time of Resident #1's fall, his/her bolster cushions to keep him/her in bed for safety were not on the bed, because she was providing direct care. CNA #1 said that although Resident #1 is care planned to have two staff members assist with repositioning and bed mobility, said she has repositioned him/her alone before. Review of the Hospital Emergency Department (ED) Report, dated 7/20/22, indicated that Resident #1 was seen in the ED for a four-foot fall (from a bed) to the floor. The Report indicated Resident #1 sustained acute fractures of his/her second and third thoracic vertebrae and a [CONDITION(S)] which was sutured. The Report indicated Resident #1 was admitted to the Hospital and treated with bed rest, a cervical collar, and Tylenol and [MEDICATION(S)] (a narcotic medication) for pain management. During an interview on 8/30/22 at 10:10 A.M., the Director of Nurses (DON) said that CNA #1 turned Resident #1 on his/her side in bed by herself to remove the mechanical lift pad from underneath Resident #1 and when this occurred, he/she fell out of bed. The DON said that Resident #1's plan of care indicates that two staff members are required for bed mobility and positioning and said that CNA #1 did not follow Resident #1's plan of care. On 8/30/22, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) On 7/20/22, the Nursing Staff immediately reviewed Resident #1's fall incident and developed preventive measures to prevent a re-occurrence. B) A telephone review of incident was conducted with Resident #1's Health Care Proxy (HCP), Family Member, and the addition of bed rails with signed consent was completed and added to his/her revised plan of care upon his/her return. C) On 7/20/22 and 7/21/22, the staff (including licensed Nurses and CNAs) were re-educated on the following: ensuring plans of care included finishing the removal of mechanical lift pads with two staff members. D) By 7/21/22, audits were completed and all residents using mechanical lifts for transfer were identified, and staff was re-educated to use two staff members for transfer when removing lift pad from under residents. E) By 7/21/22, audits were conducted and no other falls were documented to be of a scenario similar to this incident. F) Audits will continue weekly for current residents and initially for new mechanical lift residents for 3 months and reported to Quality Assurance Performance Improvement (QAPI) monthly. Re-education will be provided as indicated. Nursing orientation includes reinforcement of following plans of care with residents when rolling the mechanical lift pad and repositioning during removal. G) On 7/28/22 the Risk Meeting reviewed Resident #1's fall and interventions. H) All resident falls are investigated immediately and assessed for root cause with corresponding updates to Care Plan. All falls are reviewed at the weekly Risk Meeting. Initial interventions and care plans are assessed for effectiveness for four weeks post fall. I) Falls, related causes, and implemented interventions are reported and reviewed at the QAPI meetings. The QAPI reports include falls management status post [MEDICAL RECORD OR PHYSICIAN ORDER] J) The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on staff for care needs, had limited mobility, and required extensive assistance of two staff members with bed mobility and positioning, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent incidents/accidents resulting in injury. On 7/20/22, while attempting to remove the mechanical lift pad that had been left underneath Resident #1, Certified Nurse Aide (CNA) #1 turned and repositioned him/her in bed, without another staff member present to provide assistance, CNA #1 rolled Resident #1 onto his/her side, and Resident #1 fell out of bed onto the floor. Resident #1 was transferred to the Hospital Emergency Department and found to have two acute fractures of his/her thoracic vertebrae (bones of the back bone to which the ribs are attached), a [CONDITION(S)] that required sutures to repair, and he/she was admitted . Findings include: Review of the Facility's Policy, titled Falls Risk Reduction, dated 12/22/16, indicated that all residents will be assessed for fall risk factors. Those determined to have risk factors will receive individual interventions to reduce the risk for falls and minimize the actual occurrence of falls. Develop an individualized plan of care with fall interventions on the plan of care. Review of the Facility's standard of Practice guidelines, titled Clinical Nursing Skills and Techniques, 8th edition, indicated that resident falls are the most common type of accident with approximately 1 million falls occurring in the United States. Between 1% and 3% of these falls result in fractures. Preventing falls and fall related injuries requires diligent ongoing nursing assessment and engagement of the entire healthcare team and implementation of resident- specific interventions. Resident #1 was admitted to the Facility in May 2013, diagnoses included advanced dementia. Review of Resident #1's Activities of Daily Living Care Plan, dated 4/18/22, indicated that he/she was dependent on two staff members with bed mobility and positioning. Review of Resident #1's Fall Risk Assessment, dated 5/30/22, indicated that he/she was assessed by nursing as being at increased risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 5/30/22, indicated that Resident #1 was severely cognitively impaired, required extensive assistance of two staff members for bed mobility, and he/she had functional limitations to range of motion in his/her upper and lower extremities on both sides. Review of Resident #1's Falls Care Plan, indicated that Resident #1 was at risk for falls due to confusion and unsafe behaviors. Interventions included bilateral bed bolster cushions for positioning when in bed due to immobility and contractures. Safety devices included he/she was to have a low wide bed. Review of Resident #1's CNA Care Flow Sheet, dated July 2022, indicated that he/she was dependent on two staff members with positioning in bed. Review of a Nurse Progress Note, dated 7/20/22, (written by Nurse #2) indicated this Nurse was called by the CNA (identified as CNA #1) into Resident #1's room and found Resident #1 lying on his/her right side on the floor with a large amount of blood from a head wound. The Note indicated, per CNA #1, after removing a mechanical lift pad from underneath Resident #1, he/she fell out of bed, on the left side of the bed, onto the floor. Review of Resident #1's Fall Investigation, dated 7/20/22 at 12:40 P.M., indicated that Resident #1 had a witnessed fall when he/she rolled out of bed from the left side of the bed and hit the right side of his/her head when landing on the floor. Resident #1 had a large amount of blood by him/her, with a [CONDITION(S)]. Prior to Resident #1's fall he/she was transferred with a mechanical lift and mechanical lift pad. Resident #1's condition before the fall was confused and nonverbal. During an interview on 8/31/22 at 9:06 A.M., Nurse #2 said that CNA #1 called her into Resident #1's room and said, I need help. Nurse #2 said she found Resident #1 lying on his/her right side on the floor on the left side of his/her bed in a pool of blood from a [CONDITION(S)]. Nurse #2 said that CNA #1 told her that she turned Resident #1 onto his/her left side to remove the mechanical lift pad, and Resident #1 rolled out of bed. Nurse #2 said that Resident #1 was completely dependent and required the assistance of two staff members with bed mobility and positioning. Review of CNA #1's Written Witness Statement, dated 7/20/22, indicated that Resident #1 was on the mechanical lift pad in bed, and when she was taking the mechanical lift pad out from underneath Resident #1, he/she rolled off the bed onto the floor. During an interview on 8/30/22 at 7:40 A.M. and at 12 P.M., Certified Nurse Aide (CNA) #1 said that prior to Resident #1's fall, she and CNA #2 assisted Resident #1 with a mechanical lift transfer from his/her wheelchair to the bed. CNA #1 said CNA #2 removed the mechanical lift from the room, and left Resident #1's room. CNA #1 said although Resident #1 is care planned to have two staff member assistance with repositioning and bed mobility, said she has provided care to Resident #1 before by herself, when he/she is in bed. CNA #1 said that on 7/20/22 after lunch she repositioned Resident #1 by herself to remove the mechanical lift pad from underneath him/her. CNA #1 said she turned Resident #1 onto his/her right side, rolled up the mechanical pad, pushed it under his/her body, and then turned Resident #1 onto his/her left side, towards herself, to remove the lift pad. CNA #1 said when she pulled the mechanical lift pad from under the left side of Resident #1's body, he/she fell on to the floor (bed was in the high position, approximately 4 feet from the bed). CNA #1 said at the time of Resident #1's fall, the bolster cushions to help keep him/her in bed for safety were not on the bed, because she was providing direct care. Review of a Hospital Emergency Department (ED) Report, dated 7/20/22, indicated that Resident #1 was seen in the ED for a four-foot fall (from a bed) to the floor. The Report indicated Resident #1 sustained acute fractures of his/her second and third thoracic vertebrae and a [CONDITION(S)] which was sutured. Resident #1 was admitted to the Hospital and treated with bed rest, a cervical collar, and was administered Tylenol and [MEDICATION(S)] (a narcotic medication) for pain management. During an interview on 8/30/22 at 10:10 A.M., the Director of Nurses (DON) said that CNA #1 turned Resident #1 on his/her side in bed by herself to remove the mechanical lift pad from underneath Resident #1 and when this occurred, he/she fell out of bed. The DON said that Resident #1's plan of care indicates that two staff members are required for bed mobility and positioning and said that CNA #1 did not follow Resident #1's plan of care. On 8/30/22, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) On 7/20/22, the Nursing Staff immediately reviewed Resident #1's fall incident and developed preventive measures to prevent a re-occurrence. B) A telephone review was conducted with Resident #1's Health Care Proxy (HCP), Family Member, and the addition of bed rails with signed consent was completed and added to his/her revised plan of care upon his/her return. C) On 7/20/22 and 7/21/22, the staff (including licensed Nurses and CNAs) were re-educated on the following: ensuring plans of care included finishing the removal of mechanical lift pads with two staff members. D) By 7/21/22, audits were completed and all residents using mechanical lifts for transfer were identified, and staff was re-educated to use two staff members for transfer and when removing lift pad from under residents. E) By 7/21/22, audits were conducted and no other falls were documented to be of a scenario similar to this incident. F) Audits will continue weekly for current residents and initially for new mechanical lift residents for 3 months and reported to Quality Assurance Performance Improvement (QAPI) monthly. Re-education will be provided as indicated. Nursing orientation includes reinforcement of following plan of care with residents for rolling of lift pad during removal. G) On 7/28/22 the Risk Meeting reviewed Resident #1's fall and interventions. H) All resident falls are investigated immediately and assessed for root cause with corresponding updates to Care Plan. All falls are reviewed at the weekly Risk Meeting. Initial interventions and care plans are assessed for effectiveness for four weeks post fall. I) Falls and related causes and implemented interventions are reported and reviewed at the QAPI meetings. The QAPI reports include falls management status post falls. J) The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1), who on [DATE] experienced a change in medical status with decline, was noted by nursing to be lethargic with new onset of shortness of breath, the Facility failed to ensure the Physician and his/her Health Care Agent (HCA) or Representative, were immediately notified. Resident #1 continued to decline, he/she had poor intake and experienced a significant weight loss, however his/her physician and HCA were not immediately notified, until [DATE], when Resident #1 required transfer to the Hospital Emergency Department for acute [CONDITION(S)], where he/she was diagnosed with acute [CONDITION(S)], and bilateral pneumonia with [CONDITION(S)] (a blood infection). Findings include: The Facility Policy titled, Physician Notification, dated ,d+[DATE], indicated that: - Upon identification of a resident who has clinical changes, changes in condition, the nurse will perform appropriate data collection and report to the physician as indicated. - To communicate a change in resident's condition to physician and initiated interventions as needed and ordered. -If clinical findings indicate urgent notification, notify the physician, report pertinent data, obtain and implement specific orders for intervention. -Notify the family of a change in condition and interventions. Resident #1 was admitted to the Facility in March of 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) Form, dated [DATE], indicated that he/she was a Full Code (in the event of a cardiac or respiratory arrest, cardio-pulmonary resuscitation (CPR) will be provided, may insert an endotracheal tube (a breathing tube) and use a ventilator, treat with artificial nutrition and/or hydration and transfer to the hospital if it is needed). The Health Care Proxy Activation Form, dated [DATE], indicated Resident #1 did not have the capacity to make or communicate health care decisions due to dementia. Resident #1's Physician Orders, dated [DATE], indicated his/her Health Care Proxy was invoked. Resident #1's Physician's Admission Progress Note, dated [DATE], indicated that Resident #1 was admitted to the Facility for short term rehabilitation. Resident #1's Initial Nutrition Assessment, dated [DATE], indicated his/her minimum daily fluid intake requirement was 1400 milliliters (ml) a day. Review of the Facility's Meal intake Report, dated [DATE] through [DATE] indicated that during Resident #1's entire admission (24 days), his/her total daily fluid intake was less than 1400 milliliters (ml) per day, and were documented as follows: - 9 days were between 1000 -1400 ml. - 6 days were between 800 - 1000 ml. - 3 days were between 600 - 800 ml. - 6 days were between 0 - 600 ml. Review of Resident #1's medical record indicated there was no documentation to support that the Physician or the HCA were notified regarding his/her inadequate fluid intake. Review of Resident #1's Nursing Progress Note, - dated [DATE], indicated he/she had a poor intake. - dated [DATE], indicated he/she had a poor intake. - dated [DATE], indicated he/she had a poor intake. - dated [DATE], indicated he/she had a poor intake. Review of Resident #1's medical record indicated there was no documentation to support that the Physician or the HCA were notified of his/her poor oral intake. Review of Resident #1's medical records indicated his/her weights were recorded as follows: - [DATE] documented as 103 pounds (lbs.) - [DATE] documented as 101.6 lbs. (loss of 1.4 lbs. in 9 days) - [DATE] documented as 97.8 lbs. (loss of 5.2 lbs. in 16 days) - [DATE] documented as 93.9 lbs. (loss of 9.1 lbs. in 23 days) Based on Resident #1's weight on [DATE] and on [DATE], this is 9.1 lbs. loss, which is a significant severe weight loss of 8.8%, in 23 days. Review of the medical record indicated there was no documentation to support that the Physician or the HCA were notified about Resident #1's significant weight loss. Review of Resident #1's Nursing Progress Note, dated [DATE] at 2:07 P.M., written by Nurse #2, indicated that Resident #1 had difficulty making his/her needs known, had poor fluid intake, had difficulty holding his/her head upright, was noted to be short of breath at rest, and his/her oxygen was increased from 2 liters to 3 liters via nasal cannula with positive effect. During an interview on [DATE] at 12:50 P.M., Nurse #2 said on [DATE] at 2:07 P.M., Resident #1 had decreased energy, shortness of breath at rest, poor fluid intake, but said she could not remember if she had notified the physician or the HCA. During an interview on [DATE] at 7:10 P.M., Family Member #1 (HCA) said that she was not notified on [DATE] of Resident #1's decline in mental status, and that he/she could not even hold his/her head up. Family Member #1 said she was not made aware that nursing had to increase Resident #1's oxygen because he/she became short of breath at rest or that he/she had a poor intake. Family Member #1 said on [DATE], Resident #1 was transferred to the Hospital Emergency Department (ED), and where it was determined that he/she was extremely dehydrated with an excessively high sodium level. Review of Resident #1's medical record indicated that between [DATE] and [DATE], there was no documentation to support that nursing staff notified the Physician or the HCA of Resident #1's decline, prior to [DATE]. The Emergency Department Physician's Note, dated [DATE], indicated found Resident #1 to have acute [CONDITION(S)], bilateral pneumonia, hypoxemia, septic (a blood infection), significant dehydration, (hypovolemia low blood volume), and acute [CONDITION(S)] (an elevated sodium level, an indicator of dehydration). The Emergency Department Summary, dated [DATE], indicated Resident #1 was treated with oxygen, intravenous fluids, vasopressor agents (to increase blood pressure) and intravenous antibiotics. The Summary indicated Resident #1 was admitted to the critical care unit, his/her respiratory distress progressed, and after a discussion with his/her Health Care Agent (HCA), Resident #1 was made comfort care only. During an interview on [DATE] at 12:50 P.M., Unit Manager #1 said that Resident #1's consistent inadequate daily fluid intake and weight loss were not identified and were not reported to the Physician prior to his/her decline on [DATE], and subsequent transfer to the ED.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at increased risk for dehydration and weight loss, the Facility failed to ensure he/she maintained acceptable parameters of nutritional status during his/her admission. Resident #1 was admitted for short term rehabilitation, was in the Facility for just over three weeks, and in that time he/she experienced an undesired significant weight loss (greater than 8%) that went undetected by nursing until after he/she was transferred the Hospital Emergency Department (ED) for evaluation of an acute change in medical status, where it was also determined that Resident #1 was severely dehydrated. Resident #1 was admitted to the Hospital secondary to his/her critical care needs, and was provided with measures consistent with comfort care only. Findings include: The Facility Policy titled, Nutrition Management, dated 1/2017, indicated the following: - Residents will receive care and services to ensure acceptable parameters of nutritional status are maintained to the extent possible as indicated by the resident's clinical condition. -Nutritional assessment and care planning will be completed by the interdisciplinary team. Staff will consistently observe and monitor residents for changes and implement revisions to care plan as needed. -Based on a resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as usual body weight. The Facility Policy titled, Hydration, dated 5/02/05, indicated the staff will provide each resident with sufficient fluid intake to maintain proper hydration. The Staff will closely monitor all residents at risk for dehydration. Resident #1 was admitted to the Facility in March of 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was severely cognitively impaired, required physical assistance from staff with meals, required a mechanically altered diet, and weighed 103 pounds (lbs.) with no recent weight loss. The Care Areas Assessment Summary (CAA), dated 3/19/22, indicated Resident #1 triggered as being at risk for weight loss, and dehydration with fluid maintenance issues. Review of the Nutrition Care Plan, dated 3/17/22, indicated Resident #1 consumed a liberalized therapeutic diet due to a poor appetite and a low ideal body weight. The Care Plan indicated Resident #1 will maintain or increase his/her weight and will not become dehydrated. Interventions include to supervise and assist with meals, provide super cereal with breakfast and boost pudding, monitor weight trends, monitor and document fluid intake consumed daily, and notify the physician and dietician of weight loss. Review of Resident #1's Physician Orders, dated 3/2022, indicated his/her diet was puree solids with nectar thick (easily pourable, comparable to heavy syrup found in canned fruit) liquids. Review of the Initial Nutrition Assessment, dated 3/17/22, indicated Resident #1's minimum daily fluid requirement was 1400 milliliters (ml). Review of the Facility's Meal intake Report, dated 3/16/22 through 4/08/22 indicated that during Resident #1's entire admission (24 days), his/her total daily fluid intake was less than 1400 milliliters (ml), documentation was as follows: - 9 days were between 1000 - 1400 ml. - 6 days were between 800 - 1000 ml. - 3 days were between 600 - 800 ml. - 6 days were between 0 - 600 ml. Resident #1's daily minimum fluid requirement of 1400 milliliters (ml) was not consistently met while in the Facility and for 15 out of the 24 days (63% of the time) his/her daily fluid intake was 1000 ml or less. Review of Resident #1's medical record indicated there was no documentation to support that the Physician was notified of Resident #1's inadequate fluid intake. Review of Resident #1's Nursing Progress Note: - dated 3/20/22, indicated he/she had a poor intake. - dated 3/21/22, indicated he/she had a poor intake. - dated 4/02/22, indicated he/she had a poor intake. - dated 4/05/22, indicated he/she had a poor intake. Review of Resident #1's medical records indicated his/her weights were recorded as follows: - 3/15/22 documented as 103 lbs. - 3/24/22 documented as 101.6 lbs. (1.4 lbs. in 9 days) - 3/31/22 documented as 97.8 lbs. (5.2 lbs. in 16 days) - 4/07/22 documented as 93.9 lbs. (9.1 lbs. in 23 days) Based on Resident #1's documented weight of 103 lbs on 3/15/22, compared to his/her weight documented weight of 93.9 lbs on 4/07/22, ( 9.1 lb weight loss), he/she experienced an unplanned and undesirable severe weight loss (significant weight loss is a defined as 5% weight loss over 4 weeks) of 8.8% within approximately 3 weeks (24 days) while in the Facility. Review of Resident #1's medical record indicated there was no documentation to support that his/her Physician or the Dietician were notified of Resident #1's poor intake or significant weight loss. During an interview on 6/10/22 at 12:50 P.M., Unit Manager #1 said that Resident #1's required a minimum daily fluid intake of 1,400 to 1,600 ml, and said that from 3/16/22 through 4/08/22, staff were not monitoring his/her fluid intake for early identification of dehydration. Unit Manager #1 said that Resident #1's weight loss had not been detected or reported to the Physician or the Dietician as required for early interventions to meet his/her fluid and nutrition needs. Review of Resident #1's Nursing Progress Note, dated 4/09/22, indicated at approximately 4:30 P.M., Resident #1 had respiratory distress with loud labored breathing. Resident #1's Family Members (HCA) was updated on his/her condition and requested Resident #1 be transferred to the Hospital for evaluation. Further review of Resident #1's medical record indicated that on 4/09/22, Resident #1 had respiratory distress with labored respirations and an abnormally low blood pressure of 52/41, indicating shock or dehydration, (normal range was 120/80), and Emergency Medical Services transported him/her to the Hospital Emergency Department (ED). Review of Resident #1's Emergency Department (ED) Physician's Note indicated that he/she was found to have acute on chronic respiratory distress with bilateral pneumonia, was septic (a blood infection) and had significant dehydration (hypovolemia - low fluid volume). The ED Note indicated Resident #1 was treated with oxygen, intravenous fluids, vasopressor agents (intravenous medications to increase his/her blood pressure) and intravenous antibiotics. Review of blood laboratory work completed on Resident #1 on 4/09/22, while Hospital ED indicated he/she had significant dehydration (hypovolemia -a low fluid volume): - Resident #1's blood urea nitrogen (BUN, normal range 7 to 21 milligrams per deciliter, mg/dl ) level was 120 mg/dl, abnormally high . BUN, measures Urea Nitrogen a waste product that your kidneys remove from the blood, higher levels can be caused by dehydration (too little fluid in the body). indicative of dehydration. - Resident #1's sodium (normal 135 to 145 milliequivalent per liter mEq/l) level was 166 mEq/L, an indicator of severe dehydration (hypovolemia -a low fluid volume). - Resident #1's [MEDICATION(S)] (normal is 2.9 to 4.7 grams per deciliter, g/dl) level was 2.2 g/dl (abnormally low) an indicator of nutritional decline and dehydration. Review of Resident #1's Hospital Physician's Admission Note, dated 4/09/22, indicated he/she was admitted to critical care unit, his/her respiratory distress progressed, based on discussion with his/her HCA, Resident #1 was made comfort care only.

Based on observations, record reviews and interview, the facility failed to ensure a medication pass error rate of less than five percent (%). The medication error rate was observed to be 20% for three residents (#59, #69 and #258), out of seven applicable residents, in 25 opportunities. Findings include: Review of Lippincott's 8 Rights of Medication Administration, dated 5/27/11, included the following: 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time: double-check that you are giving the ordered dose at the correct time . 6. Right documentation: document administration after giving the ordered medication, chart time, route and other specific information as necessary . 7. Right reason 8. Right response 1. Resident #59 was admitted to the facility in April of 2016 with a [DIAGNOSES REDACTED]. Review of the medical record indicated a Physician Order, dated 1/23/20, for Humalog (rapid-acting insulin) 100 units per milliliter (ml) as per sliding scale with breakfast. For blood sugar 80-99 give 4 units, for blood sugar 100-180 give 6 units, for blood sugar 181-210 give 8 units, for blood sugar 211-331 give 9 units and for blood sugar over 331, call the physician. During an interview and observation of the medication administration pass on 2/7/20 at 9:20 A.M., Nurse #3 said that Resident #59's blood sugar result was 191 and she medicated the resident with Humalog 8 units subcutaneous (under the skin) into the right lower abdomen. During an interview on 2/7/20 at 11:00 A.M., Nurse #3 said Resident #59 had already consumed her/his breakfast meal earlier and she did not administer the Humalog insulin with breakfast, as ordered. This resulted in a medication error. 2. Resident #69 was admitted to the facility in December of 2019 with a [DIAGNOSES REDACTED]. Review of the medical record indicated a Physician Order, dated 2/6/20, for [MEDICATION NAME] (an anti-Parkinson medication) 25-250 milligram (mg) tablet, one tablet orally four times a day. Review of the February 2020 Medication Administration Record [REDACTED].M., 1:00 P.M., 5:00 P.M. and 9:00 P.M . During an observation of the medication administration pass on 2/7/20 at 7:44 A.M., Nurse #4 administered [MEDICATION NAME] 25-250 mg one tablet to Resident #69. During an interview on 2/7/20 at 11:09 A.M., Nurse #4 said she did not administer the [MEDICATION NAME] at the correct time, as ordered. This resulted in a medication error. 3. Resident #258 was admitted to the facility in February of 2020 with [DIAGNOSES REDACTED]. Review of the February 2020 Monthly Physician order [REDACTED]. Review of the February 2020 MAR indicated [REDACTED] -Pregabalin 50 mg capsule scheduled for 8:00 A.M. -Pregabalin 100 mg capsule scheduled at 8:00 P.M. -Potassium Chloride scheduled for 8:00 A.M. and 8:00 P.M. -Acamprosate Calcium scheduled for 8:00 A.M., 2:00 P.M. and 8:00 P.M. During an observation of the medication administration pass on 2/7/20 at 9:30 A.M., Nurse #3 administered Pregabalin, Potassium Chloride and Acamprosate Calcium medications to Resident #258. During an interview on 2/7/20 at 11:00 A.M., Nurse #3 said she did not administer the Pregabalin, Potassium Chloride and Acamprosate Calcium medications at the correct times, as ordered. This resulted in three medication errors.

Based on observation and interview, the facility failed to ensure that medications were of current date to provide reliability of strength and accuracy of dosage, on one of three units observed. Findings include: 1. During an inspection on [DATE] at 8:16 A.M., of the South Unit Medication cart with Nurse #5, one opened [MEDICATION NAME] Insulin pen for a specific resident was found with a documented expiration date of [DATE]. Review of the (2016) Nursing Drug Handbook indicated the following information relative to storage of insulin's: [MEDICATION NAME] (rapid-acting) Insulin-store unopened vials and pens in refrigerator until expiration date; if stored unopened at room temperature, discard after 28 days. During an interview on [DATE] at 8:20 A.M., Nurse #5 said the [MEDICATION NAME] Insulin was expired and she removed it from the cart.

Based on observation, interview and record review, the facility failed to ensure behavioral health care and services were provided to assess the mental and psychosocial well-being of one sampled resident (#18), out of a total of 23 sampled residents. Findings include: Resident #18 was admitted to the facility in March of 2016 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 8/26/19, indicated Resident #18 exhibited moderate, cognitive impairment as evidenced by the staff interview; did not trigger for mood impairments, had the ability to understand others and was able to hear with minimal difficulty. Review of Resident #18's roommate (Resident #62) progress notes, indicated the following: -11/18/19 Resident # 62 frequently demanding that Resident #18 be taken out of the room because he/she did not belong there -11/20/19 Resident #62 wanting to have Resident #18 leave, howling and yelling to disturb Resident #18 -11/28/19 Resident #62 with many behaviors .yelling at staff to remove Resident #18 from the room because he/she did not want them there -11/30/19 Resident #62 screaming at Resident #18 to get him/her out of the room, threatening to get the nurse fired -12/1/19 Resident #62 continues to scream at Resident #18 -12/28/19 Resident #62 yelling at Resident #18, one to one and redirection provided with no effect -1/8/20 when Resident #18 was brought into the room, Resident #62 said he/she cannot be there -1/11/20 Resident #62 continues to scream at Resident #18 -1/12/20 Resident #62 continues to scream at Resident #18 Review of the Resident #18's clinical record did not indicate that an assessment was conducted to ensure he/she did not have ill effects related to Resident #62's behaviors that targeted him/her, nor was there evidence of the above incidences as detailed in Resident #62's clinical record. Review of the Quarterly MDS Assessment, dated 11/18/19, indicated Resident #18 exhibited severe cognitive impairment as evidenced by the staff assessment and triggered for mood impairments as evidenced by staff interview for feeling tired and/or with little or no energy during the staff assessment. During an observation on 2/07/20 at 9:44 A.M., Resident #18 was seated in the activity room with other residents. During an interview on 2/07/20 at 1:48 P.M., Certified Nurse Aide (CNA) #1 said that Resident #62 gets upset when Resident #18 uses the bathroom in their room, so facility staff has Resident #18 use another bathroom. When Resident #18 enters the room, Resident #62 will yell and tell him/her to get out. During an interview on 2/07/20 at 1:53 P.M., CNA #2 said that Resident #18 was in the room long before Resident #62 was. She said she has observed Resident #62 yell at Resident #18 and that Resident #18 did not appear to be upset by the interactions. She said that the staff tries to intervene, but Resident #62 continues to yell at Resident #18. During an interview on 2/11/20 at 11:07 A.M., Unit Manager (UM) #1 said Resident #62 moved into the room around 11/16/19. She said that Resident #18 was out of the room most of the day and that the behaviors documented in the clinical record with Resident #62 probably occurred at night when Resident #18 was going to bed. During an interview on 2/11/20 at 11:07 A.M., Social Worker #1 said that she was unaware of Resident #62's behaviors including yelling/screaming at Resident #18. She said that staff would usually communicate this with her so that she could follow up and make sure that Resident #18 felt safe in the environment and see if he/she wanted to have a room change.

Based on observation, record interview and interview, the facility failed to ensure an accurate medical record relative to labeled administration directions on a blister pack medication card for one Resident (#258), out of a total sample of 23 residents. Resident #258 was admitted to the facility in February of 2020 with [DIAGNOSES REDACTED]. During an observation of the medication administration pass on 2/7/20 at 9:30 A.M., Nurse #4 administered Acamprosate Calcium (an alcohol deterrent) 333 milligram (mg). The label on the medication blister card indicated to administer two tablets by mouth three times a day. Review of the medical record indicated a Physician Order, dated 2/6/20, to administer Acamprosate Calcium 333 mg one tablet three times a day for 5 days. During an interview on 2/7/20 at 11:12 A.M., Unit Manager (UM) #2 said when a medication order is changed, a sticker indicating the order is changed, refer to physician orders [REDACTED]. UM #2 said the Acamprosate Calcium blister card did not have a sticker on the label to indicate a change in orders, as required.

Based on observations, interviews and record reviews, the facility failed to ensure urinary catheter (tube inserted into the bladder to allow the flow of urine from the body) care and services were provided relative to 1.) Implementation of physician's orders, and 2.) Ensuring infection control practices were adhered to, for two sampled residents (#65 and #256), out of a total sample of 23 residents. Findings include: 1. Resident #65 was admitted to the facility in April of 2019 with a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/7/19, indicated Resident #65 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15, required extensive assistance with toileting, and had a catheter. Review of a nurse's note, dated 12/5/19, indicated Resident #65 had a Suprapubic catheter (tube surgically inserted into the bladder through a cut in the abdomen to drain urine from the bladder) placed by urology. Review of the December 2019 Physicians Orders indicated the following orders: - Suprapubic catheter 16 French - flush (irrigate) the Suprapubic catheter tubing with 3 milliliters of Sodium Chloride 0.9% syringe, twice daily as needed, use alcohol wipes to cleanse each side of the tubing and slowly flush the tubing, reconnect tubing and allow it to drain. Review of the facility policy entitled Catheter Irrigation, Open System, dated 5/2/05, indicated the following: -position the resident so that the catheter is accessible, -open the sterile irrigation tray using sterile technique, -pour prescribed irrigation solution into the sterile solution container, -put on sterile gloves, -place the sterile drape under the catheter, -place the sterile collection basin under the catheter on the sterile drape, -draw 30 cubic centimeters (cc's) of the prescribed solution into the irrigating syringe, -disconnect the catheter from the drainage tubing, Cover the open end of the drainage tubing with the sterile protector cap. Position capped tubing so that it remains coiled on the bed surface. -insert the syringe into the catheter and slowly instill the solution -remove the syringe and allow the catheter to drain into the sterile collection basin via gravity. Repeat until all of the solution has been used or until the flow returns easily -remove the protector cap, clean the end of the drainage tubing with an alcohol pledget (absorbent cotton), and reconnect tubing to the catheter. Review of a nurse's note, dated 12/26/19, indicated Resident #65 had no urine output from his/her Suprapubic catheter. Nurse #1 indicated the catheter tubing was plugged, and used a [DEVICE] de-clogger (an apparatus used to unclog a gastrostomy tube/[DEVICE], which is a tube surgically inserted into the stomach to provide nutrition) to push large amounts of sediment out of the tubing. Nurse #1 indicated he/she then reconnected the catheter tubing to the urinary drainage bag using a clean technique and alcohol wipes to disinfect all tubing. During an interview on 2/11/20 at 8:36 A.M., Unit Manager (UM) #1 said Resident #65 had a Suprapubic catheter that got blocked at times due to his/her mucusy urine. She said that if the Suprapubic catheter was blocked, the nurse would follow the physician's orders to irrigate the catheter tubing in an attempt to unblock it. During an interview on 2/11/20 at 9:54 A.M., the Director of Nurses (DON) said that a physician's order was required to irrigate/flush a Suprapubic catheter. She said a Suprapubic catheter should not be unblocked with a [DEVICE] de-clogger. The DON further said there was no physician's order to use the [DEVICE] de-clogger, and there was a potential risk of contamination by utilizing the apparatus. The DON said if the Suprapubic catheter tube was blocked, then the nurse should have irrigated the catheter as per the physician's order and, if the tube was unable to be cleared, then Resident #65 should have been sent to the hospital for evaluation. 2. For Resident #256, the facility failed to ensure care and services were provided for an indwelling urinary catheter related to the positioning of the urinary privacy bag and urinary tubing. Resident #256 was admitted to the facility in January of 2020 with a [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, with an Assessment Reference Date (ARD) of 1/24/20, indicated Resident #256 was cognitively intact as evidenced by a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment and utilized an indwelling catheter. During an observation on 2/5/20 at 10:23 A.M., Resident #256 was sitting in a wheelchair across from the nursing station. A urinary privacy bag was hanging from under the wheelchair and was resting on the floor. The resident's catheter tubing, filled with blood tinged yellow liquid, was observed in the privacy bag and extended onto the floor. During an observation on 2/11/20 at 9:46 A.M., Resident #256 was sitting in a wheelchair at bedside. The urinary privacy bag was hanging from under the wheelchair and resting on the floor. The catheter tubing filled with yellow liquid was partially in the privacy bag and extended onto the floor. During an interview on 2/11/20 at 9:50 A.M., Nurse #2 said the urinary privacy bag and tubing were not positioned off the floor, as required.

Based on observation, interview and record review, the facility staff failed to follow transmission based precautions to prevent cross contamination and possible spread of infection related to use of personal protective equipment (PPE) for 2 residents (#33 and #40), in a total sample of 19 residents. Findings include: Review of the facility procedure titled Procedure for Isolation: Initiation of Isolation Precautions, dated, as revised 12/2016, indicated the following: -Contact Precautions: in addition to standard precautions, use Contact Precautions for Residents Known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items -Includes epidemiologically important organisms (multidrug resistant organisms) such as [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE), other highly transmissible infections such as [MEDICAL CONDITIONS] -Soap and water hand hygiene is required following care of a resident or surfaces in the resident's environment if the infection is a spore forming infection, for example [MEDICAL CONDITIONS] 1. During the medication pass observation on 1/9/19 at 8:30 A.M., Nurse #1 prepared Resident #33's medications and said that Resident #33 was on contact precautions for a [MEDICAL CONDITION] infection. Observation on 1/9/19 at approximately 8:30 A.M., located outside Resident #33's room, there was a stop sign indicating that you needed to check with the nurse before entering the room, and a plastic multi-draw unit that contained personal protective equipment (PPE) including disposable gloves, masks and gowns. On 1/09/19 at 8:51 A.M. Certified Nursing Assistant (CNA) #1 was observed to enter Resident #33's room without donning PPE and exited the room carrying the Resident's breakfast tray. Nurse #1 turned to CNA #1 and said the Resident is on precautions. During an interview with Nurse #1, at that time, she said the CNA should have worn gloves During an interview with CNA #1, on 1/09/19 at 8:59 AM, she said that she was just picking up a tray and did not need to wear PPE. She further said she used hand sanitizer. 2. Resident #40 had multiple [DIAGNOSES REDACTED]. During an observation on 1/9/19 at approximately 11:10 A.M., located outside Resident #40's room, there was a stop sign indicating that you needed to check with the nurse before entering the room, and a plastic multi-draw unit that contained personal protective equipment (PPE), including disposable gloves, masks and gowns. On 1/09/19 at 11:21 A.M., the surveyor observed CNA #2 enter Resident #40's room without donning PPE. The surveyor observed CNA #2 approach the Resident, who was in bed, and moved the bedside table that was positioned next to the Resident's bed while conversing with the Resident. The surveyor observed the CNA to exit the Resident's room and use hand sanitizer, located at the nursing station. During an interview with CNA #2, at that time, she said that she wears PPE gown and gloves when she provides Resident #40 care because the Resident has a [MEDICAL CONDITION] infection. She further said that she does not need to wear any PPE when touching/contacting the residents environment, as she is not providing care. During an interview on 1/9/19 at 4:20 P.M. with Director of Nursing Service (DNS) and the Corporate Quality Improvement Manager, they said that if a staff member enters the room of a resident on contact precautions and has contact with the Resident's environment, the staff member should, at a minimum be wearing gloves and if the staff member's clothing is going to be in contact with the Resident's environment, the staff member should also wear a gown. They further said that staff members should be washing their hands with soap and water and not using hand sanitizer, as the [MEDICAL CONDITION] infection organism is a spore, and can easily be transmitted.

Based on observation, record review and interview, the facility failed to follow the plan of care for Assessed For Fall Risk for 1 resident (#9) in a total sample of 20 residents. Findings include: Resident #9 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. The Minimum Data Set assessment, with an Assessment Reference Date of 6/19/17, indicated a Brief Interview for Mental Status score of 8 out of 15 (moderate cognitive impairment). The resident required extensive assist with transfers, ambulation and toilet use, had urinary incontinence, had 2 falls with no injury and 2 falls with injury. Review of the plan of care Assessed For Fall Risk, of 7/27/17, indicated the following interventions: *Bilateral Bed Bolsters. *Pad alarm in bed and chair at all times. *Wide bed. Review of Progress Notes and Fall Investigation indicated that on 8/2/17 at 10:15 A.M., the resident was found sitting on the bedroom floor, with no injury. The alarm did not sound. Documentation indicated that the resident could shut the alarm off. The plan of care was updated to include the following: when spouse (roommate) is at activity or out of room, have resident go with him/her to activity or out of room in hall. During an observation, on 9/11/17 at 12:55 P.M., Resident #9 was observed sitting in a wheelchair, alone in his/her bedroom. The chair alarm box was observed attached to the left wheelchair handle (within reach, even though the resident could shut it off). Resident #9's spouse was not in the room, and Resident #9 was not in the hallway, per plan of care. Resident #9 had taken his/her shoes off, and was attempting to get up from the wheelchair. Resident #9 asked the Surveyor to help him/her get into bed. The Surveyor asked Resident #9 to stayed seated, and then pressed the call bell. After about 5 minutes, a Certified Nursing Assistant entered the room. During an observation, on 9/11/17 at 2:15 P.M., Resident #9 was observed lying in a wide bed sleeping. The 2 bed bolsters were observed on the floor and were not in place on the bed, per plan of care. Resident #9's spouse was sitting in a chair next to his/her bed. During an interview, Resident #9's spouse said that she had left the room earlier with the physical therapist. Resident #9's spouse said that upon leaving the room, he/she alerted the nurse that Resident #9 was alone in the room. Resident #9's spouse said that his/her spouse was not supposed to be left alone in the bedroom. Resident #9's spouse said that his/her spouse had sustained multiple falls. On 9/11/17 at 2:20 P.M., the surveyor alerted Unit Manager #1 that the bed bolsters were not in place per plan of care. Unit Manager #1 said that he would take care of it. During an interview, Unit Manager #1 said that Resident #9 should not be left alone in bedroom per plan of care.

Based on record review and interview, the facility failed to ensure the accuracy of assessments for 2 residents (#5 and 8) in a total sample of 20 residents. Findings include: 1. Resident #5 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. A. Review of the vital signs documentation indicated that the resident's weight was recorded as 153 pounds, on 2/13/17. Review of Progress Notes indicated that the resident was readmitted in 3/2017, following a left above the knee amputation. Review of the Weekly Skin Evaluation Form indicated that the resident's readmission weight was 140.2 pounds (12.8 pound weight loss/9 percent weight loss in one month). Review of the significant change in status Minimum Data Set assessment (MDS), with an Assessment Reference Date (ARD) of 3/17/17, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (intact mental status). The resident's weight was incorrectly documented as 149 pounds (K0200-B.); and significant weight loss was not documented (K0300-2). Please see F514. B. Review of a physician's orders [REDACTED]. Review of the quarterly MDS assessment, with an ARD of 8/28/17, indicated a BIMS score of 15 (intact mental status). Indwelling catheter was incorrectly coded (H0100 A.); and urinary incontinence was incorrectly not rated (H0300-9.). During an interview, on 9/11/17 at 10:30 A.M., the MDS Nurse said that the assessments of 3/17/17 and 8/28/17 were incorrectly coded for weight and indwelling catheter. 2. Resident #8 was admitted to the facility in 11/2016 with a [DIAGNOSES REDACTED]. Review of Progress Notes indicated that the resident's pressure ulcer was healed on 6/5/17. A review of the quarterly MDS assessment, with an ARD of 8/7/17, indicated that the resident had short and long term memory loss. One Stage II pressure ulcer was incorrectly coded (M0300-B.1. and 2.). During an interview, on 9/11/17 at 10:30 A.M., the MDS Nurse said that the assessment of 8/7/17 was incorrectly coded for pressure ulcer.

Based on record review, observations, and staff interviews, the facility failed to provide the necessary care and services to promote healing and prevent the development of pressure ulcers, for 1 resident (#1) of 5 applicable residents, out of a sample of 20 residents. The facility failed to prevent the development of lower leg pressure ulcers acquired at the facility, failed to provide the necessary treatment and services to promote healing, by not following the physician's orders [REDACTED]. Findings included: Resident #1 was admitted to the facility in 12/29/2000. The Resident's pertinent [DIAGNOSES REDACTED]. Review of the community wound clinic sheet of 8/19/10 indicated that both the right and left lower extremity wounds were healed and to continue to protect the areas with abdominal pads and air boots. Review of the pressure ulcer care plan of 8/20/10 to present, had the following interventions: - Hill ROM low air loss mattress - Round soft heel boots bilaterally to the lower extremities to prevent the legs from crossing while in bed only. - Blue air boots bilaterally to the legs while out of bed in the wheelchair. Review of the annual Minimum Data Set Assessment of 11/26/10 indicated that this Resident had impaired short and long term memory, had severely impaired decision making, was nonambulatory, was totally dependent with bed mobility and transfers and was a 2 person physical assist. Under Section M, Skin Conditions, was at risk for developing pressure ulcers and did not have any unhealed pressure ulcers. Review of the Care Area Assessment (CAA) Summary of 12/6/10 indicated this Resident triggered for pressure ulcers. The CAA Narrative Summary indicated that this Resident has a history of pressure ulcers and advanced [MEDICAL CONDITION]. The Analysis of findings indicated this Resident has a history of bilateral lower extremity ulcers. This Resident is non-mobile, and is out of bed in the wheelchair daily. Provide air boots as ordered, turn and position every 2 hours and a Hill ROM Speciality mattress on the Resident's bed. The Resident's skin was intact and all skin areas of compromise will be managed/treated appropriately. Review of the Norton Pressure Ulcer Scale of 12/8/10 indicated this Resident had a score of 7, at high risk for a pressure ulcer. Review of the Nurse's Note of 12/8/10 indicated this Resident's lower extremities pressure ulcers had opened and the physician was notified. A physician's orders [REDACTED]. - Review of the Skin Condition Record indicated on 12/8/10 the right lower lateral leg pressure ulcers measurements were as follows: Upper area was 2 centimeters (cm) in length, by 5 cm in width, the depth of the ulcer and the stage of the ulcer were not written in the space provided. Under comments, there was a dark area which measured 1.5 cm in length, by 2.2 cm in width. Mid area was 2 cm in length, by 3 cm in width, and the depth and the stage of this ulcer were not written in the space provided. Under comments, there was a dark area which measured 1.2 cm in length, and 1.6 cm in width. Lower area was 1 cm in length and circular, the area for the width, depth, and stage were not written in the space provided. - Review of the Skin Condition Record indicated on 12/8/10, that the left lower lateral leg pressure ulcers measurements were as follows: Upper area was a stage 2, and measured 2 cm in length, by 2.5 cm in width, and the depth was not written in the space provided. Lower area was a stage 2, and measured 3 cm in length, by 3 cm in width, and the depth was not written in the space provided. Under comments there was a dark area which measured 2.2 cm in length, by 1.2 cm. in width. - Review of the Skin Condition Record indicated on 12/10/10, that the right lower lateral leg pressure ulcers measurements were as follows: Upper area was a stage 2 and measured 2 cm in length, by 5 cm in width, and the depth was not written in the space provided. Under comments there was a dark area which measured 1.5 cm in length, by 2.1 cm in width. Mid area was a stage 2 and measured 2 cm in length, by 3 cm in width, and the depth was not written in the space provided. Under comments there was a dark area which measured 1 cm in length, by 1.5 cm in width. Lower area was a stage 2 and measured 2 cm in length, by 3 cm in width, and the depth was not written in the space provided. Under tissue appearance it indicated there was yellow slough (dead tissue). This Resident was referred to the community wound clinic and a visit occurred on 1/4/11. The wound measurements were as follows: Right lower leg, the upper area was a stage 3 (an increase in the stage), and measured 0.5 cm in length, by 0.8 cm in width, and 0.1 cm. in depth. The 2 lateral lower right leg pressure ulcers were healed. Left lower leg was a stage 3 (an increase in the stage), and measured 5.5 cm in length, 2.5 cm in width, and 0.1 cm in depth Review of the wound clinic sheets indicated on 1/4/11 that debridement of the left lateral leg ulcer was done at this visit. Under the off loading section of this form, it revealed to wear the air boots at all times and a new recommendation for the dressing change with [MEDICATION NAME] AG (a [MEDICATION NAME] dressing with silver) was recommended. Review of the physician's orders [REDACTED]. Review of the Nursing Note of 1/19/11 indicated that this Resident was found to have blisters to the right and left lateral aspect of the lower legs, which were discovered by the Certified Nursing Assistant during care. The community wound clinic pressure ulcer measurements on 2/1/11 were as follows: Right lower leg pressure ulcer was a stage 3, and measured 6.2 cm in length, by 1.5 cm in width, and 0.1 cm in depth. Left lower leg pressure ulcer was a stage 3, and measured 3 cm in length, by 1.5 cm in width, and 0.1 cm in depth. Review of the wound clinic sheets indicated on 2/1/11, that the right and left lateral leg ulcers were debrided at this visit. On the Patient instruction sheet to the facility a wound clinic nurse wrote, " Please note Conform on legs too tight." The community wound clinic pressure ulcer measurements on 2/22/11 were as follows: Right lower leg pressure ulcer was a stage 3, and measured 7 cm in length, by 1.7 cm in width, and 0.8 cm in depth. Left lower leg pressure ulcer was a stage 3, and measured 4.6 cm in length, by 1.5 cm in width, and 0.9 cm in depth. During this wound clinic visit on 2/22/11, the right leg pressure ulcer was debrided. The community wound clinic pressure ulcer measurements on 3/15/11 were as follows: Right lower leg - pressure ulcer was a stage 3 and measured 3.5 cm in length, 3 cm in width and 0.6 cm in depth. Left lower leg - pressure ulcer was a stage 3 and measured 3.7 cm in length by 1.5 cm in width and 0.6 cm in depth. Review of the wound clinic sheets of 3/5/11, recommended [MEDICATION NAME] Santyl (a [MEDICATION NAME] and tissue stimulating agent) to the wound bed and to pack the ulcers with depth (on both legs) with gauze. Review of the physician's orders [REDACTED]. For the right and left pressure ulcers with depth on both legs apply Santyl on the area with 2 by 2 gauze and pack wounds to fill the dead space. The community wound clinic pressure ulcer measurements on 4/12/11 were as follows: Right lower leg - pressure ulcer was a stage 3 and measured 6.5 cm in length, 2.5 cm in width and 0.5 to 1 cm in depth. Left lower leg, the upper area - pressure ulcer was a stage 3 and measured 5 cm in length by 1 cm in width and 1 cm in depth. Left lower leg, the lower area - pressure ulcer was a stage 3 and measured 0.7 cm in length, by 0.5 in width, and 0.1 cm in depth. Review of the wound clinic sheets of 4/12/11, recommended to continue [MEDICATION NAME] Santyl and filling the dead space of the wound with gauze. Review the physician's orders [REDACTED]. On 5/3/11 at 11:00 A.M., the surveyor observed Nurse #1 in this Resident's room sitting on the floor, on a towel performing the dressing change. The Resident's Room was dark, there was no light on in the room during the dressing change (which would make it difficult to adequately assess this ulcer). This Nurse was not wearing a gown for contact precautions (as required for infection control) during this dressing change. Nurse #1 removed the dressing to the right lower leg and did not wash hands, just changed gloves, over dirty hands. Physical Therapy Assistant #1 came into the room and indicated this Resident need to have a diathermy treatment (the use of sub-thermal heat to promote healing of the pressure ulcers) to this Resident's lower legs, right away. Nurse #1 stopped the dressing change and indicated that this dressing to the right leg would be performed after the diathermy treatment. During the right lower leg dressing change on 5/3/11 at 11:45 AM., Nurse #1, removed a dressing on the right upper and lower leg, which did not have any gauze in the dead space of the pressure ulcer. Nurse #1 indicated the right wounds were both stage 3 pressure ulcers. The lower right leg pressure ulcer measured 4 centimeters in length (cm), by 2.3 cm in width, and 0.1 cm in depth. The right upper leg pressure ulcer measured 3 cm in length, by 2.8 cm in width and 0.6 cm in depth. Nurse #1 applied Santyl to the wound beds, then Vaseline gauze and Kerlix. There was no gauze placed in the wound bed to fill the dead space, as ordered by the Physician to promote wound healing. During this dressing change Nurse #1 donned gloves over dirty hands and did not wash hands. Observation of Resident #1 on 5/3/11 at 1:40 P.M. was of this Resident sitting in the specialized wheelchair with no air boots applied to the legs and heels. During the left leg dressing change on 5/3/11 2:15 P.M., this Resident had a wedge cushion under the resident's legs, behind the knees to prevent pressure on the lateral leg pressure ulcers. The heels were bilaterally pressured into the bed. When Nurse #1 and Certified Nursing Assistant (CNA) #1 were asked where this Resident's heel boots and the blue air boots were, Nurse #1 and the CNA indicated that they did not known where the boots were and they confirmed that the boots were not worn by the Resident today. During the left leg dressing change on 5/3/11 at 2:15 P.M., with Nurse #1 and Unit Manager (UM) #2, Nurse #1, removed a dressing to the left lower extremity, which did not have gauze in the dead space in this ulcer. Nurse #1 indicated this ulcer was a stage 3 pressure ulcer. This ulcer measured 5.2 cm in length by 1 cm in width and 0.8 cm in depth. Nurse #1 applied Santyl to the wound bed, then Vaseline gauze and Conform. There was no gauze placed in the wound bed to fill the dead space as ordered by the Physician, to promote wound healing. During an interview on 5/3/11 at 2:30 P.M., Nurse #1 acknowledged that the dead space in the pressure ulcers on the right and left legs were not filled with gauze as ordered. During an interview on 5/3/11 at 2:55 P.M., UM #2 acknowledged that the dead space in the left leg pressure ulcer was not filled with gauze by Nurse #1 during the dressing change. During an interview on 5/3/11 at 2:58 P.M., UM #2 acknowledged that the physician's orders [REDACTED]. UM #2 also, acknowledged that the TAR of 5/11 indicated the dressing to the right and left pressure ulcers on the lower legs were done without filling the dead space in the wound for 3 days. Interview with UM #2 on 5/3/11 at 3:45 P.M. indicated that the Resident's care plan for the blue air boots while out of bed and wearing the soft heel boots while in bed, were not followed. Please refer to F 282, Example #1, F 441, Example #1, and F514 Example #1.

Based on record review, interview and observations, the facility failed to implement physicians orders for 2 residents, (#8 and #11) out of a total sample of 12 residents. Findings included: 1. For Resident #8, the facility failed to administer Oxygen as ordered. Resident #8 was admitted to the facility in 5/2011 with [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation of the resident 6/21/11 at 10:00 A.M., was of the resident sitting in a chair. The resident did not appear short of breath. During discussion on 6/22/11 at 11:45 A.M., Unit Manager #1 confirmed that the resident should have received Oxygen 2 liters per minute via nasal cannula at night and did not. During discussion on 6/22/11 at 2:45 P.M., the Director of Nurses acknowledged that there was no documentation in the clinical record that the resident received the Oxygen 2 liters per minute via nasal cannula as ordered by the physician. Please refer to F328. 2. For Resident #11, the facility failed to discontinue the medication [MEDICATION NAME] as ordered by the physician. Resident #11 was admitted to the facility in 1/18/11 and readmitted to the facility in 6/20/11. The resident's [DIAGNOSES REDACTED]. Review of the clinical record indicated the resident had a history of [REDACTED]. Review of the physician's orders [REDACTED]. Review of the record indicated the resident developed symptoms of a urinary tract infection (blood in the urine and elevated temperature) and was transferred to the hospital with a [DIAGNOSES REDACTED]. The resident was transferred to the hospital 6/15/11 and admitted with a [DIAGNOSES REDACTED]. While in the hospital, the [MEDICATION NAME] was discontinued and the resident was started on another antibiotic [MEDICATION NAME]. The resident returned to the facility on [DATE]. Review of the hospital discharge summary indicated the resident's [MEDICATION NAME] was discontinued in the hospital and the discharge summary instructions included the following instructions to the facility "May restart [MEDICATION NAME] when the [MEDICATION NAME] is finished." Review of the June 21 and June 22 2011 Medication Administration Sheet indicated that the resident received the [MEDICATION NAME] on 6/21/11 and 6/22/11 while still receiving the [MEDICATION NAME]. During interview on 6/22/11, Unit Manager #1 acknowledged that the resident received the [MEDICATION NAME] on 6/21/11 and 6/22/11 while still receiving the [MEDICATION NAME] in error.

Based on record review, interview, and observation the Facility failed to ensure that three of seven sampled Residents (Resident #2, Resident #3, and Resident #5) were treated with dignity and respect. Specifically, Accused Nurse #1 called Resident #2 "[***] face" in Resident #2 presence; Accused Nurse #1 called Resident # 3 "the beast" in Resident # 3's presence; and Accused Nurse #1 antagonized Resident # 5 with inappropriate "love life" questions during meal time and constantly prodded Resident # 5 to eat until Resident # 5 became upset and stopped eating. The findings included: 1). Resident #2 was admitted to the Facility in December 2010, with [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated 4/5/11, indicated Resident #2 had unclear speech, only sometimes understood others and was only sometimes understood by others. The MDS indicated Resident #2 had impaired short term memory, impaired long term memory, and Resident #2 had severely impaired decision making ability. The MDS indicated Resident #2 had periods of inattention, but Resident #2 displayed no problem behavioral symptoms. The MDS indicated Resident #2 was totally dependent on staff for all activities of daily living. A cognitive care plan, updated on 4/5/11, indicated Resident #2 had confusion, memory loss, and cognitive deficits. Care plan interventions included approaching Resident #2 in a gentle and friendly manner, being alert to non-verbal clues of problems, and keeping the environment quiet whenever possible. Nursing Assistant #1 was interviewed at 10:01 A.M. on 4/22/11. Nursing Assistant #1 said maybe two weeks ago at about 10:30 A.M., Nursing Assistant #1 was doing morning care for two Residents (Resident #2 and Resident #3, who were in the same room). Nursing Assistant #1 said Nursing Assistant #1 was providing care to Resident #2 and Accused Nurse #1 said oh, now your doing "[***] face". Nursing Assistant #1 said Accused Nurse #1 clowned around often, but that was just inappropriate. Nursing Assistant #1 said Nursing Assistant #2 was in the room when Accused Nurse #1 called Resident #2 "[***] face". Nursing Assistant #2 was interviewed at 10:50 A.M. on 4/22/11. Nursing Assistant #2 said about two to three weeks ago, Nursing Assistant #2 was in Resident #2's room with Nursing Assistant #1 and Accused Nurse #1 entered the room and said oh, your doing "[***] face" and then Accused Nurse #1 left the room. Resident #2 was interviewed at 2:30 P.M. on 4/22/11. Resident #2 was asked if Resident #2 knew Accused Nurse #1 and Resident #2 just stared at the Surveyor, but would not answer any questions. 2). Resident #3 was admitted to the Facility in December 2000, with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 2/28/11, indicated Resident #3 had no speech, was rarely or never able to make self understood, and only sometimes understood others. The MDS indicated Resident #3 had impaired short term memory, impaired long term memory, and Resident #3 had severely impaired decision making ability. The MDS indicated Resident #3 had periods of altered level of consciousness and psychomotor [MEDICAL CONDITION]. The MDS indicated Resident #3 displayed no problem behavioral symptoms. The MDS indicated Resident #2 was totally dependent on staff for all activities of daily living. Nursing Assistant #1 was interviewed at 10:01 A.M. on 4/22/11. Nursing Assistant #1 said Nursing Assistant #1 was doing morning care for Resident #2 and Resident #3 (they were in the same room). Nursing Assistant #1 said that while Nursing Assistant #1 was washing Resident #3, Accused Nurse #1 came into the room and said oh, I see your doing the "beast" and then left. Nursing Assistant #1 said this was said right in front of Resident #3. Nursing Assistant #2 was interviewed at 10:50 A.M. on 4/22/11. Nursing Assistant #2 said Nursing Assistant #2 had heard Accused Nurse #1 call Resident #3 the "beast" right out in the hallway where others could hear, but Accused Nurse #1 was careful not to make those kinds of comments when the "higher ups" were around. Nursing Assistant #3 was interviewed at 11:45 A.M. on 4/22/11. Nursing Assistant #3 said Nursing Assistant #3 heard Accused Nurse #1 call Resident #3 a "beast" right in front of Resident #3. Nursing Assistant #3 said Resident #3 did not respond to much, but could still hear what was said right in front of Resident #3. Nurse #2 was interviewed at 10:25 A.M. on 4/22/11. Nurse #2 said Accused Nurse #1 had referred to Resident #3 as the "beast", but Nurse #2 had not heard Accused Nurse #1 say that in front of Resident #3; however, a statement written by Nurse #2 on 4/8/11, indicated that Nurse #2 had heard Accused Nurse #1 call Resident #3 a "beast" in front of Resident #3 on at least one occasion. The statement indicated that Nurse #2 heard Accused Nurse #1 make negative of disparaging remarks about many residents in the hallway in front of the residents. The Surveyor attempted to interview Resident #3 at 3:10 P.M. on 4/22/11, but Resident #3 was unable to participate in an interview due to impaired cognition. 3). Resident #5 was admitted to the Facility in June 2001, with [DIAGNOSES REDACTED]. An impaired cognition care plan, updated on 1/26/11, indicated Resident #5 had an impaired thought process, poor judgement, and difficulty with decision making related to major [MEDICAL CONDITION] with paranoid delusional ideation. Care plan interventions included approaching Resident #5 calmly and positively, give instructions one at a time, providing periods of decreased or low stimulation, and not overwhelming Resident #5 with questions. A quarterly Minimum Data Set (MDS) assessment, dated 2/4/11, indicated Resident #5 was sometimes able to make self understood and usually understood others. The MDS indicated Resident #5 scored 7 out of 15 possible points on a brief interview for mental status, which was representative of severe cognitive impairment. The MDS indicated Resident #5 had periods of disorganized thinking and Resident #5 displayed no problem behavioral symptoms. The MDS indicated Resident #5 was totally dependent on staff for transfers, locomotion, toilet use, personal hygiene, dressing, and bathing and Resident #5 required extensive staff assistance with bed mobility. The MDS indicated Resident #5 was able to eat independently and required a therapeutic diet. Nursing Assistant #1 was interviewed at 10:01 A.M. on 4/22/11. Nursing Assistant #1 said Accused Nurse #1 liked to clown around with Resident #5 while Resident #5 ate and Resident #5 became very upset and said keep Accused Nurse #1 away from Resident #5. Nursing Assistant #1 said Accused Nurse #1 kept asking Resident #5 about boyfriends and that sort of thing while Resident #5 ate meals. Nursing Assistant #1 said Accused Nurse #1 monitored the dining room, so Accused Nurse #1 was there all the time. Nursing Assistant #2 was interviewed at 10:50 A.M. on 4/22/11. Nursing Assistant #2 said Accused Nurse #1 antagonized Resident #5 to the point that Resident #5 became frustrated. Nursing Assistant #2 said Accused Nurse #1 kept badgering Resident #5 to eat, but Resident #5 got so upset that Resident #5 stopped eating. Nursing Assistant #2 said Accused Nurse #1 monitored the dining room, so was often there with Resident #5. Nursing Assistant #3 was interviewed at 11:45 A.M. on 4/22/11. Nursing Assistant #3 said Resident #5 ate slowly and Accused Nurse #1 antagonized Resident #5 so much that Resident #5 got really upset. and told Accused Nurse #1 to go away. Nursing Assistant #3 said Accused Nurse #1 made comments to Resident #5 in a joking type of voice, but Resident #5 clearly did not like it and Accused Nurse #1 should have just let Resident #5 eat in peace. Nurse #2 was interviewed at 10:25 A.M. on 4/22/11. Nurse #2 said Accused Nurse #1 teased Resident #5 to the point that Resident #5 did not eat well. Nurse #2 said one time when Accused Nurse #1 told Resident #5 that Accused Nurse #1 was Resident #5's lover, Resident #5 became so upset that Resident #5 tried to hit Accused Nurse #1. Nurse #2 said it seemed harmless at first, but it went over the line. Nurse #2 said Resident #5 ate much better now that Accused Nurse #1 was no longer at the Facility. The Surveyor attempted to interview Resident #5 at 3:40 P.M. on 4/22/11. Initially Resident #5 just stared at the Surveyor when the Surveyor asked questions. After a while Resident #5 spoke to the Surveyor but Resident #5 was unable to recall Accused Nurse #1 or the incidents. Accused Nurse #1 was interviewed at 1:55 P.M. on 5/17/11 with Accused Nurse #1's Attorney present. Accused Nurse #1 denied that Accused Nurse #1 ever called Resident #2 "[***] face" or called Resident #3 "the beast". Accused Nurse #1 said Accused Nurse #1 would never call any resident names or verbally abuse any resident. Accused Nurse #1 said Nursing Assistant #1 had an axe to grind with Accused Nurse #1, because Accused Nurse #1 disciplined Nursing Assistant #1 and then the next day the allegation appeared. Accused Nurse #1 said Nursing Assistant #2 also had an ax to grind with Accused Nurse #1, because Nursing Assistant #2 wanted more that a professional relationship with Accused Nurse #1 and Accused Nurse #1 re-buffed Nursing Assistant #2. Accused Nurse #1 said Accused Nurse #1 had a history with Resident #5 and knew Resident #5 prior to being at the Facility. Accused Nurse #1 said Resident #5 always greeted Accused Nurse #1 as "my little angel" in Italian. Accused Nurse #1 said Resident #5's oral intake decreased the last couple months and Accused Nurse #1 tried to encourage Resident #5 to eat, but never got Resident #5 upset or caused Resident #5 to stop eating. Accused Nurse #1 said Accused Nurse #1 had a good relationship with Resident #5 and all Accused Nurse #1 tried to do was encourage Resident #5 to eat.

Based on record review and interview, for two out of seven sampled Residents (Resident #1 & Resident #4) the Facility failed to ensure that Facility staff reported two alleged allegations of abuse to the Facility Administrator in a timely manner when it was alleged Accused Nurse #1 pulled Resident # 1's hair so that Resident # 1's mouth would open to administer medication and that Accused Nurse #1 smashed Resident # 4's doll against the bed footboard in Resident # 4's presence, but neither of these allegations were reported to Facility management until weeks after the incidents allegedly occurred. Findings included: 1). Resident #1 was admitted to the Facility in August 2010, with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment, dated 3/4/11, indicated Resident #1 had unclear speech, moderate difficulty hearing, and Resident #1 rarely understood others and was rarely understood by others. The MDS indicated Resident #1 had impaired short term memory, impaired long term memory, and Resident #1 had severely impaired decision making ability. The MDS indicated Resident #1 had periods of inattention and an altered level of consciousness. The MDS indicated Resident #1 was totally dependent on staff for all activities of daily living, including eating meals. The MDS indicated Resident #1 was wheelchair dependent. A social service note, dated 4/14/11, indicated the social worker was made aware of an alleged incident involving a member of the nursing staff and Resident #1 (the note failed to indicate who the staff member was or what the incident was). The social service note indicated Resident #1 was seen by the social worker and no ill effects from the incident were noted. Nursing Assistant #1 was interviewed at 10:01 A.M. on 4/22/11. Nursing Assistant #1 said Nursing Assistant #1 had twice observed Accused Nurse #1 pull Resident #1's hair intentionally to get Resident #1 to open Resident #1's mouth in order to put medication into Resident #1's open mouth. Nursing Assistant #1 said the first time Nursing Assistant #1 observed this was a couple months ago and Nursing Assistant #1 was really not paying much attention and so was not really sure of what Nursing Assistant #1 had observed. Nursing Assistant #1 said about 2 weeks ago Nursing Assistant #1 again observed Accused Nurse #1 pull Resident #1's hair and when Resident #1 opened Resident #1's mouth to say ouch, Accused Nurse #1 put medication into Resident #1's mouth. When asked why there was a delay in reporting the allegation, Nursing Assistant #1 said the former Director of Nursing and Accused Nurse #1 were close and Nursing Assistant #1 was afraid that if Nursing Assistant #1 went to the Administrator with the concerns, the Director of Nursing would have found out and Nursing Assistant #1 was concerned there would be retaliation aganist Nursing Assistant #1. Nursing Assistant #1 said Nursing Assistant #1 could have done better with reporting the allegation. Nurse #2 was interviewed at 10:25 A.M. on 4/22/11. Nurse #2 said Nurse #2 had not observed Accused Nurse #1 pull Resident #1's hair, but Nurse #2 had observed Accused Nurse #1 with Accused Nurse #1's hand at the back of Resident #1's head and Nurse #2 never thought anything about it until Nurse #2 heard that Accused Nurse #1 had pulled Resident #1's hair to get Resident #1 to open Resident #1's mouth to take medication, then it all made sense. When the Surveyor asked Nurse #2 why Nurse #2 failed to report the allegations involving Resident #1 in a timely manner, Nurse #2 replied that the former Director of Nursing liked Accused Nurse #1 and Nurse #2 did not believe anything would have been done regarding the allegations. Nurse #2 said that Nurse #2 was afraid of the former Director of Nursing and also afraid of retaliation. Resident #1 was unable to participate in a meaningful interview due to severely impaired cognition. 2). Resident #4 was admitted to the Facility in May 2008, with [DIAGNOSES REDACTED]. A review of a cognitive loss care plan, updated on 3/15/11, indicated Resident #4 had cognitive deficits and severely impaired decision making ability. Care plan interventions included speaking slowly and in short concrete sentences, approaching Resident #4 in a gentle and friendly manner, keeping the environment quiet whenever possible, and explaining all activities and procedures prior to starting. A review of an annual Minimum Data Set (MDS) assessment, dated 3/17/11, indicated Resident #4 had unclear speech, was sometimes able to make self understood, and only sometimes understood others. The MDS indicated Resident #4 scored 3 out of 15 possible points on a brief interview for mental status, which was representative of severe cognitive impairment. The MDS indicated Resident #4 had periods of inattention and Resident #4 displayed no problem behavioral symptoms. The MDS indicated Resident #4 was totally dependent on staff for transfers, locomotion, toilet use, and personal hygiene, and Resident #4 required extensive staff assistance with bed mobility, dressing, and bathing, and limited assistance with eating. Nursing Assistant #2 was interviewed at 10:50 A.M. on 4/22/11. Nursing Assistant #2 said on one occasion Nursing Assistant #2 observed Accused Nurse #1 take Resident #4's doll, which Resident #4 carried everywhere, and smashed the doll against the footboard of Resident #4's bed. Nursing Assistant #2 said Accused Nurse #1 held the doll by the feet and banged the doll's head against the footboard. Nursing Assistant #2 said Resident #4 was in bed at the time and became very upset, because Resident #4 believed the doll was Resident #4's child. Nursing Assistant #2 could not recall what Accused Nurse #1 said to Resident #4 while banging the doll against the footboard. Nursing Assistant #2 said this happened within the last month. When the Surveyor asked Nursing Assistant #2 why this was not reported sooner, Nursing Assistant #2 said Nursing Assistant #2 did not believe the former Director of Nursing would have done anything about the allegation and Nursing Assistant #2 was also concerned about retaliation. Nursing Assistant #3 was interviewed at 11:45 A.M. on 4/22/11. Nursing Assistant #3 said Nursing Assistant #3 was with Resident #4 and Accused Nurse #1 entered the room and took Resident #4's doll from Resident #4 and bashed the doll on the end of Resident #4's bed. Nursing Assistant #3 said Resident #4 believed the doll was Resident #4's child and Resident #4 tried to speak and grab the doll away from Accused Nurse #1. Nursing Assistant #3 said Resident #4 was very upset. When asked by the Surveyor why Nursing Assistant #3 failed to report this sooner, Nursing Assistant #3 replied that Nursing Assistant #3 was new at the Facility and the other staff said nothing, so Nursing Assistant #3 was afraid they (Facility management) would not believe Nursing Assistant #3. Nursing Assistant #3 said Nursing Assistant #3 knew that it should have been reported sooner, but Nursing Assistant #3 did report the allegation within a week of observing it. Nurse #2 was interviewed at 10:25 A.M. on 4/22/11. Nurse #2 said Nurse #2 observed Accused Nurse #1 punch Resident #4's doll. Nurse #2 said it seemed playful at first, but it's a fine line between playful and going over the line, which this was. When the Surveyor asked Nurse #2 why Nurse #2 failed to report the allegations involving Resident #4 in a timely manner, Nurse #2 replied that the former Director of Nursing liked Accused Nurse #1 and Nurse #2 did not believe anything would have been done regarding the allegations. Nurse #2 said that Nurse #2 was afraid of the former Director of Nursing and also afraid of retaliation. The Surveyor attempted to interview Resident #4 at 3:20 P.M. on 4/22/11, but Resident #4 was unable to participate in an interview due to impaired cognition. Resident #4 just smiled at the Surveyor when the Surveyor asked questions. The Unit Manager was interviewed at 11:30 A.M. on 5/17/11. The Unit Manager said the Unit Manager was not made aware of the allegations until quite awhile after the allegations occurred and as soon as the Unit Manager was made aware, the Unit Manager reported the allegations to the Director of Nursing. The Unit Manager said Nursing Assistant #3 told the Unit Manager that Nursing Assistant #3 had not reported the allegations sooner, because Nursing Assistant #3 was new, nervous, and had never seen anything like that before, so was not sure what to do about the allegation. The Unit Manager said the other staff members said they were just nervous about reporting the allegations to the former Director of Nursing. The Director of Nursing was interviewed at 8:30 A.M. and throughout the day on 4/22/11. The Director of Nursing said staff were not comfortable going to the former Director of Nursing with their concerns because the former Director of Nursing was friendly with Accused Nurse #1. The Director of Nursing said after the former Director of Nursing left and the Director of Nursing took over, staff came forward with the allegations and the Facility initiated an investigation. Refer to F 223.

Based on record review and interview, for one out of seven sampled Residents (Resident #4) the Facility failed to prevent abuse when two staff members (Nursing Assistant #2 and Nursing Assistant #3) observed Resident #4 become upset when Accused Nurse #1 smashed Resident # 4's doll (which Resident #4 believed was Resident #4's child) against the bed footboard in Resident # 4's presence and on another occasion when Nurse #2 observed Accused Nurse #1 punch Resident #4's doll and none of the three staff members intervened or promptly reported the incidents. Findings included: Resident #4 was admitted to the Facility in May 2008, with [DIAGNOSES REDACTED]. A cognitive loss care plan, updated on 3/15/11, indicated Resident #4 had cognitive deficits and severely impaired decision making ability. Care plan interventions included speaking slowly and in short concrete sentences, approaching Resident #4 in a gentle and friendly manner, keeping the environment quiet whenever possible, and explaining all activities and procedures prior to starting. A review of an annual Minimum Data Set (MDS) assessment, dated 3/17/11, indicated Resident #4 had unclear speech, was sometimes able to make self understood, and only sometimes understood others. The MDS indicated Resident #4 scored 3 out of 15 possible points on a brief interview for mental status, which was representative of severe cognitive impairment. The MDS indicated Resident #4 had periods of inattention and Resident #4 displayed no problem behavioral symptoms. The MDS indicated Resident #4 was totally dependent on staff for transfers, locomotion, toilet use, and personal hygiene, and Resident #4 required extensive staff assistance with bed mobility, dressing, and bathing, and limited assistance with eating. Nursing Assistant #2 was interviewed at 10:50 A.M. on 4/22/11. Nursing Assistant #2 said on one occasion Nursing Assistant #2 observed Accused Nurse #1 take Resident #4's doll, which Resident #4 carried everywhere, and smashed the doll against the footboard of Resident #4's bed. Nursing Assistant #2 said Accused Nurse #1 held the doll by the feet and banged the doll's head against the footboard. Nursing Assistant #2 said Resident #4 was in bed at the time and became very upset, because Resident #4 believed the doll was Resident #4's child. Nursing Assistant #2 could not recall what Accused Nurse #1 said to Resident #4 while banging the doll against the footboard. Nursing Assistant #2 said this happened within the last month. Nursing Assistant #3 was interviewed at 11:45 A.M. on 4/22/11. Nursing Assistant #3 said Nursing Assistant #3 was with Resident #4 and Accused Nurse #1 entered the room and took Resident #4's doll from Resident #4 and bashed the doll on the end of Resident #4's bed. Nursing Assistant #3 said Resident #4 believed the doll was Resident #4's child and Resident #4 tried to speak and grab the doll away from Accused Nurse #1. Nursing Assistant #3 said Resident #4 was very upset. Nurse #2 was interviewed at 10:25 A.M. on 4/22/11. Nurse #2 said Nurse #2 observed Accused Nurse #1 punch Resident #4's doll. Nurse #2 said it seemed playful at first, but it's a fine line between playful and going over the line, which this was. The Surveyor attempted to interview Resident #4 at 3:20 P.M. on 4/22/11, but Resident #4 was unable to participate in an interview due to impaired cognition. Resident #4 just smiled at the Surveyor when the Surveyor asked questions. The Unit Manager was interviewed at 11:30 A.M. on 5/17/11. The Unit Manager said the Unit Manager was not made aware of the allegations until quite awhile after the allegations occurred and as soon as the Unit Manager was made aware, the Unit Manager reported the allegations to the Director of Nursing. The Director of Nursing was interviewed at 8:30 A.M. and throughout the day on 4/22/11. The Director of Nursing said staff were not comfortable going to the former Director of Nursing with their concerns because the former Director of Nursing was friendly with Accused Nurse #1. The Director of Nursing said after the former Director of Nursing left and the Director of Nursing took over, staff came forward with the allegations and the Facility initiated an investigation. Accused Nurse #1 was interviewed at 1:55 P.M. on 5/17/11 with Accused Nurse #1's Attorney present. Accused Nurse #1 said there were two residents on the unit with dolls, one of which was Resident #4. Accused Nurse #1 said the doll was very real to Resident #4 and if anyone took the doll, it would be like taking Resident #4's child. Accused Nurse #1 denied that Accused Nurse #1 took, hit, or punched Resident #4's doll. Refer to F 225.