Every finding on record at North End Rehabilitation and Healthcare Center

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for two of three residents (Resident #89 and #23) observed to receive medication during the survey. This resulted in a facility medication error rate of 28%.Findings include: Review of the facility's policy and procedure titled Administering Medications dated 2001, indicated, but was not limited to:Medications are administered in accordance with prescribed orders, including any required time frames.Medications are administered within one (1) hour of their prescribed time, unless the otherwise specified (for example, before and after meal orders).On 4/29/26 between 9:52 A.M. and 10:25 A.M., the surveyor observed 25 opportunities of medication administration by two nurses (Nurse #1 and Nurse #2) and 7 of the 25 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 28%.1.On 4/29/26 at 10:06 A.M., the surveyor observed Nurse #1 administer the following medications to Resident #23:Gabapentin 600 mg tabletDiltiazem 300 mg capsuleClopidogrel Bisulfate 75 mg tabletColace 100 mg capsuleBrimonidine Tartrate Ophthalmic Solution 0.2 %Review of Resident #23's physician's orders and medication administration record dated April 2026 indicated:Gabapentin oral tablet 600 mg. Give 1 tablet by mouth three times a day for neuropathy. To be given at 8 AM, 1 PM and 5 PM.Diltiazem capsule extended release 24 hour 300 mg. Give 1 capsule by mouth one time a day related to essential (primary) hypertension. To be given at 8 AM.Clopidogrel Bisulfate tablet 75 mg. Give 1 tablet by mouth one time a day related to cerebral infarction, unspecified. To be given at 8 AM.Colace capsule 100 mg (Docusate Sodium). Give 1 capsule by mouth two times a day for constipation. To be given at 8AM and 5 PM.Brimonidine Tartrate Ophthalmic Solution 0.2 %. Instill 1 drop in both eyes two times a day for ophthalmic agents. To be given at 8 AM and 8 PM.During an interview with Nurse #1 on 4/29/26 at approximately 10:25 A.M., she said some of the medications she administered to Resident #23 were scheduled to be given at 8:00 A.M. and that she administered them late. Nurse #1 said medications are required to be given within one hour of the time prescribed by the physician's order. Nurse #1 said she often has difficulty administering all the residents' medications on time because of how many are ordered to be given at 8:00 A.M.2. On 4/29/26 at 9:52 A.M., the surveyor observed Nurse #2 administered the following medications to Resident #89:Eloquis 2.5 milligrams (mg)Torsemide 2.5 mgReview of Resident #89's physician's orders and medication administration record dated April 2026 indicated:Eliquis oral tablet 2.5 mg (Apixaban). Give 2.5 mg by mouth two times a day to be given at 8 AM and 8 PM.Torsemide tablet 10 mg tablet. Give 0.5 tablet by mouth two times a day indicated o be given at 8 AM and 4 PM.During an interview with Nurse #2 on 4/29/26 at 10:03 A.M., she said some of the medications she administered to Resident #89 were scheduled to be given at 8:00 A.M., and that she administered them late. Nurse #2 said medications are required to be given within one hour of the time prescribed by the physician's order. Nurse #2 said she often has difficulty administering all the residents' medications on time because of how many are ordered to be given at 8:00 A.M.During an interview with the Director of Nursing at approximately 11:00 A.M. on 4/29/26, she said nursing staff are required to administer medications within one hour of the time prescribed in the physician's order.

Based on observation, record reviews and interviews, the facility failed for one Resident (#69), out of 20 sampled residents, to provide standards of quality nursing practice related to diabetes mellitus management. Specifically, for Resident #69 the nursing facility staff failed to obtain and record Resident #69's blood sugar in accordance with the physician's orders.Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus revision date November 2020 indicates: Purpose to provide and overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. For further diabetes education and guidelines, refer to the provider orders and instructions as well as the American Diabetes Association, Standards of medical Care in Diabetes. Glycemic Targets, 4. The provider will order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. Resident #69 was admitted to the facility in August 2024 and has diagnoses that include dementia, acquired right leg amputation and type 2 diabetes mellitus.Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 scored 14 out 15 on the Brief Interview for Mental Status exam, indicating he/she is cognitively intact. Further review of the MDS indicated Resident #69 has been administered insulin during the last seven days.During an observation on 4/28/26 at 10:52 A.M., Resident #69 was sitting up in a wheelchair. Resident #69's left leg was observed wrapped in a dressing and his/her right leg was observed to be amputated. Resident #69 greeted surveyor but he/she did not participate in answering any questions about his/her care. Review of Resident #69's physician's orders indicated the following: -Check FSBS (finger stick blood sugar, a method of measuring blood glucose levels) two times a day, order date 9/20/24.Review of Resident #69's Medication Administration Record (MAR) dated 4/1/26 through 4/29/26 indicated the following: Check FSBS two times a day for DMT2 (diabetes mellitus type two) start date 9/20/24, 0600 (6:00 A.M.). The following dates were blank on the MAR; 4/6/26, 4/7/26, 4/19/26, 4/21/26, 4/22/26, 4/25,26, 4/27/26, and 4/28/26 for a total of 9 out of 29 6:00 A.M., FSBS checks.During an interview on 4/30/26 at 6:56 A.M., Nurse #3 said Resident #69 has diabetes and accepts having blood sugar checks. Nurse #3 said Resident #69 has blood sugar checks two times a day to manage his/her diabetes. Nurse #3 said he obtains the 6:00 A.M., blood sugars and passes the results to the oncoming nurse. Nurse #3 said he does not always enter the blood sugar results in the clinical record. Nurse #3 said Resident #69's blood sugar results should be available for the doctor or nurse practitioner to see in the record. Nurse #3 said if blood sugars are not on the MAR, you cannot validate the blood sugar monitoring was completed. During an interview on 4/30/26 at 7:09 A.M., the Assistant Director of Nursing (ADON) said blood sugars are according to the physician's orders. The ADON said the blood sugars results are expected to be in the electronic MAR, and available for the nurse practitioner and doctor to review. The ADON said the night nurse would be responsible for the 6:00 A.M. blood sugar checks and she would expect the blood sugars checks to be completed as ordered.

Based on observations, record review and interviews, the facility failed for one Resident (#10), out of a total sample of 20 residents to provide quality standards of nursing care. Specifically, the facility staff failed to identify a large discoloration consistent with a bruise on Resident #10's right forehead. Findings include: Review of the facility's policy, titled Falls-Clinical Protocol revision date September 2012 indicated Monitoring and Follow Up. Staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. A. 'Delayed complications such as late fractures and major bruising may occur hours or several days after a fall'Resident #10 was admitted to the facility in August 2024 and has diagnoses that include but are not limited to chronic obstructive pulmonary disease, and unspecified dementia.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 scored a 5 out of 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. Further, the MDS indicated Resident #10 requires partial to moderate assistance with daily care including bathing, and dressing. During an observation and interview on 4/28/26 at 7:35 A.M., Resident #10 was observed with a discolored area that was dark purple/blue/yellowish in color on the right side of his/her forehead. The discolored area was consistent with a bruise and was approximately the size of a silver dollar. Resident #10 said he/she fell. During an observation on 4/28/26 at 9:49 A.M., Resident #10 was in the hallway outside of his/her room, yelling and screaming at staff nearby. Resident #10 was observed with an area of discoloration visible on his/her right forehead/temple area, while staff were interacting with him/her. On 4/28/26 the following observations were made: -At 10:57 A.M., Resident #10 was walking in the hallway and said to another resident that he/she just came from the hairdresser. Resident #10 was observed with a large, discolored area on his/her right forehead.-At 11:27 A.M., Resident #10 was walking with activity staff, who was standing on his/her right side, the same side as the area on his/her forehead. -At 11:48 A.M., Resident #10 was in the dining room with staff present eating his/her lunch. The discoloration on his/her forehead was visible.-At 3:51 P.M. Resident #10 observed sitting on the side of his/her bed with a walker in front of him/her. Resident #10 said he/she got the bruise from all the water in the bathroom and said he/she fell.Review of Resident #10's clinical record indicated the following: A weekly skin check dated 4/22/26 indicated a skin tear left outer elbow. A progress note dated 4/22/26 'At 4:00 am (sic) patent yelled for help. This nurse and the CNA (certified nursing assistant) got to the room and found the patient on the floor near his/her closet.Review of Resident #10's care plans indicated the following:-Resident #10 had an actual fall r/t (related to) unsteady gait, s/p (status post) fall on 4/22/26. The care plan did not indicate Resident #10 sustained a right forehead bruise. -I have an ADL (activities of daily living) Self-care performance deficit due to impaired balance, cognitive decline dated 8/27/24. An intervention dated 8/27/24 indicated Provide skin inspection daily during care. Observe for redness, open areas, cuts, bruises, etc. and report changes to the Nurse.-I am at risk for impaired skin integrity due to incontinence, history of lower leg vascular ulcers, frequent falls dated 9/9/25, Interventions included: Notify nurse immediately of any skin changes, redness, blisters, bruises, discoloration, etc. noted during care dated 9/9/25.Review of the progress notes from 4/22/26 through 4/27/26 failed to indicate Resident #10 was identified by staff with an alteration on his/her right forehead.Review of the physician's orders failed to indicate any order to monitor any area on Resident #10's right forehead. During an interview and observation on 4/28/26 at 4:34 P.M., Nurse #2 said she is on shift from 7:00 A.M, through 7:00 P.M., today. Nurse #2 said she did not know anything about a bruise on Resident #10's right side of his/her forehead. Nurse #2 and the surveyor went to Resident #10's room and Resident #10 let Nurse #2 look at his/her forehead. Nurse #2 said the area was a bruise with faded yellow edges indicating it was fading. Nurse #2 said Resident #10 fell recently and got a skin tear on his/her forearm. Nurse #2 said she had not noticed the area until the surveyor brought it up to her, and that no staff brought the bruise to her attention. Nurse #2 said staff were with Resident #10 today and no one mentioned the area. Nurse #2 said when a resident has a change like a bruise the staff are to report it to the nurse. Nurse #2 said the doctor or nurse practitioner are notified of bruises, and orders are put in place to monitor the area. Nurse #2 said the nursing staff would document the bruise in the clinical record if it had been identified. During an interview on 4/28/26 at 4:47 P.M., the Director of Nursing (DON) said Resident #10 had a fall recently and was placed on neuro checks. The DON said she would expect staff to identify and report any new areas on a resident including a bruise. The DON said she spoke to the Resident after the fall and implemented neuro checks because the Resident said he/she bumped his/her head. The DON said there was no documentation in the clinical record that staff identified the bruise on the resident's right temple.

Based on observations, records review and interview the facility failed to ensure for one Resident (#46) out of total sample of 20 residents, was provided professional standards of care. Specifically, the facility failed to implement having Resident #46's suprapubic catheter changed in accordance with the urology medical plan. Findings include: Resident #46 was admitted to the facility in March 2022 and has diagnoses that include but are not limited to, other obstructive and reflux uropathy and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #46 scored a 7 out of 15 on the Brief Interview for Mental Status exam, indicating he/she had severely impaired cognition. Further review of the MDS indicated he/she has an indwelling catheter. Review of the comprehensive MDS dated [DATE], indicated Resident #46 triggered for use of an indwelling catheter. On 4/28/26 9:14 A.M., Resident #46 was observed in the hallway looking out the window. A urine collection bag was covered under his/her wheelchair. During an observation and interview on 4/29/26 at 8:20 A.M., Resident #46 was sitting up in a wheelchair with his/her breakfast tray. A stale odor of urine was detected around the Resident, and the tube from the suprapubic catheter was dark purple. The area on top of the collection bag was filled with white/brown substance and debris. Resident #46 said he/she did go out to urology and said he/she could not recall when. Review of Resident #46's care plan indicated the following: I have a suprapubic urinary catheter due to chronic urinary retention dated 12/28/22. Interventions included but not limited to, change catheter as clinically indicated and as ordered. Review of Resident #46's physician's orders indicated the following:-replace suprapubic catheter (SPT) 14 Fr (French) (tube size) and 10 cc balloon monthly. as needed, order date 5/23/24. Review of the document with the encounter date 11/23/25, titled progress note indicated drainage bag tubing and foley catheter noted to be purple with foul odor on arrival. While maintaining sterile technique, existing SPT catheter gently removed. Then a 14 fr. (French) silastic was gently inserted into the bladder. 10 ml sterile water placed in catheter balloon. Patient tolerated the procedure well. He/she will return in 4 to 6 weeks for next SPT change. Review of the urology office visit document dated 4/1/26, indicated he/she has an indwelling #14-French suprapubic catheter. Urine in the bag and tubing is extremely cloudy and dark. Further, review of the of the urology visit document indicated the suprapubic catheter gets exchanged at the Nursing facility. Review of the medical record indicated there were no further provider progress notes provided to indicate Resident #46 had the suprapubic catheter changed in 4 to 6 weeks from 11/23/25. Further, review of the medical record indicated Resident #46's subpubic catheter was changed on 11/23/25 and had not been changed in over 5 months. Review of the Treatment Administration Record (TAR) for 1/1/26-1/31/26, 2/1/26-2/28/26, 3/1/26-3/31/26, 4/1/26-4/30/26, failed to indicate the suprapubic catheter was changed. During an interview on 4/29/26 at 11:55 A.M. Nurse #2 said Resident #46's plan for the suprapubic catheter is to monitor the site. Nurse #2 said that the Resident goes out to have the catheter changed. Nurse #2 said the facility does not change suprapubic catheters at the facility. Nurse #2 did not know when the suprapubic catheter was changed but said the Resident did go to urology the beginning of the month (April). During an interview on 4/29/26 at 1:48 P.M., Nurse Practitioner (NP) #1 said a suprapubic catheter should be changed about the six to eight weeks mark, or in some cases longer, or if it is clogged or denatured (the process of losing its original structure or function). NP #1 said she is not aware if Resident #46 had gone out to have the suprapubic catheter changed, and it would be her expectation to have it changed in house (facility). NP #1 reviewed the physician's order for the change and said it does not provide clear instructions for changing the SPT monthly or prn (as needed). NP #1 reviewed the provider visit notes dated 11/23/25 and 4/1/26 and said it appeared the tube was not exchanged and should have been changed since 11/23/25. NP #1 said by not having a plan to change the suprapubic catheter could put the Resident as risk for infection or change in condition. NP #1 said she saw the resident on Monday or Tuesday this week and did not look at the tube. During an interview on 4/29/26 at 3:06 P.M., the Director of Nursing (DON) said the nurses at the facility are not currently changing suprapubic catheters, and that a resident would need to go out to a clinic, urology or interventional radiology to have it exchanged. The DON reviewed the 4/1/26 urology consult that indicated the suprapubic catheter gets changed at the facility and said they are not changing suprapubic catheters at the facility and there was confusion on the urology provider's part. The DON said the physician's order is meant to be prn (as needed) and could not explain why there was an order for changing a SPT, when they do not have a policy to provide that treatment. During an interview on 4/29/26 at 4:54 P.M., and 4/30/26 at 12:38 P.M., the DON said there was no further information to support that Resident #46 had his/her suprapubic catheter changed since 11/23/25. The DON said that she will need to clarify with the urologist and nurse practitioner for a plan of care to change Resident #46's suprapubic catheter.

Based on record review and interview, the facility failed to ensure the assigned nurse was competent to perform Cardiopulmonary Resuscitation (CPR) on one Resident (#89), who was a full code, after he/she was found unresponsive, out of a total sample of 26 residents. Findings include: Review of the current American Heart Association: CPR (cardiopulmonary resuscitation) and First Aide indicates that CPR - or Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest. Review of the facility assessment indicated the following: Staff Education and Competency: Department specific training and competencies are completed with staff throughout employment to ensure that they can safely and competently provide the levels and types of care required by our resident population .As a part of ongoing education and training, mock drills are scheduled on a rotating shift and day schedule . The facility also implements additional staff education as a result of QAPI (Quality Assurance and Performance Improvement) actions and those incorporated in plans of correction. Review of the facility assessment also indicated that staff are to receive annual CPR competencies and ensure that CPR certification is renewed every two years. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #89 could not participate in the Brief Interview for Mental Status exam due to severely impaired cognition. Review of the MDS indicated that Resident #89 was a full code (a medical term indicating a patient's consent to receive all life saving measures). Review of the nursing progress note, dated [DATE], indicated the following: At 5:00 am this nurse went into residents' room to change his/her feeding but observed that resident do [sic] not have the rising and falling of chest. This nurse touched Resident, and he/she was warm to touch but without response and no pulse. This nurse paged code blue, initiated CPR on patient and called 911. 911 arrived and took over from this nurse, on assessment, they said the patient may have expired about an house [sic] ago. The DON has been notified, so also is the family [sic]. At present, the family do not have a funeral home of choice and will notify the facility as soon as they nominate one. During an interview on [DATE] at 8:27 A.M., Nurse #1 said that he left Resident #89 with a CNA to go call 911 and a code blue (an overhead page indicating that emergency services are required), then retrieved the crash cart (a cart with supplies to perform life saving measures) before starting CPR on Resident #89. Review of the CPR certification for Nurse #1 indicated his CPR certification expired in August of 2024. Review of Nurse #1's annual competencies failed to indicate the facility ensured he completed the required annual CPR competency. Review of Nurse #1's CPR certification indicated his CPR certification expired in August of 2024, six months prior to the incident that occurred in February 2025. During an interview on [DATE] at 9:27 A.M., the Director of Nursing said she did not know that Nurse #1 was not CPR certified at the time of the code. The Director of Nursing said that the facility should have made sure that Nurse #1 had renewed his CPR certification at the time of renewal. During an interview on [DATE] at 7:55 A.M., the Director of Nursing said that the Staff Development Coordinator (SDC) was responsible for ensuring staff competencies and CPR recertification. The Director of Nursing said that both the staff development coordinator and human resources had left and she was taking over the assigned duties of both roles. The SDC left on [DATE] and human resources left on [DATE]. The Director of Nursing said that the facility hadn't done any mock codes (practice codes for when a real one takes place) in the past year, as indicated in the facility assessment, and that the CPR certification is what nurses receive for their CPR competencies. The Director of Nursing said that they did another audit during survey, as part of the facility's removal plan, and identified another nurse whose CPR certification had expired. During an interview on [DATE] at 8:20 A.M., the Medical Director said it is his expectation that the facility and the individual nurse ensure that their CPR certifications are renewed on time.

Based on record review and interview, the facility failed to immediately perform cardiopulmonary resuscitation (CPR) according to professional standards of care for one Resident (#89), who was a full code, out of a total sample of 26 residents. Specifically, after Resident #89 was found with no pulse the nurse on duty, whose CPR certification had expired, left the Resident in a room with a Certified Nursing Aide (CNA), while he retrieved life saving materials and called 911, delaying life saving CPR measures for Resident #89. Findings include: Review of the current American Heart Association: CPR (cardiopulmonary resuscitation) and First Aide indicates that CPR - or Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest. The American Heart Association indicates that after successfully completing CPR training, your CPR certification lasts 2 years. Review of the facility policy titled Emergency Procedure- Cardiopulmonary Resuscitation and Basic Life Support (BLS), dated 2001, indicated the following: - If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is certified in CPR for healthcare providers/BLS will administer CPR unless: * It is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual - General Sequence for Adult Basic Life Support * Ensure scene safety. * Check for response. * Shout for nearby help/activate the resuscitation team * Check for no breathing or only gasping and check pulse (ideally simultaneously) * Retrieve and activate the AED (automated external defibrillator) /Emergency equipment immediately after the check for no normal breathing and no pulse identifies cardiac arrest. * Immediately begin CPR and use the AED/defibrillator when available. * When the second rescuer arrives, provide 2-rescuer CPR and use the AED/defibrillator Resident #89 was admitted in [DATE] with diagnoses including chronic kidney disease, hypertension, and type 2 diabetes. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #89 could not participate in the Brief Interview for Mental Status exam due to severely impaired cognition. Review of the MDS indicated that Resident #89 was a full code (a medical term indicating a patient's consent to receive all life saving measures). Review of the nursing progress note, dated [DATE], written by Nurse #1, indicated the following: At 5:00 am this nurse went into residents' room to change his/her feeding but observed that resident do [sic] not have the rising and falling of chest. This nurse touched Resident, and he/she was warm to touch but without response and no pulse. This nurse paged code blue, initiated CPR on patient and called 911. 911 arrived and took over from this nurse, on assessment, they said the patient may have expired about an house [sic] ago. The DON has been notified, so also is the family [sic]. At present, the family do not have a funeral home of choice and will notify the facility as soon as they nominate one. During an interview on [DATE] at 8:27 A.M., Nurse #1 said that he believes Resident #89 was a full code at the time of the code and said the Resident was alive at 2:00 A.M. when he did rounds. Nurse #1 said he went to check on the Resident when doing the morning medication pass, about 5:00 am, and saw that he/she was not breathing and had no pulse. Nurse #1 said he initiated a sternum rub, but got no response. Nurse #1 said he had to call 911 immediately so he asked a Certified Nursing Aide (CNA) to stay with the Resident while he went to call 911 and a code blue (a page made overhead to alert the building that emergency response is necessary). Nurse #1 said that after he called 911 and a code blue, he went to get the crash cart (a cart with supplies to perform life saving measures). After he retrieved the crash cart, he put the board behind the Resident's back and started CPR compressions. Nurse #1 said that Nurse #2, from the other unit, came up to assist with setting up the AED (automated external defibrillator) before EMS (emergency medical services) arrived. Nurse #1 said that the CNA, who was left with the Resident, did not start CPR and was told to wait until he got back from calling emergency response. Nurse #1 said that he wasn't sure if the CNA could start CPR, but it was his judgement call to have the CNA stay with the Resident before he went to call 911. Review of the nursing progress note, dated [DATE], written by Nurse #2, indicated the following: Around 5:00 am assigned nurse reported that resident was found unresponsive. Code blue was called x 3. 911 was called. CPR initiated. 911 came in around 5:20 am and pronounced the resident dead. Physician [sic] was notified and gave order to do the RN (registered nurse) pronouncement and release the body to the family's funeral home of choice. HCP (health care proxy) was notified and said she will be in shortly. During an interview on [DATE] at 10:07 A.M., Nurse #2 said that he was the Registered Nurse in the facility that shift and went up to the unit when he heard the code blue being called. Nurse #2 said that when he arrived, the crash cart had already been set up, the AED had been used, and he saw Nurse #1 performing CPR. Nurse #2 said that he called the pronouncement for Resident #89's death after EMS arrived. Review of the Emergency Medical Services report indicated that emergency services was dispatched at 5:16 A.M. and arrived to the facility at 5:20 A.M. Review of the report indicated the following: 76 yo (year old) patient found supine (lying flat) in bed of dispatched address. Pt unresponsive, skin cool pale, with lividity (reddish-purple discoloration on the skin) on posterior, and apneic (cessation of breathing). Staff reports unknown downtime and performing CPR on pt prior to EMS (emergency medical services) arrival. Upon assessment pt found to have lividity on posterior of back, lung sounds absent bilaterally, pupils fixed and dilated, carotid pulse (a way to assess a patients heart rate) completely absent. Pt declared non-viable (dead), and Pt left with rehabilitation facility for post mortem (after death) handling . Review of the CPR certification for Nurse #1 indicated his CPR certification expired in August of 2024. Review of the current CPR certification indicated Nurse #1 renewed his CPR certification on [DATE], approximately one month after the incident with Resident #89. During an interview on [DATE] at 9:30 A.M., the Director of Nursing said that if a Resident is unresponsive with no pulse, then the Nurse on duty should check the code status of the Resident and immediately start CPR. The Director of Nursing said that it is not the expectation for the CNA to start CPR. The Director of Nursing said that she would have expected CNA to go call 911 and code blue, and retrieve the crash cart while the nurse starts performing CPR. The Director of Nursing said that the facility uses a code sheet (a sheet to record the timing and event of the code) to determine when CPR was started, but it was not completed for the code that occurred with Resident #89. The Director of Nursing said she was unsure if code sheets were being implemented at that time. During an interview on [DATE] at 9:54 A.M., the Physician said that the facility should be following the standard ACLS (Advanced Cardiovascular Life Support) protocol. Review of the American Heart Association's Adult Basic and Advanced Life Support Guidelines indicate the following (https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support): - Recognition of cardiac arrest: 1. If a victim is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the healthcare provider should check for a pulse for no more than 10 s (seconds) and, if no definite pulse is felt, should assume the victim is in cardiac arrest. - It has been shown previously that all rescuers may have difficulty detecting a pulse, leading to delays in CPR, or in some cases CPR not being performed at all for patients in cardiac arrest. Recognition of cardiac arrest by lay rescuers, therefore, is determined on the basis of level of consciousness and the respiratory effort of the victim. Recognition of cardiac arrest by healthcare providers includes a pulse check, but the importance of not prolonging efforts to detect a pulse is emphasized. 2. After identifying a cardiac arrest, a lone responder should activate the emergency response system first (911) and immediately begin CPR. During an interview on [DATE] at 9:27 A.M., the Director of Nursing said she did not know that Nurse #1 was not CPR certified. The Director of Nursing said that the facility should have made sure that Nurse #1 had a current CPR certification upon hire. The Director of Nursing said that both CNAs on the floor confirmed they did not start CPR on Resident #89 at the time of the code. During an interview on [DATE] at 7:55 A.M., the Director of Nursing said that the facility did a house-wide CPR course on all staff on [DATE], as part of the facility's immediate removal plan, and told the surveyors that the fire department educated the staff on immediately performing CPR and having another staff member call emergency response. The Director of Nursing said the fire department instructed the staff that, if there were no other staff around, to immediately perform CPR for at least 2 minutes before running to call 911. Refer to F726.

Based on observation, record review and interview, the facility failed to ensure nursing staff adhered to professional standards of practice for the administration of free water flushes and enteral tube feeding (water and nutrition taken through a tube directly into the stomach) for six out of seven Residents (#18, #40, #67, #71, #72 and #73) with a tube feed observed. Specifically: 1. For Resident #18, the facility failed to label and date the enteral free water administration bag. 2. For Resident #40, the facility failed to label and date the water administration bag and failed to ensure the amount of tube feeding administered followed the physician's order. 3. For Resident #67, the facility failed to label the tube feeding bottle and the free water administration bag with the date and time hung. 4. For Resident #71, the facility failed to label the free water administration bag with the date hung and failed to ensure the amount of tube feed administered followed the physician's order 5. For Resident #72, the facility failed to label the free water administration bag with the date hung. 6. For Resident #73, the facility failed to label the free water administration bag with the date hung and failed to ensure the amount of tube feed administered followed the physician's order. Findings include: Review of the facility policy titled Enteral Nutrition, revised November 2018, indicated adequate nutrition support through enteral nutrition is provided to residents as ordered. Review of the facility policy titled Enteral Feedings-Safety Precautions, revised November 2018, indicated that feed formulas are to be discarded 48 hours after opening. Further review failed to indicate that tube feedings and free water administration bags are to be labeled and dated. 1. Resident #18 was admitted to the facility in March 2025 with diagnoses including protein-calorie malnutrition, dependence on ventilator, and muscle wasting and atrophy. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #18 was moderately cognitively impaired and totally dependent of staff for all activities of daily living. Further review indicated that Resident #18 received 51% or more of their nutrition through the use of a feeding tube. Review of the current care plan indicated a focus of enteral tube feeding due to dysphagia with an intervention to administer tube feeding as ordered. Review of the physician's orders dated May 2025 indicated an order for free water flushes of 200 ml (milliliters) every six hours every shift. On 5/4/25 at 8:30 A.M., the surveyor observed that the water bag, instilling free water into the enteral tube, was not labeled with the date hung. 2. Resident #40 was admitted to the facility in February 2024 with diagnoses including protein-calorie malnutrition, dysphagia, and dependence on ventilator. Review of the Minimum Data Set assessment, dated 2/27/25, indicated that Resident #40 was severely cognitively impaired and totally dependent on staff for all activities of daily living. Further review indicated that Resident #40 received 51% or more of their nutrition through the use of a feeding tube. Review of the physician's orders indicated the following: every shift for nutrition Vital AF 1.2 @ 55 ml/hr (milliliters per hour), may use peptaman 1.5 until vital available. Further review indicated the following order: Enteral Feed order every 6 hours for hydration additional FWF (free water flush) of 200 ml q6h (every 6 hours). Review of the current care plan indicated a focus of enteral tube feeding due to dysphagia with an intervention to administer tube feeding as ordered. Review of the dietician's note dated 2/27/25 indicated the following: Note Text: TF (tube feed) reviewed. Rt (resident) currently on continuous feed of vital AF 1.2 @ 55 ml/hr w/additional FWF of 200 ml q6h (every 6 hours). This current regimen provides a total daily volume of 1320 ml, 1584 kcal, 99g pro (grams protein), 1871 ml fluid, meeting 100% of goal needs. No s/s/x (signs or symptoms) of intolerance noted. Wt (weight) reviewed. Unable to assess wt trend, last wt taken on 11/21/24. Rt (resident) known to refuse wt. Encourage obtaining wt as able to monitor accurate wt trend. Skin remains intact. Labs and meds reviewed. Recent lab notable for abnormally low creatinine. Continue current nutritional care plan and intervention. Continue to monitor. On 5/4/25 at 8:15 A.M., the surveyor observed a 1500 ml tube feed bottle hung, dated 5/2/25, and running at @ 55 ml/hr (milliliters per hour) with the label indicating the feed was started at 1800 (6 P.M.). The surveyor observed that the amount left in bottle was 300 ml. The surveyor also observed that the water bag was not labeled with the date hung. At a rate of 55 ml/hr for 38 hours the amount instilled should have been 2090 ml and not the 1200 ml as indicated on the bottle. 3. Resident #67 was admitted to the facility in September 2023 with diagnoses including protein-calorie malnutrition, dysphagia and Alzheimer's disease. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #67 was severely cognitively impaired and substantially to totally dependent on staff for all activities of daily living. Further review indicated that Resident #67 received 51% or more of their nutrition through the use of a feeding tube. Review of the physician's orders dated May 2025 indicated the following: every shift for Nutrition Continuous feed of Glucerna 1.0 @ 75 ml (total daily volume of 1800 ml) via J-tube. Further review indicated an order for free water flushes of 75 ml every 4 hours via J-tube (a tube directly inserted into the jejunum for the purpose of administering nutrition). On 5/4/25 at 8:11 A.M., the surveyor observed Resident #67 lying in bed with an enteral tube feeding bottle and enteral water administration bag hanging at bedside. The surveyor observed the tube feed running at 75 ml (milliliters) per hour. The surveyor also observed that the tube feeding bottle, and the free water administration bag were not labeled with the date and time hung. 4. Resident #71 was admitted to the facility in January 2025 with diagnoses including protein-calorie malnutrition, dysphagia, and Guillain-Barre Syndrome. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #71 was severely cognitively impaired as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #71 was substantially/dependent on staff for all activities of daily living. Further review indicated that Resident #71 received 51% or more of their nutrition through the use of a feeding tube. Review of the physician's orders dated May 2025 indicated the following order: Enteral: Glucerna 1.2 Cal liquid via feeding tube every shift, feeding pump set at 65 ml/hr (milliliters per hour) for 24 hours, total volume 1560 ml. Further review indicated an order for free water flushes of 200 ml every 4 hours. On 5/4/25 at 7:50 A.M., the surveyor observed Resident #71 lying in bed with a 1500 ml tube feed bottle with a time stamp of 1900 hours (7 P.M.), hanging and running at 65 ml/hr (milliliters per hour). The surveyor also observed the tube feed bottle to be dated 5/2/25 with 1000 ml left in the 1500 ml bottle. Based on the date and volume left in the bottle the amount that should have been instilled from 5/2/25 at 7 P.M. through 5/4/25 at 7:50 A.M. is 2405 ml and not the 500 ml indicated on the tube feed bottle. The surveyor also observed that the free water administration bag was not dated. 5. Resident #72 was admitted to the facility in November 2024 with diagnoses including protein-calorie malnutrition, dysphagia, and amytrophic lateral sclerosis. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #72 cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #72 was totally dependent on staff for all activities of daily living. Further review indicated that Resident #72 received 51% or more of their nutrition through the use of a feeding tube. Review of the physician's orders dated May 2025 indicated the following order: Enteral Feed Order: Jevity 1.5 liquid via feeding tube hung up at 9 P.M. and take down at 6 P.M., via feeding pump set at 65 ml/hr (milliliters per hour) for 18 hours, total volume 1170 ml. Further review indicated an order for free water flushes of 150 ml every 4 hours. On 5/4/25 at 8:24 A.M., the surveyor observed that the free water administration bag was not dated. 6. Resident #73 was admitted to the facility in June 2024 with diagnoses including severe protein-calorie malnutrition, dysphagia and amytrophic lateral sclerosis. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #73 was severely cognitively impaired. Further review indicated that Resident #73 was totally dependent on staff for all activities of daily living. Further review indicated that Resident #73 received 51% or more of their nutrition through the use of a feeding tube. Review of the physician's orders dated May 2025 indicated the following order: every shift Enteral: Osmolite 1.5 Cal liquid via feeding tube every shift, feeding pump set at 60 ml/hr for 21 hours. On 5/4/25 at 8:32 A.M., the surveyor observed the tube feed free water administration bag was not labeled with the date hung. The surveyor also observed an enteral feed running at 60 ml/hr, the tube feed bottle was dated 5/2/25, with a time stamp of hung up at 1800 (6 P.M.). The tube feed bottle had 350 ml left in it. At 60 ml/hr for a total of 35 hours, 2100 ml should have been instilled, not 1150 ml as was indicated by what was left in the bottle. During an interview on 5/5/25 at 8:16 A.M., the Director of Nursing (DON) said all enteral free water administration bags and tube feeding bottles should be labeled with the date and time hung as well as the prescribed rate of flow. The DON also said that the nurses should be checking to make sure that the prescribed amount to be instilled over a specific period of time was administered as ordered.

Based on record review and interview, the facility failed to implement adverse event monitoring to potentially prevent future adverse events from occurring. Specifically, one Resident (#89), who was a full code, was found unresponsive and expired and the facility failed to identify and investigate the death, as it relates to Quality Assurance and Performance Improvement (QAPI). Findings include: According to the U.S. Department of Health and Human Services Office of Inspector General, an adverse event is defined as the following: An event in which care resulted in an undesirable clinical outcome-an outcome not caused by underlying disease-that prolonged the patient stay, caused permanent patient harm, required life-saving intervention, or contributed to death. https://oig.hhs.gov/reports/featured/adverse-events/ Review of the Facility Assessment, dated [DATE], indicated the following: Risk Identification and Quality Assurance Performance Improvement (QAPI) - The facility utilizes a comprehensive approach to risk identification and mitigation to ensure continous quality of care for its residents. - The interdisciplinary team addresses both the reactive and proactive aspects of risk identification and mitigation. Resident incidents are reviewed to ensure appropriate interventions have been implemented to prevent reoccurrence. A root cause analysis is conducted to ensure causal factors have been identified and addressed. - The QAPI committee will prioritize topics for performance improvement projects based on the current needs of the residents and our facility. Priority will be given to areas we define as high-risk to residents and staff, high- prevalence, or high-volume areas that are problem prone. Consideration of staff affected, and anticipated training needs will be reviewed prior to implementation of a performance improvement project. Resident #89 was admitted in [DATE] with diagnoses including chronic kidney disease, hypertension, and type 2 diabetes. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #89 could not participate in the Brief Interview for Mental Status exam due to severely impaired cognition. Review of the MDS indicated that Resident #89 was a full code (a medical term indicating a patient's consent to receive all life saving measures). On [DATE], Resident #89, who was a full code, was found unresponsive and pulseless. Nurse #1 left the Resident in the room with a certified nursing aide and proceeded to dial 911, call a code blue, then retreive the crash cart before initiated CPR. Nurse #1's CPR certification had expired 6 months prior to the incident. Review of the nursing progress note, dated [DATE], written by Nurse #1, indicated the following: At 5:00 am this nurse went into residents' room to change his/her feeding but observed that resident do [sic] not have the rising and falling of chest. This nurse touched Resident, and he/she was warm to touch but without response and no pulse. This nurse paged code blue, initiated CPR on patient and called 911. 911 arrived and took over from this nurse, on assessment, they said the patient may have expired about an house [sic] ago. The DON has been notified, so also is the family [sic]. At present, the family do not have a funeral home of choice and will notify the facility as soon as they nominate one. During an interview on [DATE] at 7:55 A.M., the Director of Nursing said she was unaware that Nurse #1's CPR certification had expired and that Nurse #1 should not have provided CPR. The Director of Nursing said that it was the responsibility of the Staff Development Coordinator and Human Resources to ensure staff are up to date with their certification, but that both staff had left the facility, one on [DATE] and one on [DATE] . The Director of Nursing said she had taken over responsibilities of both positions until filled. The Director of Nursing said the positions had not been filled yet, but an SDC was starting soon. The Director of Nursing said that the facility had implemented a code sheet (a sheet used to record the event and timing of a code) to keep track of full code incidents in the building, but she was unsure of when they initiated the code sheets and said that sheet was never completed for the Resident that Nurse #1 performed CPR on. The Director of Nursing said that when an adverse event occurs, she will do an investigation into the event, however; the Director of Nursing said that she reviewed the notes in the electronic medical record and said that nothing stood out to her that would warrant an investigation of the situation. The Director of Nursing said she was notified of the incident, but was not aware that Nurse #1 did not start CPR immediately. During an interview on [DATE] at 8:33 A.M., the Administrator (at the time of the event) said when a death occurs (for someone who is a full code), the facility staff complete a code sheet and the Director of Nursing and Physician will review the code sheet, especially if the death was unexpected. The Administrator said that the facility will typically look into an unexpected death to find out what occurred in real time. The Administrator said that the Medical Director is very involved and would help the facility look into an unexpected death. The Administrator said that in January and February, the facility did an audit of human resources and employee files to improve the process, but CPR certification was not something that was identified during that audit and it was not brought to QAPI. During an interview on [DATE] at 8:20 A.M., the Medical Director said that it his expectation that all staff are recertified every 2 years. The Medical Director said he remembers being notified of the incident with Resident #89 because he is the one who completes the death certificates. The Medical Director said this Resident was tricky because he/she had a lot of comorbidities, but was not considered an expected death because the Resident was not on hospice. After a facility-wide audit, conducted during survey as part of the facility's removal plan, the facility identified that one more additional staff member's CPR certification had expired.

Based on observation, record review, and interview, the facility failed to maintain an accurate medical record for two Residents (#71 and #72), out of a total sample of 26 residents. Specifically: 1. For Resident #71, the facility documented the ventilator tubing was changed when it was not. 2. For Resident #72, the facility documented the Resident recieved tube feedings at the wrong time. 1. Resident #71 was admitted to the facility in January 2025 with diagnoses including protein-calorie malnutrition, and dysphagia. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #71 was severely cognitively impaired, as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Stats exam. Further review indicated that Resident #71 was substantially/dependent on staff for all activities of daily living. Further review indicated that Resident #71 was on a ventilator. On 5/4/25 at 8:17 A.M., the surveyor observed Resident #71 in bed on a ventilator. The surveyor also observed that the ventilator tubing was dated 4/20/25. Review of the physician's orders dated May 2025 indicated an order for trach (tracheostomy) mask via cool mist at 35% continuously every shift. Further review indicated an order to change all disposable equipment weekly on Wednesday 11p-7a and PRN (as needed). Review of the current care plan, dated 5/1/25, indicated an intervention to keep respiratory equipment clean and change disposable equipment per facility policy. Review of the facility document titled Respiratory Administration Record, dated April 2025, indicted the respiratory therapist signed, on 4/23/25 and 4/30/25, that the ventilator tubing was changed when it was not. During an interview on 5/4/25 at 8:24 A.M., Respiratory Therapist #1 said the Respiratory Therapist changes all ventilator tubing every Sunday. During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing (DON) said that all respiratory tubing connected to a trach or vent is to be changed according to the physician's orders. The DON then said that the respiratory therapists should not be documenting that they changed the tubing when they did not. 2. Resident #72 was admitted to the facility in November 2024 with diagnoses including protein-calorie malnutrition, dysphagia, and amytrophic lateral sclerosis. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #72 cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #72 was totally dependent on staff for all activities of daily living. Further review indicated that Resident #72 received 51% or more of their nutrition through the use of a feeding tube. Review of the physician's orders dated May 2025 indicated the following conflicting orders: 1. Enteral Feed Order: Jevity 1.5 liquid via feeding tube hung up at 9 P.M. and take down at 6 P.M., via feeding pump set at 65 ml/hr (milliliters per hour) for 18 hours, total volume 1170 ml. 2. Enteral Feed Order: Jevity 1.5 liquid via feeding tube hung up at 9 A.M., and take down at 6 A.M., via feeding pump set at 65 ml/hr (milliliters per hour) for 18 hours, total volume 1170 ml. Review of the Medication Administration Record (MAR) dated May 2025 indicated that nurses signed for both conflicting orders 5/1/25, 5/2/25, 5/3/25 and 5/4/25. During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing (DON) said that the tube feed orders were in error and the nurses should be signing only for one time frame.

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure a medication cart and treatment carts on the fourth floor were locked while a nurse was not present. Findings include: Review of the facility policy titled Medication Labeling and Storage, revised February 2023, indicated the following: - The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 5/4/25 at 7:05 A.M., the surveyor observed a medication cart in the 4th floor hallway unlocked and without a nurse present. The surveyor opened the medication cart drawers and stood there while a certified nurse's aide walked by the surveyor and continued down the hall. The surveyor also observed another staff member sitting in a room at the end of the hall looking at the surveyor at the open medication cart. The surveyor was able to access the medication cart for 4 minutes without staff interference. During an interview on 5/4/25 at 7:09 A.M., Nurse #6 said that she is the only one allowed access to the medication cart and it should not be open. On 5/4/25 at 8:03 A.M., the surveyor observed a treatment cart, unlocked, next to the nurse's station on the 4th floor. The surveyor then observed the Admissions Director walking by the unlocked treatment cart multiple times without locking it. The surveyor was able to access the treatment cart without staff interference. On 5/4/25 at 8:04 A.M., the surveyor observed a treatment cart in the hallway of the 4th floor, unlocked, without a nurse in the surrounding area. The surveyor was able to access the treatment cart without staff interference. On 5/4/25 at 8:41 A.M., the surveyor observed a treatment cart next to the nurse's station unlocked, without the nurse present. Multiple other staff members were around the unlocked treatment cart. During an interview on 5/5/25 at 8:16 A.M., the Director of Nursing said that all medication carts and treatment carts are to be locked at all times when not in use.

Based on observations, interviews, and record review, the facility failed to ensure staff provided the necessary care and services in accordance with professional standards of practice for two Residents (#47 and #71), out of a total sample of six residents on a ventilator. Findings include: Review of the facility policy titled Departmental (Respiratory therapy)-Prevention of Infection, dated revised November 2011, indicated to change respiratory tubing every seven (7) days, or as needed. 1. Resident #47 was admitted to the facility in April 2025 with diagnoses including respiratory failure, paraplegia and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #47 has severe cognitive impairment and was unable to complete the Brief Interview for Mental Status exam. Further review indicated that Resident #47 requires total dependence on staff for all activities of daily living and receives a high concentration of oxygen via a tracheostomy mask. On 5/4/25 at 8:15 A.M., the surveyor observed Resident #47 lying in bed receiving humidified oxygen via a trach (tracheostomy) collar. The surveyor also observed that the trach tubing was dated 4/13/25. Review of the physician's orders dated May 2025 indicated an order for Humidified Air via Trach Collar at 35% continuously every shift. Further review failed to indicate an order for when the trach tubing via trach collar is to be changed. During an interview on 5/4/25 at 8:24 A.M., Respiratory Therapist #1 said the Respiratory Therapist changes all ventilator tubing every Sunday. During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing said that all respiratory tubing connected to a trach or vent is to be changed according to the physician's orders. If there are no physician's order, then the tubing would be changed weekly per facility policy. She then said that all respiratory tubing should have a physician's order in place for frequency of tubing changes. 2. Resident #71 was admitted to the facility in January 2025 with diagnoses including protein-calorie malnutrition, dysphagia, and Guillain-Barre Syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #71 was severely cognitively impaired, as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Stats exam. Further review indicated that Resident #71 was substantially/dependent on staff for all activities of daily living. Further review indicated that Resident #71 was on a ventilator. On 5/4/25 at 8:17 A.M., the surveyor observed Resident #71 in bed on a ventilator. The surveyor also observed that the ventilator tubing was dated 4/20/25. Review of the physician's orders dated May 2025 indicated an order for trach (tracheostomy) mask via cool mist at 35% continuously every shift. Further review indicated an order to change all disposable equipment weekly on Wednesday 11p-7a and PRN (as needed). Review of the current care plan, dated 5/1/25, indicated an intervention to keep respiratory equipment clean and change disposable equipment per facility policy. During an interview on 5/4/25 at 8:24 A.M., Respiratory Therapist #1 said the Respiratory Therapist changes all ventilator tubing every Sunday. During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing said that all respiratory tubing connected to a trach or vent is to be changed according to the physician's orders. If there are no physician's order, then the tubing would be changed weekly per facility policy. She then said that all respiratory tubing should have a physician's order in place for frequency of tubing changes.

Based on observations, record review and interviews, the facility failed to ensure a comprehensive resident-centered care plan was developed for two Residents (#5 and #33) out of a total sample of 26 Residents. Specifically, 1. For Resident #5, the facility failed to identify the make, model, serial number, cardiologist information, implant date, and pacer rate for the monitoring and care of a pacemaker. 2. For Resident #33, the facility failed to develop an individualized comprehensive resident-centered care plan related to the monitoring and care of a pacemaker. Findings include: Review of the facility policy titled Pacemaker, Care of a Resident with, revised December 2015, indicated the following: Purpose and Procedure: - The purpose of this is to provide information about and guidance for the care of a resident with a pacemaker. Monitoring: - Monitor the resident for pacemaker failure by monitoring signs and symptoms of bradycardia. - The resident will have an EKG (electrocardiogram) annually, or as ordered, to monitor changes in the heart's electrical activity. Documentation: - For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist. b. Type of pacemaker. c. Type of pacemaker. d. Manufacturer and model. e. Serial number. f. Date of implant. g. Paced rate. 1. Resident #5 was admitted to the facility September 2024 with diagnoses including chronic obstructive pulmonary disease (COPD) and the presence of a pacemaker. Review of Resident #5's most recent Minimum Data Set (MDS) assessment, dated 3/13/25, indicated a Brief Interview for Mental Status (BIMS) exam score of 14 out of a possible 15, indicating intact cognition. Further review of the MDS indicated Resident #5 was dependent on staff for functional daily activities and had an active diagnosis of a cardiac pacemaker. Review of Resident #5's care plan, initiated 11/21/24, failed to indicate a pacemaker care plan identifying the pacemakers' serial number, make and model, date of implant, paced rate, frequency of pacemaker checks and cardiologist information. During an interview on 5/5/25 at 2:43 P.M., Nurse #3 said she monitors vital signs for any resident with a pacemaker and that she follows the doctors' recommendations. Nurse #3 said she was unsure if the specific pacemaker information and pacer rate should be included in the care plan and that she monitors the vital signs and notifies the doctor of any irregularities. During an interview on 5/5/25 at 3:47 P.M., the Director of Nursing said a pacemaker care plan should include the paced rate, frequency of checks, make and model, cardiologist information, the serial number, and implant date so the nurses are aware. 2. Resident #33 was admitted to the facility in August 2024 with diagnoses including atrioventricular block and the presence of a cardiac pacemaker. Review of Resident #33's most recent Minimum Data Set (MDS) assessment, dated 4/24/25, indicated a Brief Interview for Mental Status (BIMS) exam score of 14 out of a possible 15, indicating intact cognition. Further review of the MDS indicated Resident #33 required partial/moderate to substantial/maximal assistance with functional daily activities and had an active diagnosis of a cardiac pacemaker. Review of Resident #33's care plans, initiated 8/2/24, failed to indicate a pacemaker care plan identifying the cardiologist information, pacemakers' paced rate, and frequency of pacemaker checks. During an interview on 5/5/25 at 2:43 P.M., Nurse #3 said she monitors vital signs for any resident with a pacemaker and that she follows the doctors' recommendations. Nurse #3 said she was unsure if the specific pacemaker information and pacer rate should be included in the care plan and that she monitors the vital signs and notifies the doctor of any irregularities. During an interview on 5/25/25 at 3:47 P.M., the Director of Nursing said she would expect a physician order to be put in place for the monitoring of the pacemaker, and a care plan should include the paced rate, frequency of checks, make and model, cardiologist name and phone number, the serial number, and implant date so the nurses are aware.

Based on observation, record review and interview the facility failed to maintain accurate medical records for one Resident (#41) out of a total sample of 19 residents. Specifically, the facility inaccurately documented the changing and replacement of a suprapubic catheter. Findings Include: Resident #41 was admitted to the facility in March 2022 with diagnoses that include muscle wasting and atrophy, benign prostate hyperplasia and retention of urine. Review of Resident #41's most recent Minimum Data Set (MDS) Assessment, dated 5/1/24, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating that the Resident has severe cognitive impairment. The MDS further indicated the presence of an indwelling urinary catheter. On 5/23/24 at 6:46 A.M., the surveyor observed a urinary drainage bag hanging on Resident #41's bed frame. Review of Resident #41's physician's orders indicated an order, dated 2/6/23, to replace the suprapubic catheter 14 fr (French), 10 ml (milliliters) balloon, monthly on the 6th of every month. Review of Resident #41's care plan indicated, I have a suprapubic catheter: for urinary retention, dated 4/5/22. Review of Resident #41's Treatment Administration Record indicated that the suprapubic catheter was documented as replaced 23 days in February 2024 and three days in March 2024. Review of Resident #41's progress notes indicated the following: -A progress note dated 4/1/24, Resident returned back from Mass General for sp (suprapubic) blockage. New sp cath (catheter) installed and patent. 2500 (ml) of urine obtained from resident at the hospital. -A progress note dated 4/8/24 The Resident was scheduled for urology appointment to have [suprapubic catheter] changed. Next appointment is scheduled for May 6th at 11:30 A.M. During an interview on 5/23/24 at 9:36 A.M., the Director of Nurses (DON) said that the suprapubic catheter was not changed 23 days in February and that the documentation was inaccurate. She said that the staff at the facility do not change suprapubic catheters as it is not a procedure performed in the facility. The DON said that the Resident goes out to urology for catheter replacements.

Based on observations, record review, policy review and interviews, the facility failed to meet professional standards of nursing practice for two Residents ( #18 and #3) out of a total sample of 19 Residents. Specifically, 1. For Resident #18, the facility failed to failed to address suicide threats in a timely manner. 2. For Resident #3 the facility failed to follow the recommendations from a physiatrist (a doctor who specializes in physical medicine and rehabilitation) for physical therapy and occupational therapy evaluations. Findings include: A review of the facility policy titled 'Suicide Threats' with a revision date of December 2007 indicated the following: -Resident suicide threats shall be taken seriously and addressed appropriately. -Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. -A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident. -After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party and shall seek further direction from the physician. -All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. -As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. -If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. -Staff shall document details of the situation objectively in the resident's medial record. 1. Resident #18 was admitted to the facility in December 2020 with diagnoses including major depressive disorder and psychotic disorder with delusions. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental (BIMS) score of 2 out of a possible 15, indicating severe cognitive impairment. On 5/21/24 at 8:03 A.M., the surveyor observed Resident #18 in bed, he/she was teary, rocking side to side in bed. The Resident told the surveyor he/she was going to kill himself/herself, the Resident said he/she was going to throw himself/herself out of the window and no one could stop him/her, the Resident said he/she was a nobody. During an interview on 5/21/24 at 8:09 A.M., the surveyor told the Unit Manager that the Resident was making suicidal threats. The Unit Manager said that the Resident makes suicidal threats all the time, she told the surveyor that the Resident was not going to kill himself/herself. The unit manager walked away and continued to pass breakfast trays. During an interview on 5/21/24 at 12:24 P.M., the Social Workers, Director of Nurses and Assistant Director of Nurses said the Unit Manager had not communicated to them about any concerns with Resident #18. They said that staff are expected to immediately put any resident who voices suicidal threats on one-to-one supervision while they notify the Director of Nurses. The Director of Nurses said the Resident is expected to remain on one-to-one supervision until a Psychiatric Nurse Practitioner assesses them and determines the risk of suicide does not appear to be present. The Director of Nurses said the Resident has had a lot of losses recently. She said the Unit Manger did not address the Resident's suicidal threats appropriately. 49880 2. Resident #2 was admitted to the facility in September 2021 with diagnoses that include Alzheimer's disease, insomnia, and history of falling. Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 4/3/24, indicated a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, indicating that Resident #2 has moderate cognitive impairment. Review of Resident #2's Physiatrist's progress note, dated 5/12/24, indicated, PT (physical therapy)/OT (occupational therapy) consult for ADLs (activities of daily living), bed mobility, transfers and ambulation training, to assess the candidacy for another bout of therapy, and to verify if right foot eversion is affecting gait. [Resident] was seen and examined at bedside this morning. IDT (interdisciplinary team) asked us to see this patient due to ongoing functional decline. Review of the medical record indicated that the most recent therapy evaluation was completed in January 2024. The medical record failed to indicate that the physiatrist's recommendations were acted upon for PT and OT consults. During an interview on 5/23/24 at 9:48 A.M., the Director of Nurses (DON) said that the IDT had asked physiatry services to see Resident #2 due to an ongoing functional decline. The DON said that usually the physiatrist will relay orders or recommendations to the nursing staff to communicate with Rehab staff. The medical record was reviewed with the DON and she said the request for therapy evaluations was not communicated to rehab, and that Resident #2 is not on rehabilitation services at this time.

Based on record review and interview, the facility failed to develop and implement care plans for one Resident (#57) out of a total of 19 sampled residents. Specifically, the facility failed to develop and implement a plan of care related to an implantable cardioverter defibrillator. Findings include: Review of the facility's policy Care of Implantable Cardioverter Defibrillator, undated, indicated: Overview: An implantable cardioverter defibrillator (ICD) is a small device placed in the chest that detects and corrects life-threatening irregular heart rhythms and can help the heart maintain a steady, stable rhythm. ICD's can deliver a defibrillating shock to attempt to correct the heart rhythm. Monitor: Monitor the resident for ICD failure by monitoring for signs and symptoms of arrhythmias. Monitor the resident for a defibrillating shock (ICD). If the ICD delivers a shock, encourage the resident to stay calm, find a safe place for the resident to assist or lie down, perform an assessment of the resident and notify the physician for further actions. Call emergency services and initiate CPR if indicated. The ICD battery will be monitored closely through the telephone or an internet connection. Documentation: For each resident with an ICD, document the resident's individualized needs and intervention in the care plan. For residents with an ICD, document the following in the medical record upon admission: The name, address and telephone number of the cardiologist, type of ICD, type of leads, manufacturer and model, serial number, date of implant. Resident #57 was admitted to the facility in [DATE] with diagnoses including end stage renal disease and chronic systolic heart failure. Review of Resident #57's hospital discharge paperwork indicated he/she had an ICD placed in [DATE]. Review of Resident #57's clinical record failed to indicate information related to Resident #57's ICD and failed to include a care plan with individualized interventions, methods or means for staff to monitor or identify his/her ICD. During an interview on [DATE] at 1:45 P.M., the Assistant Director of Nursing (ADON) said all information related to internal defibrillators should be included in the resident record. The ADON was not aware that Resident #57 had an internal defibrillator.

Based on observations, interviews, record review and policy review, the facility failed to identify and assess the use of pillows underneath a fitted sheet, bilaterally, as a potential restraint for one Resident (#63) out of a total sample of 19 residents. Findings Include: Review of facility policy titled Use of Restraints, dated as revised April 2017, indicated the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. -1. Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -6. Prior to placing a resident in restraints there shall be a pre-restraining assessment and review to determine the need for restraints. Resident #63 was admitted to the facility in September 2021 with diagnoses that include dementia, spinal stenosis, and anxiety disorder. Review of Resident #63's most recent Minimum Data Set (MDS) Assessment, dated 4/19/24 indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. On 5/21/24 at 7:58 A.M., the surveyor observed Resident #63 sleeping in bed with pillows tucked under his/her fitted sheet bilaterally. On 5/21/24 at 12:30 P.M., the surveyor observed Resident #63 in bed, pillows were tucked under his/her fitted sheet bilaterally. On 5/22/24 at 7:13 A.M., the surveyor observed Resident #63 sleeping in bed with pillows tucked under his/her fitted sheet bilaterally. On 5/23/24 at 6:42 A.M., the surveyor observed Resident #63 sleeping in bed with pillows tucked under his/ her fitted sheet bilaterally. Review of Resident #63's medical record failed to indicate a restraint assessment was completed to assess whether pillows tucked under the fitted sheet on his/her bed could be a restraint. Review of Resident #63's plan of care failed to indicate the use of pillows tucked into his/her fitted sheet. During an interview on 5/23/24 at 6:57 A.M., Certified Nursing Assistant (CNA) #1 said that she had worked overnight and took care of Resident #63. CNA #1 said that Resident #63 moves a lot in bed and the pillows tucked under the sheets prevent her from rolling out of the bed. During an observation and interview on 5/23/24 at 7:01 A.M., the Assistant Director of Nurses (ADON) observed the pillows under the fitted sheet and said that the pillows tucked into the sheets would be considered a restraint and Resident #63 was not assessed to have the use of a restraint. The ADON said that if staff are using any device that could be considered a restraint, an assessment would need to be completed. During an interview on 5/23/24 at 9:53 A.M., the Director of Nurses (DON) said that Resident #63 has not been assessed for the use of the pillows as a potential restraint and that staff have not been instructed to tuck pillows under the fitted sheet of Resident #63. The DON said that the pillows tucked under the fitted sheet could be considered a restraint.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at risk for nutritional decline, the Facility failed to ensure based on his/her comprehensive assessment, that he/she maintained acceptable parameters of nutritional status, when he/she experienced a severe undesired significant weight loss and required the addition of protein supplements due to malnutrition. Findings include: The Facility Policy titled Nutritional Assessment, undated, indicated the dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframe's) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The multidisciplinary team shall identify, upon the resident's admission and upon his/her change of condition and co-existing risk factors that may place the resident at increased risk for impaired nutrition. Sources of information may include, standardized nutrition screening and assessment tools, Resident Assessment Instrument, assessments from other disciplines, observation, resident and family interviews and the resident's medical record. Once current conditions and risk factors are identified, assessed and analyzed, the individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Interventions will be developed within the context of the resident's prognosis and personal preferences. The individualized care plans shall address to the extend possible: identified causes of impaired nutrition, resident's personal preferences, goals and benchmarks for improvement, timeframe's and parameters for monitoring and reassessment. The Facility Policy titled Weight Assessment and Intervention, undated, indicated that resident's weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team and or physician orders. - Any weight change of 5% or more since the last weight assessment is retaken for confirmation, - If the weight is verified, nursing will immediately notify the dietician in writing. - The threshold for significant unplanned and undesired weight loss will be based on: - 1 month - 5% weight loss is significant; greater than 5% is severe. - 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. - 6 months - 10% weight loss is significant: greater than 10% is severe. - If the weight loss is desirable, this is documented. - Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change is met or not. - Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, dietician, pharmacist, and the resident or legal surrogate. - Individualized care plans will address the identified causes of weight loss, goals and benchmarks for improvement, timeframe's and parameters for monitoring and reassessment. - Interventions for undesirable weight loss are based on careful consideration of resident choice and preferences, nutrition hydration needs, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities and the need for diet modifications, medications that may interfere with appetite, chewing, swallowing or digestion, the use of supplementation and or feeding tubes, end of life decisions and advanced directives. Resident #1 was admitted to the Facility in December of 2022, diagnoses included dementia, hallucinations, delusions, paranoia, atrial fibrillation (irregular heart beat), high blood pressure and SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion), and a fall at home that resulted in a left fractured wrist and ulnar. Review of Resident #1's Care Plan titled Nutritional Problem,, initiated 12/2022 and reviewed and renewed with the completion of his/her MDS's in March and May of 2023, indicated Resident #1 was at risk for weight loss due to variable oral intake and cognitive decline with interventions that included the following: - he/she will consume at least 50% of meals. - encourage family to bring in culturally preferred meals. - maintain skin integrity. - obtain weights as ordered. - report a significant weight loss of 3 pounds (lbs) in 1 week, > (greater than 5% in 1 month, >7.5% in 3 months or > 10% in 6 months. - provide supplements as ordered to promote a gradual weight gain. Review of Resident #1's Admission Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 required supervision of 1 staff member for eating, had swallowing difficulty, received speech therapy and weighed 140 lbs. Review of Resident #1's Quarterly MDS, dated [DATE], indicated Resident #1 required extensive physical assistance of 1 staff member for eating, had no difficulty with swallowing, no speech therapy, weight was 168 lbs. and he/she had no weight loss in the past 3 months. Review of Resident #1's Quarterly MDS, dated [DATE], indicated Resident #1 required extensive physical assistance of 1 staff member for eating, had coughing or choking during meals or when swallowing medications, was holding food in his/her mouth, received speech therapy, weight was 105 lbs, and he/she had a significant weight loss of 10% or more, in 6 months. The MDS indicated Resident #1 was not on a prescribed weight loss regime. Review of Resident #1's monthly weights, as documented by nursing indicated the following: 12/01/22 - 140.0 lbs. on admission, standing scale 12/18/22 - 140.0 lbs. hospital weight 01/07/23 - 166.2 lbs. via wheelchair scale 02/04/23 - 168.0 lbs. via wheelchair scale 03/10/23 - 118.8 lbs. standing scale 04/01/23 -114.0 lbs. via wheelchair scale 05/04/23 - 110.4 lbs. via wheelchair scale 06/01/23 - 104.8 lbs. via wheelchair scale 07/06/23 - 92.0 lbs. via wheelchair scale Resident #1 had a documented weight gain of greater than 10%, (in less than 30 days) with a weight of 140 lbs. on 12/01/22 and a weight of 169.9 lbs. on 12/24/22, however Resident #1 was not re-weighed per facility policy. Based on his/her documented weights, Resident #1 had a weight loss greater than 7.5 % 3 months, with a weight of 140.0 lbs. on 12/18/22 and a weight of 118.8 lbs. on 3/10/23, however Resident #1 was not re-weighed per facility policy. Further review of Resident #1's Dietician Progress Note, dated 3/13/23, indicated the admission weight of 140 lbs., (obtained back in December 2022) was likely inaccurate and the recorded weight on 3/10/23 of 118 lbs., was due to decreased oral intake and poor appetite. The Note indicated Glucerna supplements 3 times daily were implemented, continue weekly weights and trend weights from the new baseline of 118 lbs. obtained on 3/10/23. During an interview on 7/13/23 at 3:19 P.M., the Dietician said Resident #1 did have a weight loss, but the weight documentation in the 168 pound area were disputed due to inaccurate scales. The Dietician said the Facility re-calculated all the weight scales and re-weighed all the residents in March 2023. The Dietician said at that time, the Interdisciplinary Team decided the baseline weight for Resident #1 was 118 lbs. The Dietician said there was a period of time when Resident #1 was not eating anything. The dietician and the Food Service Director initiated serving rice and cooked vegetables for lunch and dinner to Resident #1 when no food was available from family members. The dietician said Resident #1 had been eating better but, she had not observed Resident #1 eating recently. The dietician said Resident #1 continued to suffer severe weight loss from March 2023 to through July 2023. However, although the facility determined in March 2023 that Resident #1's actual baseline weight was 118.0 lbs, he/she continued to experience an undesired weight loss, and based on his/her documented weight of 92.0 lbs., on 7/06/23, he/she had a severe significant weight loss of greater than 7.5 % in a 90 day period (with of loss of greater than 20% in that period). Further review of Resident #1's clinical record indicated on 5/31/23, Resident #1 developed a stage 2 pressure (break in skin, presents as an abrasion, blister or shallow crater) wound to his/her right buttock, a wound consult was completed and blood tests were ordered. Review of Resident #1's blood laboratory test results indicated his/her pre-albumin (blood test to measure malnutrition) level was critically low and he/she required the addition of a supplement for protein malnutrition (lack of proper nutrition). During an interview on 7/13/23 at 2:29 P.M., Certified Nursing Aide (CNA) #2 said Resident #1 was on her assignment almost everyday. CNA #2 said she feeds Resident #1 each morning while he/she is in bed. CNA #2 said breakfast is his/her best meal and likes 2 bowls of hot cereal, bananas and sometimes will drink orange juice. CNA #2 said Resident #1 does not eat well for lunch unless food brought in by the family is available. During an interview on 7/13/23 at 2:50 P.M., CNA #3 said she has cared for Resident #1 and that he/she eats breakfast in bed and usually is confused. CNA #3 said Resident #1 needs to be fed all meals, that he/she likes bananas. CNA #3 said Resident #1 but does not eat much at all for lunch. CNA #3 said an Ensure supplement is always available on his/her bedside table and Resident #1 will take a sip sometimes when offered by staff, but that she was not sure how much he/she drinks if staff does not and physically go in help him/her. During an interview on 7/13/23 at 4:30 P.M., Nurse #1 said she cares for Resident #1 daily, providing medications and treatments as ordered. Nurse #1 said Resident #1 eats breakfast in bed daily and needs to be fed by staff for all meals. Nurse #1 said Resident #1 eats fairly well for breakfast, but not much for lunch and dinner. Nurse #1 said Resident #1 will eat food brought in by family when available, and that Family brings in food approximately every other day. Review of Resident #1's Progress Note, dated 7/13/23, written by the Assistant Director of Nursing, indicated Resident #1 had triggered for weight loss on 7/12/23 and a re-weight was completed on 7/13/23, and he/she weighed 100.6 lbs.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who experienced a significant change with a decline in overall status, related to Activities of Daily Living (ADLs), skin condition, and his/her nutritional status, the Facility failed to ensure nursing adequately identified the decline and completed a comprehensive Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), as required. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated a Significant Change in Status Assessment (SCSA) must be completed within 14 days of determining the status was significant. A significant change means a major decline or improvement in the Resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the Resident's health status, and requires interdisciplinary review or revision of the care plan. The Facility Policy titled Acute Condition Changes - Clinical Protocol, undated, indicated direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse. The staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regime and diagnostic test results. Resident #1 was admitted to the Facility in December of 2022, diagnoses included dementia, hallucinations, delusions, paranoia, atrial fibrillation (irregular heart beat), high blood pressure and Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH), and a fall at home that resulted in a left fractured wrist and ulnar. Review of Resident #1's Admission MDS, dated [DATE], indicated he/she had severe cognitive impairment, and his/her level of staff assistance required for ADL care was documented as; - required limited assistance of 2 for transfers, - he/she was non-ambulatory, - required extensive physical assistance of 2 for dressing, - required supervision of 1 with eating, - required supervision of 1 for personal hygiene care, - always incontinent of bowel and bladder, - required limited assistance of 1 for toileting, - documented admission weight was 140 pounds. - skin was intact, he/she had no wounds. Review of Resident #1's Quarterly MDS, dated [DATE], indicated he/she had severe cognitive impairment. and his/her level of staff assistance required for ADL care was documented as; - required extensive physical assistance of 2 for transfers. - required limited physical assist of 1 to walk 50 feet with walker. - required extensive physical assistance of 2 for dressing. - required extensive physical assistance of 1 for eating. - required extensive physical assistance of 1 for personal hygiene. - was frequently incontinent of bowel and bladder. - required extensive physical assistance of 2 for toileting. - documented weight was 168 pounds (lbs.), - skin was intact, he/she had no wounds. Although, Resident #1 experienced a decline in ADL status related to his/her ability to participate in transfers, eating, hygiene, and toileting care needs, a Significant Change MDS was not initiated or completed. Review of Resident #1's Quarterly MDS, dated [DATE], indicated he/she had severe cognitive impairment. and his/her level of staff assistance required for ADL care was documented as; - required extensive physical assistance of 2 for transfers, - was non-ambulatory, - required extensive physical assistance of 2 for dressing, - required extensive physical assistance of 1 for eating. - required extensive physical assistance of 1 for personal hygiene. - was always incontinent of bowel and bladder. - required extensive physical assistance of 2 for toileting. - documented weight was 105 lbs. - skin, he/she had a Stage 2 (break in skin that presents as abrasion, blister, or shallow crater) pressure wound to right buttock. Although Resident #1 had a documented change in status which indicated he/she had a decline in two areas, a significant weight loss and the development a pressure injury, a Significant Change in Status MDS Assessment was not initiated or completed, within 14 days as required. Further review of Resident #1's medical record indicated that although he/she continued to experience significant weight loss, a Significant Change MDS was not initiated or completed. Review of Resident #1's monthly weights, as documented by nursing indicated the following: 12/01/22 - 140.0 lbs. on admission, standing scale 12/18/22 - 140.0 lbs. hospital weight 01/07/23 - 166.2 lbs. via wheelchair scale 02/04/23 - 168.0 lbs. via wheelchair scale 03/10/23 - 118.8 lbs. standing scale 04/01/23 -114.0 lbs. via wheelchair scale 05/04/23 - 110.4 lbs. via wheelchair scale 06/01/23 - 104.8 lbs. via wheelchair scale 07/06/23 - 92.0 lbs. via wheelchair scale Review of Resident #1's current Care Plan titled Nutritional Problem, indicated Resident #1 was at risk for weight loss due to variable oral intake and cognitive decline. Further review of Resident #1's Care Plan for Nutrition indicated interventions included the following: - Obtain weights at ordered intervals. - Dietician to evaluate nutritional status and make recommendations as needed. - Monitor, record, report signs or symptoms of malnutrition, emaciation, muscle wasting and significant weight loss of > (greater than) 3 pounds in 1 week, > 5% in 1 month, >7.5 % in 3 months or >10% in 6 months. Review of the Dietician Progress Note, dated 3/13/23, indicated the following: - Dietician reviewed and was aware of Resident #1's baseline weight and that it indicated significant weight loss, - Resident #1's weight loss is likely inaccurate, - documentation in January and February 2023 of 168 lbs, was due to inaccurate scale, - 168 lbs. was inconsistent with the hospital discharge summary weight of 140 lbs, - Resident #1's weight trend was indicative of a 22 lbs. weight loss in 3 months (140 lbs. to 118 lbs.) due to decreased oral intake and poor appetite. - Resident #1 receives Glucerna with meals. - Will maintain orders for weekly weights and trend from the new baseline. Although the Dietician's Progress Note indicated that Resident #1's weight loss trend was indicative of a 22 lbs. weight loss in 3 months, which therefore reflected an overall weight loss of greater than 15% in 3 months, there was no documentation to support a SCSA MDS was initiated or completed related to his/her weight loss. During an interview on 7/13/23 at 3:19 P.M., the Dietician said Resident #1 had experienced a weight loss, but that his/her weights in the 168 pound (lbs) area (January 2023 and February 2023) were disputed due to inaccurate scales. The Dietician said the Facility re-calibrated all the facility's weight scales and then re-weighed all the residents in March 2023. The Dietician said at that time, the Interdisciplinary Team decided the baseline weight for Resident #1 was 118 lbs. During an interview on 7/24/23 at 1:31 P.M., the MDS Nurse said she did not open a SCSA MDS when completing the March 2023 or May 2023 Quarterly MDS's for Resident #1. The MDS Nurse said Resident #1 had been on her radar for weight loss, said she looked at the Resident #1's MDS documentation again (during this survey) said she was not sure why a SCSA MDS had not been initiated. The MDS Nurse said she does not attend Care Plan Meetings routinely but would attend if a nurse was not available. The MDS Nurse said the Assistant Director of Nursing, Unit Manager, Social Worker, Dietary, Activities and the Resident or family member, attend the Care Plan meetings.

Based on records reviewed and interviews the facility failed to implement the plan of care for 5 Residents (#11, #67, #69, #4 and #56), out of a total sample of 28 residents. Findings include: 1.) For Resident #11 the facility failed to ensure staff implemented a physician's order for blood pressure checks. Resident #11 was admitted to the facility in March 2023 with diagnoses including muscle wasting, atrophy and thrombocytopenia (a bleeding condition where there is a deficiency of platelets in the blood that can cause bleeding into the tissues, bruising and slow clotting after injury). Review of the physician's order, dated 3/2/23, indicated: - no blood pressures in Resident #11's right arm due a deep vein thrombosis (blood clot). Review of Resident #11's medical record indicated that nursing obtained his/her blood pressure in the right arm on: 3/3/23 3/6/23 3/11/23 3/12/23 3/15/23 3/16/23 3/17/23 3/20/23 3/21/23 During an interview on 3/24/23, at 8:04 A.M., Nurse #3 said that she is only supposed to obtain Resident #11's blood pressure in the left arm. During an interview on 3/24/23, at 9:03 AM Unit Manager #2 said that nursing should only obtain blood pressure from Resident #11's left arm. During an interview on 3/24/23, at 9:56 A.M., the Director of Nursing said that nursing should only obtain blood pressure from Resident #11's left arm. 2.) For Resident #67 the facility failed to ensure a physician's order for Lovenox (an injection medication used to decrease the chance of blood clots) administration was implemented as ordered. Resident #67 was admitted to the facility in August 2022 with diagnoses including amyotrophic lateral sclerosis (disease that breaks down nerve cells), diverticulitis and left anterior fascicular block (cardiac condition). Review of the physician's order dated 3/6/23, indicated an order to administer: -Lovenox 40 milligrams inject one syringe subcutaneously under the skin one time a day for anticoagulant. Further review indicated to only administer the injection into the arms. Review of the Medication Administration Record, dated March 2023, indicated nursing administered Resident #67's Lovenox injection in his/her abdomen on: 3/10/23 3/11/23 3/12/23 3/13/23 3/14/23 3/15/23 3/16/23 3/17/23 3/18/23 3/19/23 3/22/23 During an interview on 3/23/23, at 9:02 A.M., Nurse #10 said that Resident #67's Lovenox injection can be injected into either his/her arm or in his/her abdomen. During an interview 3/24/23, at 8:09 A.M., Nurse #3 said that Resident #67's Lovenox administration is to be done in his/her arm. Nurse #3 said that when nursing administers Lovenox in Resident #67's abdomen that Resident #67 would bleed a lot. During an interview on 3/24/23, at 8:51 A.M., Unit Manager #2, said that nursing should have implemented the physician's order and administered Resident #67 his/her Lovenox injection in his/her arms. Unit Manager #2 said that Resident #67 bleeds a lot from injections in the abdomen. During an interview on 3/23/23, at 11:15 A.M., the Nurse Practitioner said that Resident #67's Lovenox injection should be in his/her arms. The NP said that she switched order to give Resident #67's abdomen a break because he/she was having prolonged episodes of bleeding after the Lovenox injection in the abdomen. During an interview on 3/24/23, at 10:02 A.M., the Director of Nursing (DON) said that nursing should have implemented the physician's order for the Lovenox administration. The DON said that the order indicated to administer in the arms and she was not sure why nursing would administer the Lovenox into the abdomen. 3.) For Resident #69 the facility failed to ensure nursing implemented a physician's order for Midodrine (a blood pressure medication used to treat low blood pressures). Resident #69 was admitted to the facility in March 2022 with diagnosis including chronic respiratory failure, chronic obstructive pulmonary disease and hypotension. Review of the physician's order, dated 12/23/22, indicated to administer: -Midodrine Tablet 5 milligrams, administer 3 tablets by mouth at bedtime for hypotension. Further review indicated to hold the medication for a systolic blood pressure greater than 130 (top number of a blood pressure, written as systolic/diastolic blood pressure). Review of the Medication Administration Records, dated December 2022, January 2023, February 2023 and March 2023 indicated that Resident #69's Midodrine was documented as administered on the following dates: 12/27/22 administered, blood pressure 148/88 1/21/23 administered, blood pressure 148/76 1/30/23 administered, blood pressure 139/82 2/11/23 administered, blood pressure 149/76 2/18/23 administered, blood pressure 138/76 2/22/23 administered, blood pressure 132/87 2/23/23 administered, blood pressure 136/82 2/27/23 administered, blood pressure 143/93 3/6/23 administered, blood pressure 134/77 3/9/23 administered, blood pressure 147/82 3/10/23 administered, blood pressure 132/84 3/13/23 administered, blood pressure 150/86 3/19/23 administered, blood pressure 136/74 During an interview on 3/24/23, at 6:54 A.M., Nurse #8 said Resident #69's Midodrine medication should be held if his/her systolic blood pressure is greater than 130. Nurse #8 said if Resident #69's systolic blood pressure is greater than 130 she would document the medication as not administered and she would write a note. During an interview on 3/24/23, at 8:46 A.M., Unit Manager #2 said that nursing should implement the physician's order and should not administer Resident #69's Midodrine when the systolic blood pressure is greater than 130. During an interview on 3/23/23, at 11:01 A.M., the Nurse Practitioner said that nursing should implement the physician's order and should not administer Resident #69's Midodrine when his/her systolic blood pressure is greater than 130. During an interview on 3/24/23, at 9:50 A.M., the Director of Nursing said that nursing should implement the physician's order and should not administer Resident #69's Midodrine when the blood pressure is greater than 130. 45984 4.) For Resident #4 the facility failed to implement a physician's order for weekly skin checks. Resident #4 was admitted to the facility in January 2023 with diagnoses that include spinal stenosis, end stage renal disease, unspecified protein calorie malnutrition, major depressive disorder and anxiety disorder. Review of Resident #4's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of possible 15 indicating that he/she had moderate cognitive impairment. Further review of the MDS indicated that the Resident requires extensive assistance with all activities of daily living and exhibited no behaviors. Review of Resident #4's physician orders indicated the following: *Skin Checks weekly on Tuesday 7-3, one time a day every Tuesday with a start date of 1/31/23 and an end date of 2/24/23 indicating this is a discontinued order. *Skin Checks weekly on Tuesday 7-3 one time a day every Tuesday with a start date of 2/28/23 and an end date of 3/14/23 indicating this is a discontinued order. *Skin Checks weekly on Monday 7-3 every day shift every Monday with a start date of 3/27/23 and no end date indicating this is an active order. Review of Resident #4's care plan for potential skin breakdown indicated the following intervention: *Document skin checks weekly and PRN (as needed). Notify the physician of new areas if observed, Follow-up as indicated. The facility failed to document a weekly skin check occurring on 2/21/23 and 3/7/23. Review of Resident #4's nursing progress notes and treatment administration record did not indicate any refusal of weekly skin checks. During an interview on 3/24/23 at 7:58 A.M., Nurse #1 said Resident #4 has a history of a pressure ulcers on his/her sacrum and has had a recent toe amputation. She continued to say that weekly skin checks should be done when residents have skin concerns and as ordered. She further said if weekly skin checks are not documented in the electronic medical record, then they were not completed. Nurse #1 said she was not sure why Resident #4 was missing two skin checks. 5.) For Resident #56 the facility failed to implement a physician's order for providing a dressing on a recent amputation site. Resident #56 was admitted to the facility in December 2022 with diagnoses that include encounter for orthopedic care aftercare following surgical amputation and end stage renal disease. Review of Resident #56's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam indicating that he/she is cognitively intact. Further review the MDS indicated that the Resident requires extensive assistance with all activities of daily living and no behaviors were documented. The surveyor made the following observations: *On 3/21/23 at 11:24 A.M., Resident #56's above knee amputation site had exposed staples and was not wrapped. *On 3/23/23 at 5:42 A.M., Resident #56's above knee amputation had exposed staples and was not wrapped. Resident #56 was observed scratching at his/her amputation site. *On 3/23/23 at 9:40 A.M., Resident #56's above knee amputation site had exposed staples and was not wrapped. *On 3/24/23 at 7:43 A.M., Resident #56's above knee amputation site had exposed staples and was not wrapped. Review of Resident #56's physician orders indicated the following: *Cleanse with vashe (wound cleanser), pat dry, cover AKA with vashe moistened ABD pad (gauze pad) and wrap with kerlix (dressing for a wound). Change daily and PRN (as needed). Start Date: 3/10/23 7:00 A.M., Discontinue date: 3/21/23 2:55 P.M. *Right AKA incision: Cleanse with NS (normal saline), paint incision with Betadine (topical antiseptic) daily. Cover with DSD (dry sterile dressing) and change as needed every day shift for AKA incision. Start Date: 3/23/23 7:00 A.M. Review of Resident #56's nursing progress notes did not indicate any refusal of care or behaviors of the Resident removing his/his dressing for his/her above knee amputation (AKA) site. During an interview on 3/24/23 at 8:11 A.M., Nurse #1 said Resident #56's AKA site should be wrapped until it is changed again. The surveyor and Nurse #1 looked at Resident #56's AKA site together and it was not wrapped. Nurse #1 said it is odd that it is not covered and it should be covered. She said her expectation is that it should be covered until the next time it is scheduled to be changed.

Based on observations, policy review and interviews, the facility failed to 1.) maintain privacy during the provision of care for 1 Resident (#50) out of a total of 28 sampled Residents and 2.) failed to provide a dignified dinning experience for Residents on the 2nd and 4th floor nursing units. Finding Include: Review of the policy titled Dignity, dated as revised October 2022, indicated: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self- esteem. -Residents are to be treated with dignity and respect at all times. -Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1.) Resident #50 was admitted to the facility in August 2019, with diagnoses including Parkinson's, generalized anxiety disorder and unspecified mood [affective] disorder. Review of Resident #50's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) examination score of 10 out of a possible 15, indicating moderate cognitive impairment. The MDS also indicated Resident #50 required extensive assistance from staff for all daily functional tasks. On 3/21/23 at 8:46 A.M., a remote baby monitor camera was observed in Resident #50's room on the dresser opposite his/her bed where he/she was lying in bed sleeping. The corresponding video monitor was observed on the nursing medication cart in the hallway with a full view of Resident #50 sleeping. Record review indicated a physician's order, dated 3/10/23: -Continuous video monitoring of resident at all times (when not with resident or in resident's room). On 3/22/23 at 7:47 A.M., the video monitor was observed on nursing medication cart with Resident #50 visible sleeping in his/her bed. On 3/23/23 at 6:40 A.M., a CNA was observed entering Resident #50's room for morning care. The video monitor was observed on the counter at nursing station facing the hallway with Resident #50 visible to surveyor, staff and other residents while Resident #50 received morning care. During an interview on 3/23/23 at 8:57 A.M., Nurse #11 was asked about the video monitor on her medication cart. Nurse #11 said Resident #50 had many falls, so they decided to try the baby video monitor. Nurse #50 said the video monitor is working pretty well and she was instructed to keep the monitor on the medication cart. Nurse #11 said she did not feel it was the best idea as she is not at her medication cart while she is passing medications and she can't look at the monitor all the time. Nurse #11 also said she will leave it with the person covering the nurse's station if there is staff covering the desk, otherwise it is kept on the medication cart. During an interview on 3/24/23 at 9:11 A.M., Unit Manager #1 she said she was off for a few days and when she returned the baby monitor was being used due to Resident #50's fall risk. Unit Manager #1 said she understood having the monitor visible with Resident #50 in clear view at the nursing station was a privacy concern, but didn't have any recommendations for an alternative location to maintain Resident #50's privacy. During an interview on 3/24/23 at 9:20 A.M., the Regional Risk Manager acknowledged the concern for Resident #50's privacy. During an interview with the Director of Nursing on 3/24/23 at 9:20 A.M., the surveyor shared the above observations. The Director of Nursing acknowledged the concern for Resident #50's privacy with use of the video monitor during care. 45984 2a.) The following observations were made on the 2nd floor unit: *On 3/21/23 at 8:35 A.M., a staff member was observed sitting next to a resident in his/her bed assisting with a meal. While doing so, the staff member had her laptop open on her lap and was using her cell phone. *On 3/23/23 at 8:08 A.M., Nurse #1 was observed standing over a resident, not at eye level while feeding a resident oatmeal. During an interview on 3/24/23 at 8:46 A.M., the Administrator said staff should be sitting at eye level while assisting residents with eating. The Administrator said that staff should not be on their cell phones or laptops while assisting residents with meals. 44095 2b.) On 3/22/23 at 12:12 P.M., the surveyor observed staff on the 4th floor to be in the middle of hall, going through the lunch food cart, during which the surveyor heard staff loudly refer to 6 different residents as 'feeders'. During an interview on 3/22/23, at 12:19 P.M., the Regional Nurse said staff should not call Residents feeders. During an interview on 3/24/23, at 9:16 A.M., Unit Manager #2 said that staff should not have called Residents feeders. During an interview on 3/24/23, at 10:29 A.M., the Director of Nursing said that staff should not have called Residents feeders.

Based on observation, record review, and interview, the facility failed to ensure residents received appropriate treatments and interventions to prevent the development and deterioration of pressure injuries for 3 residents (#75, #9 and #27) out of a total of 29 sampled Residents. Findings include: 1. For Resident #75, the facility failed to A) identify the deterioration of an existing pressure ulcer, B) failed to ensure wound treatments were implemented correctly and timely, C) failed to ensure the use of a wound vac (a device used to help treat pressure ulcers) was monitored and used with valid physician orders, and D) failed to ensure wound treatments were completed as ordered. Subsequently, Resident #75's existing pressure ulcers deteriorated and new pressure ulcers developed. Resident #75 was admitted to the facility in October 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's most recent Minimum Data Set Assessment indicated he/she was moderately cognitively impaired and required physical assistance with eating, transfers, bathing and dressing. During an interview with Resident #75 on 4/20/22 at 8:43 A.M., the surveyor observed a wound vac on Resident #75's night table. Resident #75 said that he/she had wounds that the nursing staff were treating. A). Review of Resident #75's progress note dated 12/3/21, indicated Resident #75 was readmitted to the facility on [DATE] with a Stage II (ulcer which affects the top two layers of skin) open area on his/his her sacrum measuring 3 CM (centimeters) X 2 CM surrounding wound, skin excoriated (superficial reddened). Review of Resident #75's December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 12/4/21 - 12/9/21. Review of the Wound Physician's Progress note dated 12/8/21, indicated: Sacral pressure ulcer: Unstageable 2.5 X 2.5 CM (Indicating deterioration from the previously documented Stage II) 100 % slough (dead skin) Procedure: Debridement (a surgical procedure to remove dead tissue). Review of Resident #75's daily progress note dated 12/9/21 indicated: Skin/Wound: No changes in skin integrity. Review of Resident #75's Weekly Skin Check dated 12/10/21, 10:00 A.M., indicated: Stage II open area measured 3 CM X 2 CM, surrounding skin excoriated. Treatment applied as ordered. During an interview with Nurse #1 on 4/21/22 at 11:03 A.M., she said that Resident #75's wound was initially a superficial Stage II. Nurse #1 said that she thought Resident #75's wound may have deteriorated because agency nurses were not doing the dressings or skin checks. Nurse #1 said that she has had difficulty in getting agency nurses to complete skin checks or treatments and they have told her that's not my job. B). During an interview with the Wound Physician on 4/25/22 8:08 A.M., he said that he visits his patients weekly and rounds with the Wound Nurse. He said he will recommend orders which the Wound Nurse will then enter into the Resident's electronic record, or he will speak directly to the Resident's Nurse Practitioner. The Wound Physician said that he has never experienced a declination or a disagreement from a Resident's physician or Nurse Practitioner in his/her treatment recommendations. During an interview with the Wound Nurse on 4/25/22 at 8:08 A.M., he said that he rounds with the Wound Physician and logs updated orders into the computer, and the Wound Physician will also send over recommended orders after the visit. The Wound Nurse also said that he or the Wound Physician will also contact the nurse manager or nurse on duty to relay orders or recommendations for treatment after seeing residents. The Wound Nurse said that many times the orders are not correct in the computer and when he assists in performing dressings, he has seen incorrect dressings on residents. The Wound Nurse said that nurses will make up their own dressings, mix up orders, or input orders wrong into the resident's electronic record. Review of Resident #75's Wound Physician Notes from December 2021 indicated: 12/8/21: Sacral pressure ulcer treatment: NS wash, santyl to wound bed cover with dry sterile dressing (DSD) once daily and as Zinc to peri wound and buttocks. 12/15/22: Sacral pressure ulcer: No change to treatment plan. New wound identified: Left Buttock Deep Tissue Injury (DTI). Treatment: Zinc to peri wound. Skin prep. 12/22/22: Sacral pressure ulcer: No change to treatment plan. Left buttock pressure ulcer. Unstageable. 80% Granulation (New tissue) 20% Slough. Deteriorating. Review of Resident #75's physicians orders dated December 2021 indicated the following: *Wash coccyx with normal saline, apply santyl cover with dry protective dressing (DPD) one time a day for wound. 12/9/21 through 12/21/21. (The order failed to include the use of Zinc for Resident #75's buttocks as indicated by the Wound Physician peri wound and buttocks.) *Left buttock zinc to peri wound. Skin prep Daily. 12/22/21 - 12/25/21. (Ordered 14 days after first indicated by the Wound Physician.) Review of Resident #75's Wound Physician Notes from January 2022 indicated: 1/12/22: Unstageable sacral pressure ulcer: 4 CM X 2 CM X 2 CM. Deteriorating. 30% Necrotic 70% Slough. Treatments: Sacral: Clean with Dakins 1/2 strength. Pack with Dakins wet to dry twice daily for 3 days, then wash with Dakins 1/2 strength pack with normal saline wet to dry kerlix or gauze daily, cover with dsd/island dressing. 1/19/22: Unstageable sacral pressure ulcer: 4 CM X 4X CM x 3 CM. Deteriorating. 15% Necrotic. 85% Slough. Treatment: Clean with sound cleanser. Santyl, pack with clacium alginate and sacral dressing. Needs to be packed. No dressing on wound. 1/26/22: Unstageable sacral pressure ulcer: 4 CM X 3 CM X 3 CM. Deteriorating. 15% Necrotic. 85% Slough. Patient incontinent of stool. Stool in wound. Treatment: Clean with Dakins 1/2 strength. Pack with Dakins wet to dry for 3 days then NS wet to dry. DSD or coccyx/sacral dressing daily and as needed. Needs to be packed. Wound has been deteriorating. Recommend wound vac after next wound visit. Stool in wound. Review of Resident #75's January 2022 Physician's orders indicated: Sacral wound: Cleanse with wound cleanser, pack with Dakins soaked gauze and calcium alginate. Cover with Dry protective Dressing (DPD) . One time a day for wound. 1/13/22 - 1/19/22. (The Wound Physician did not indicate the use of calcium alginate and indicated a treatment to be completed twice daily for the first three days on 1/12/22.) Sacral wound: Cleanse with wound cleanser, apply santyl to wound bed, pack with calcium alginate and cover with coccyx dressing one time a day for wound. 1/20/22 - 1/28/22. (The Wound Physician had indicated on 1/19/22 to not cover Resident #75's wound.) C. Review of the clinical record indicated Resident #75 was hospitalized in February 2022 from 2/3/22 and returned on 2/16/22. Review of Resident #75's Wound Physician's note dated 2/2/22 indicated: Sacral pressure ulcer Unstageable. 75% Slough. 25% Necrotic. Deteriorating. Treatment: Clean with Dakins 1/2 strength, pack with Dakins wet to dry for 3 days then NS wet to dry. DSD or coccyx sacral dressing twice daily. Needs to be packed. Wound has been deteriorating. Recommended wound vac next wound visit after Debridement. Review of Resident #75's clinical record indicated he/she was hospitalized on [DATE] and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #75 was readmitted to the facility on [DATE]. Review of Resident #75's Wound Physician's notes for February 2022 indicated: 2/16/22: admitted to the facility with new areas: Deep Tissue Injury (DTI) of the left heel and DTI of the right heel: Both areas Unstageable Skin intact. Exudate (fluid): None Treatments: Off load heels, prevalon boots. Stage IV sacral pressure ulcer: 5.5 CM X 5.6 CM X 2.3 CM. Treatment: Negative pressure wound therapy (wound vac) apply three times per week use white foam for undermining. 2/23/22: DTI of the left heel: Unstageable. Skin intact. Exudate: None Treatment: Off load heels, prevalon boots. DTI of the right heel: Unstageable. 1.9 CM X 1.3 CM (A deterioration from the previous visit): Exudate: Light serous. Treatment: Iodosorb dressing once daily for 30 days. Stage IV sacral pressure ulcer: No changes in treatment plan 3/2/22: Left Heel: Unstageable. (A deterioration from the previous visit.) 2 CM X 3 CM Exudate: light serous. Treatment: Iodosorb dressing once daily. Right heel: Unstageable Necrosis. Exudate: light serous. 100% necrotic tissue. Treatment: Iodosorb Stage IV sacral pressure ulcer. No changes in treatment plan. Review of the February 2022 physicians orders indicated: *Bilateral heels Iodosorb and cover with gauze sponge daily for wound care. 3/4/22 through 3/24/22. (The Wound Physician first indicated the start of this treatment on 2/23/22; 10 days prior.) *Sacral Wound: Green foam to wound bed, pack with white foam, set wound vac at 44. Change Monday, Wednesday and Friday. 2/17/22 through 3/17/22. (The Wound Physician indicated the use of only white foam for healing, not green.) During an interviews with the Director of Nursing (DON) on 4/25/22 at 11:09 A.M., she said she was aware of the concerns regarding accurate orders being implemented for resident pressure ulcers. Review of Resident #75's physicians orders indicated two different orders for wound vac treatment: *Change Wound Vac two times a week; pack with green foam drape and set negative pressure to 40 MM one time a day every Monday, Thursday and Friday for wound care. 2/17/22 through 3/17/22. *Sacral Wound Cleanse with NS, green foam to wound bed, pack with white foam, set at 44. Change Monday, Wednesday and Friday every day shift for wound care. 2/21/22 through 3/17/22. Review of Resident #75's March 2022 TAR indicated he/she received wound vac treatment on: 3/2/22, 3/3/22, 3/7/22, 3/11, 3/10/22, 3/14/22, and 3/16/22. During a follow up interview with the DON and the Administrator on 4/27/22 at 9:45 A.M., the DON said that when Resident #75 initially returned from the hospital the orders were for him/her to receive wound vac treatment 2 days a week but it was increased. The DON said she would have to look into why there were 2 standing orders from 2/21/22 through 3/17/22 wherein Resident #75 received wound vac treatment 4 days a week at differing settings instead of 3 days week per the Wound Physicians guidelines. Review of the Wound Physician's note dated 3/23/22 indicated a recommendations to reinstate the previous orders of the wound vac 3 times a week. Review of the Risk Meeting Note dated 4/1/22 indicated: Wound vac to sacrum. Review of clinical Progress notes dated 3/27/22, 4/1/22, and 4/18/22 all indicated Resident #75 had a wound vac in place and functioning. Review of Resident #75's Physician's orders failed to indicate any active orders for a wound vac between between 3/17/22 - 4/18/22. Review of Resident #75 February 2022 Treatment Administration Record (TAR) indicated: Wound Vac check and functioning every shift, 2/15/22 through 3/17/22: *The TAR box read N which indicated it was not completed on the morning shifts on 2/15/22, 2/16/22, 2/18/22, 2/21/22 and the night shift on 2/17/22. The TAR box was blank indicating that it was not completed on the morning shift on 2/25/22. D. During an interview with Nurse #1 on 4/21/22 at 11:03 A.M., she said that it was possible that facility staff were not performing treatments as ordered for Resident #75. Nurse #1 said that she often goes to provide wound care for Residents and they are dated a long time ago. During an interview with the Wound Nurse on 4/24/22 at 8:08 A.M., he said that when he rounds with the Wound Physician they discover dressings that had not been changed for days. The Wound Nurse said that each time this occurs he takes pictures of the old dressings and notifies the DON and sends the photos to her. He said that in March 2022 when he observed that Resident #75's heel dressing had not been changed for a few days he took a photo and informed the DON. During initial interview with the DON on 4/25/22 at approximately 12:15 P.M., the surveyor requested any investigations regarding skin care. The DON said she had none. During a follow-up interview on 4/25/22 at 12:45 P.M., the DON said that the Wound Nurse and Wound Physician had made her aware that Nurse #3 and Nurse #4 were not completing wound treatments as ordered, and she had done an investigation, contradicting her previous statement. Review of the facility investigation dated 3/16/22 indicated that the Wound Physician asked the DON to observe Resident #75's heel dressing. The DON observed the dressing was dated 3/10/22, indicating it had not been changed in 6 days, when the orders indicated the dressing was to be changed daily. The statement indicated the Treatment Administration Record had been reviewed [and nursing staff had documented they had changed Resident #75's dressing as ordered] and the nurses involved had been disciplined. Review of Nurse #3's disciplinary action form indicated: Date of offense: 3/11/22, 3/14/22, 3/15/22 Nature of offense: Patient rights; failure to complete an MD order Did not change residents dressing for 3 days causing worsened area. Signed treatment as completed. Dressing in place noted to be 6 days old. Review of Nurse #4's disciplinary action form indicated: Date of offense: 3/12/22, 3/13/22 Nature of offense: Patient rights, failure to complete and MD order Did not change resident dressing for 2 days causing worsened area. Signed treatment as completed. Dressing in placed noted to be 6 days old. 2. For Resident #9, the facility failed to implement interventions related to existing and newly developed pressure ulcers. Resident #9 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated that he/she is cognitively intact and requires assistance with dressing, bathing and bed mobility. Review of Resident #9's Nursing Admission Skin assessment dated [DATE] indicated he/she had the following skin injuries: *Stage II: Upper/mid back pressure area. *Stage I: Sacrum pressure area Review of Resident #9's Wound Physician's notes indicated: 2/9/22: Stage III sacrum pressure ulcer. 1 CM X .6 CM 10% necrotic tissue. Exudate: moderate serous. Treatment: Vashe apply once daily, alginate calcium with silver apply once daily. Foam silicone border apply once daily. Unstageable right upper back pressure ulcer. 4.7 CM X 2.9 CM 100% necrotic tissue. Exudate: light serous Treatment: Silver [MEDICATION(S)] apply once daily. Treatment: Silver [MEDICATION(S)], silicone bordered foam, apply once daily. 2/16/22: Stage III sacrum pressure ulcer: 20% necrotic tissue. (indicating an increase in necrotic tissue from the previous visit) Exudate: Moderate Serous. Treatment: No changes in treatment plan. Stage IV right upper back pressure ulcer. 100% necrotic tissue. Exudate: Moderate Serous. Treatment: Vashe alginate calcium with silver apply silicone bordered foam apply once daily. Review of Resident #9's treatment orders indicated: Sacrum: Cleanse with wound wash then apply alginate cover with foam dressing one time a day, 2/10/22. (The Wound physician indicated to use alginate with calcium with silver.) There were no orders implemented for Resident #9's unstageable right upper back wound for the month of February 2022. During an interview with the Wound Nurse on 4/25/22 at 8:08 A.M., he said that he rounds with the Wound Physician and logs updated orders into the computer and the Wound Physician will also send over recommended orders after the visit. The Wound Nurse also said that he or the Wound Physician will also contact the nurse manager or nurse on duty to relay the orders or recommendations for treatment after seeing residents. The Wound Nurse said that many times the orders are not correct in the computer and when he assists in performing dressings, he has seen incorrect dressings on residents. The Wound Nurse said that nurses will make up their own dressings, mix up orders, or input orders wrong into the resident's electronic record. During an interviews with the Director of Nursing (DON) on 4/25/22 at 11:09 A.M., she said that she was aware of the concerns regarding orders being accurately implemented for resident pressure ulcers. 3. For Resident #27, the facility failed to implement treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy titled, Assessment of skin condition and integrity undated, indicated: Conduct a comprehensive head-to-toe skin assessment upon admission, weekly, prior to discharge and as needed. During the skin assessment, inspect for: 1. Presence of skin impairments 2. Type of skin impairments 3. Location of skin impairments Resident #27 was admitted in August 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's comprehensive Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #27 was cognitively intact and required extensive assistance with self-care tasks. During an interview on 4/21/22 at 8:43 A.M., Resident #27 said he/she has had wounds consistently since admission close to a year ago. Review of Resident #27's medical record indicated the following: - An admission nursing assessment dated [DATE] which indicated: skin assessment: Site: coccyx, type: pressure, length: 5.5 length x 4.5 width, stage: III. -A care plan dated 8/20/21 indicated Resident #27 had pressure ulcer development, with interventions including: a.) Monitor nutritional status and intake. Serve diet as ordered. b.) Monitor/Document/report to MD PRN (as needed) changes in skin status weekly. -A Certified Nursing Assistant (CNA) skin check dated 8/26/21 at 10:06 P.M., Skin observation: open area, not a new skin issue. -A weekly skin check dated 8/29/21 indicated new area of excoriation to Resident #27's coccyx. -Nursing note from 8/30/21 indicated open skin to coccyx and a dressing was applied. Review of Resident #27's August 2021 Treatment Administration Record (TAR) indicated treatment orders dated 8/31/21: (11 days after Resident #27's Stage 3 pressure ulcer was documented) -Cleanse right inner buttock with normal saline, apply wound gel and foam dressing daily and as needed every shift. Further review of the Resident's medical record failed to indicate any additional treatment orders. During an interview on 4/21/22 at 11:06 A.M., Nurse #5 said a head-to-toe skin assessment is completed on admission and documented in the nursing admission assessment. During an interview on 4/21/22 12:43 P.M., Nurse# 5 said Resident #27 was identified as having a pressure ulcer present upon admission and physician's orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review and interview, the facility failed to implement the fall care plan and provide adequate supervision to prevent falls for 1 Resident (#236) resulting in fall with injury. Findings include: Resident #236 was readmitted to the facility in June 2021, with diagnoses including [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated Resident #236 had moderately impaired cognition and required physical assistance with bathing, dressing, transfers, and supervision with ambulation. During an observation and interview with Resident #236 on 4/20/22 at 9:02 A.M., the surveyor observed Resident #236 seated at the edge of his/her bed eating breakfast with significant bruising to his/her face. There were fall mats in the room, propped up on the walls. Resident #236 told the surveyor that he/she sustained the bruises because he/she had fallen but could not remember any other specific information regarding the fall(s). Review of Resident #236's clinical indicated: * Resident #236 had 11 falls between October 2021 and April 2022. * Resident #236 had a fall care plan, initiated 1/22/18 and reviewed 1/4/22, indicating Resident #236 was at risk for falls due to gait/balance/problems, history of falls. Interventions on the care plan included: Interventions: -I use a walker when ambulating. Keep items in reach when I am in my chair or bed. 6/11/21 -Keep frequently used items in reach. (11/26/21). -Encourage out of room when awake. (11/26/21). -If resident is awake at night in room, encourage him/her to come out in the hall for closer monitoring by staff or have staff sit by her doorway for closer monitoring. (1/4/22). Review of Resident #236's 11 falls reports from October 2021 through April 2022 indicated the following: 1.) A falls report dated 10/13/21 indicated Resident #236 sustained a fall at 8:00 P.M., while ambulating with a walker near the nurse's station. -Intervention implemented: Staff will offer to assist him/her before P.M., and change for the evening, although the report failed to indicate this was a circumstance of the fall. 2.) A falls report dated 10/24/21 indicated Resident #236 sustained a fall at 4:30 P.M., while ambulating with a walker near the nurse's station. -Intervention implemented: Offer resident nap in the afternoon. 3.) A falls report dated 10/26/21 indicated Resident #236 sustained a fall at 7:30 P.M., while ambulating out of room to nurse's station. According to the report, Resident #236 experienced increased pain following the fall and on 10/31/22 was transferred to the hospital where he/she was diagnosed with a rib fracture. -Outcome: Rib fracture. -Intervention implemented: Staff to assist with ambulation. 4.) A falls report dated 11/25/21 indicated Resident #236 sustained a fall at 1:43 P.M., while trying to get something out of closet without assistance. -Intervention: encourage resident to allow staff to assist him/her with items in the closet, despite there already being an intervention on the care plan, dated 6/11/21, to Keep items in reach when I am in my chair or bed. 5.) A falls report dated 12/28/21 indicated Resident #236 sustained a fall at 5:00 P.M. According to the report Resident #236 was found on the floor in his/her room. -Interventions: Keep me in an area where I can be observed when I'm out of bed, have staff supervise at night if awake and in room. 6.) A falls report dated 1/1/22 indicated Resident #236 sustained a fall at 8:00 P.M., while walking out of room asking for peanut butter sandwich. The report failed to indicate why Resident #236 was not in an area where he/she could be supervised, despite this being an intervention in the plan of care, following the fall on 12/28/21 -Interventions: Resident #236 will be a offered bedtime snack. 7.) A falls report dated 1/4/22 indicated Resident #236 sustained a fall at 1:00 A.M., According to the report Resident #236 was found on the floor in his/her room after leaning forward in his/her chair. Alarm was sounding. -Intervention: encourage to be outside of room when awake at night. 8.) A falls report dated 1/18/22 indicated Resident #236 sustained a fall at 6:40 P.M., after standing up from wheelchair in the hallway and pushed wheelchair out of his/her way. -Interventions: Wheelchair to be inspected by maintenance 9.) A falls report dated 2/18/22 indicated Resident #236 sustained a fall at 7:00 P.M., when he/she slid to floor after missing chair in his/her room. -Interventions: Resident to be screened by rehab department. 10.) A falls report dated 4/3/22 indicated Resident #236 sustained a fall at 1:10 P.M., (The falls report failed to indicate where Resident #236 fell .) Resident found on floor by staff. -No interventions implemented. 11.) A falls report dated 4/11/22 indicated Resident #236 sustained a fall at 6:45 A.M.: Resident observed standing in doorway of room without a walker. Nurse #2 went to assist Resident #236 to remind him/her to use his/her walker and upon getting to his/her room found him/her laying supine (laying horizontally with face and torso facing up) on the floor. Resident #236 was assisted back to bed. Nurse #2 left to bring vital machine for assessment and on coming back to the room found the resident on the floor near his/her bed in a prone [position] (lying face down). Resident was assisted back to bed with a Certified Nursing Assistant. At this time, bump noted on right side of forehead, unable to speak, both eyes closed being in a state stupor. Resident #236 was sent to the hospital. Review of the hospital paperwork indicated that a [CONDITION(S)] was ruled out and Resident #236 had sustained a concussion from the fall. Resident #236 was hospitalized and returned to the facility 8 days later. During an interview with Nurse #2 on 4/22/22 at 8:01 A.M., she said that on the morning of Resident #236's fall, she said she saw Resident #236 standing in his/her doorway across the hall from the nurses' station. She said that she walked quickly over to get Resident #236's walker to him/her, but it was too late as she then found him/her on the floor of the room. Nurse #2 said Resident #236 was then assisted back to his/her bed in a seated position to be assessed. Nurse #2 said she then left the room to get the vital machine to further assess Resident #236. Nurse #2 said that she did not ask Resident #236 to sit outside of the room to be supervised by other staff because he/she did not seem like she wanted to, and he/she that she had left Resident #236 sitting comfortably in his/her bed. Nurse #2 said that when she left the room, Resident #236 was alone and when she came back, Resident #236 had fallen again and was face down on the floor. Nurse #2 said that Resident #236 has [CONDITION(S)], falls frequently does not walk very well, and does not always use his/her walker like he/she is supposed to. Nurse #2 said she knows Resident #236 very well and needs assistance while walking. During an interview with the Director of Nursing on 4/22/22 at 8:46 A.M., she said that it may be difficult for the overnight staff to be aware of interventions, (such as encouraging residents to be out of rooms while awake), of resident care plans.

Based on record review and interview, the facility failed to complete wound treatments as ordered by a physician for 1 Resident (#75) out of a 29 sampled Residents. Subsequently, Resident #75's existing pressure ulcer deteriorated. Findings include: Resident #75 was admitted to the facility in October 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's most recent Minimum Data Set Assessment indicated he/she was moderately cognitively impaired and required physical assistance with eating, transfers, bathing and dressing. During an interview with Nurse #1 on 4/21/22 at 11:03 A.M., she said that it was possible that facility staff were not performing treatments as ordered for Resident #75. Nurse #1 said that she often goes to provide wound care for Residents and they are dated a long time ago. During an interview with the Wound Nurse on 4/24/22 at 8:08 A.M., he said that when he rounds with the Wound Physician they discover dressings that have not been changed for days. The Wound Nurse said that each time this occurs he takes pictures of the old dressings and notifies the Director Of Nursing (DON). He said that in March 2022 when he observed that Resident #75's heel dressing had not been changed for a few days he took a photo and informed the DON. During the initial interview with the DON on 4/25/22 at approximately 12:15 P.M., the surveyor requested any investigations regarding skin care. The DON said she had none. During a follow-up interview on 4/25/22 at 12:45 P.M., the DON said that the Wound Nurse and Wound Physician had made her aware that Nurse #3 and Nurse #4 were not completing wound treatments as ordered, and she had done an investigation, contradicting her previous statement. Review of the facility investigation dated 3/16/22 indicated that the Wound Physician asked the DON to observe Resident #75's heel dressing. The DON observed the dressing was dated 3/10/22, indicating it had not been changed in 6 days, when the orders indicated the dressing was to be changed daily. The statement indicated the Treatment Administration Record had been reviewed [and nursing staff had documented they had changed Resident #75's dressing as ordered] and the nurses involved had been disciplined. Review of Nurse #3's disciplinary action form indicated: Date of offense: 3/11/22, 3/14/22, 3/15/22 Nature of offense: Patient rights; failure to complete an MD order Did not change residents dressing for 3 days causing worsened area. Signed treatment as completed. Dressing in place noted to be 6 days old. Review of Nurse #4's disciplinary action form indicated: Date of offense: 3/12/22, 3/13/22 Nature of offense: Patient rights, failure to complete and MD order Did not change resident dressing for 2 days causing worsened area. Signed treatment as completed. Dressing in placed noted to be 6 days old. The facility failed to ensure Resident #75 received necessary treatments to prevent the worsening of his/her heel wound.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1's Physician was notified of a change in condition with a decline in status, in a timely manner when on 7/09/21, Resident #1 was assessed by the wound Physician and found to have an infection to the pressure injury on his/her spine, recommended Resident #1 be started an antibiotic, and the Physician was not immediately notified of the change. Findings include: Resident #1 was admitted to the Facility in May 2021. Resident #1's medical history included [CONDITION(S)], chronic [CONDITION(S)] (ventilator), urinary tract infection, pneumonia, diabetes, failure to thrive, muscle wasting and atrophy. Review of Resident #1's Plan of Care, dated 5/05/2021, indicated he/she had an unstageable spine pressure injury, nursing to monitor, document and report changes to the Physician, including the wound(s) appearance, color, and signs and symptoms of infection. Review of Resident #1's Integrated Wound Care physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Note indicated to continue Resident #1's wound Vacuum-Assisted Closure (a method of decreasing air pressure around a wound to assist with healing), administer Resident #1 an antibiotic for his/her wound infection and obtain an [CONDITION(S)] (inflammation of bone caused by infection) evaluation. During an interview on 8/26/21 at 11:55 A.M., the Unit Manager said on 7/09/21 Resident #1 was seen by the wound Physician, and said she did not notify Resident #1's Physician about his/her wound changes or the recommendations made by the wound Physician. The Unit Manager said on 7/13/21, Resident #1 was assessed by his/her Physician at the facility. The Unit Manager said on 7/13/21, she did not notify the Physician of Resident #1's wound changes or the wound physician 's recommendations from his/her wound evaluation four days earlier. Review of Resident #1's Nurse Practitioner Follow up Wound Infection Note, dated 7/15/21, indicated on 7/14/21 the Nurse Practitioner reviewed Resident #1's wound Physician Note dated 7/09/21, and the recommendations to continue with the wound VAC , to give him/her antibiotics for the wound infection, and obtain an [CONDITION(S)] evaluation. The Nurse Practitioner Note indicated, according to nursing, Resident #1's spinal wound (pressure injury) had a very foul odor for one week and had purulent discharge. The Nurse Practitioner said Resident #1 needed to be transferred to the Hospital Emergency Department for his/her wound infection and to be evaluated for [CONDITION(S)]. During an interview on 8/27/21 at 2:32 P.M., the Director of Nursing (DON) said on 7/09/21 Resident #1 was seen by the wound Physician to evaluate the pressure injury on his/her spine, and said the wound Physician recommended that Resident #1 be started on an antibiotic. The DON said Resident #1's Physician was not immediately notified of the change in the pressure injury wound, or of the recommendation made by the Wound Physician until 7/14/21, when the Nurse Practitioner reviewed the wound Physician note and recommendations. The DON said it is best practice to notify the residents Physician with any type of wound changes and wound Physician recommendations. On 8/27/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidence by: A. Resident #1 did not return to the Facility. B. Unit Managers conducted medical record audits to ensure any resident with Physician Consults, that recommendations were reported to the Physician as required. C. A Quality Assurance Performance Improvement Action Plan meeting was conducted on 7/16/21 and areas of concern discussed. D. Nursing staff were in-serviced (July 2021) with mandatory education (reporting wound recommendations timely to the residents Physician) for all nurses provided by the DON. E. Licensed Nursing Staff Meeting was conducted July 2021 and concerns areas discussed with Nurses will continue. F. Facility implemented changes to Wound Physician scheduled visits of resident, with wound rounds to be conducted during week days to ensure recommendations are reviewed and followed up on, timely. G. The DON and his/her designee will review wound notes weekly, validate recommendations are notified to the residents Physician and will continue. H. The DON and his/her designee is responsible for overall compliance.

Based on records reviewed and interviews for one of six sampled residents (Resident #1), the Facility failed to ensure nursing staff provided care and treatments to promote the healing of a pressure injury when Resident #1 was admitted to the Facility with a stage two pressure injury (partial thickness skin loss) on his/her coccyx, the Facility failed to ensure nursing completed a thorough skin assessment upon admission, and the pressure injury was not immediately identified or treated until twelve days later. Resident #1's wound progressed to a stage four pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) to his/her sacrum and he/she was transferred to the Hospital Emergency Department for treatment. Findings Include: The Facility Policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated as revised November 2020, indicated: -the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. -the Nurse shall describe, document, and report the full assessment of pressure sore including location, stage, length, width, depth, presence of exudates or necrotic tissue and current treatments. -the Physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. A Quality Assurance Report, dated 1/22/21, indicated that a skin incident regarding Resident #1 was investigated. The Report indicated that an investigation concluded that Resident #1 developed a stage four pressure injury because he/she was admitted from the Hospital with a stage two pressure injury, no treatment was in place for the existing wound, the wound was not identified at the Facility with the initial skin check and that Resident #1 did not have a thorough skin check upon admission, which led to not having proper wound care or monitoring. The Quality Assurance Report indicated that the base of Resident #1's wound was black, with moderate serosanguinous (composed of blood and serum) drainage and necrotic tissue (death of tissue through injury). Review of Resident #1's Hospital Patient Care Referral Form, dated 12/29/20, indicated that he/she had a Stage 2 (partial thickness skin loss) pressure injury to his/her coccyx. Resident #1 was admitted to the Facility in December of 2020, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Norton Plus Skin Risk Assessment, dated 12/29/20, indicated Resident #1 was at high risk for skin breakdown. Review of Resident #1's Admission Nursing Evaluation, dated 12/29/20, indicated that no skin issues were identified. Review of Resident #2's Physician Orders, dated 12/29/20, indicated that a moisturizing lotion was ordered to be applied to Resident #1's skin as a preventative treatment lotion, however there was no documentation to support that he/she had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nurse Progress Note, dated 1/10/21, indicated that Resident #1 had new changes in skin integrity and that he/she had an ulcer on his/her bottom that was cleaned with normal saline and covered with a foam dressing. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1's sacrum wound every shift. Review of Resident #1's Treatment Administration Record (TAR), dated 1/2021, indicated that a weekly skin check was due on 1/05/21 and the skin check was not signed off by a nurse to indicate that it had been completed and there was no indication that a Weekly Skin Check Evaluation Form was completed. Review of Resident #1's Treatment Administration Record (TAR), dated 12/2020 and 1/2021, indicated there was no documentation to support that nursing administered treatment to his/her sacral pressure injury until 1/14/21. Review of the Nurse Practitioner/Certified Wound Specialist Note, dated 1/22/21, indicated that Resident #1 had a 5 centimeter (cm) x 6 cm x 3 cm stage four sacral pressure injury. The Note indicated that the wound had heavy serous exudate and a strong odor. Review of the Nurse Progress Note, dated 1/26/21, indicated that Resident #1 was transferred to the Hospital for a change of condition. The Nurse Progress Note indicated that Resident #1 had a worsening stage four pressure injury and that his/her Physician had extensively debrided (removal of nonviable necrotic or dead tissue) and indicated that Resident #1's Physician ordered immediate intervention with intravenous antibiotics. During an interview on 3/23/21 at 1:12 P.M., Nurse #6 said she admitted Resident #1 to the Facility, could not recall if she assessed Resident #1's skin upon admission, and did not recall seeing a pressure injury on Resident #1's sacrum. Nurse #6 said Resident #1's pressure injury worsened to a stage four and said that after it got worse, she reviewed the Hospital Discharge paperwork and discovered that it indicated that Resident #1 had a stage two pressure injury upon discharge from the Hospital. Nurse #6 said she had not seen that portion of the Hospital discharge paperwork when she completed Resident #1's Facility admission. During an interview on 3/31/21 at 3:25 P.M., Physician #2 said that although he was not aware that Resident #1 was admitted to the Facility with a stage two pressure ulcer, after seeing Resident #1's wound, he felt that Resident #1 likely had the pressure injury before he/she was admitted to the Facility and said that he thought that it was likely a deep tissue injury on admission rather than a stage two. Physician #2 said said if the Facility had notified him that Resident #1 had a pressure injury on admission, he would have ordered a treatment and assessed the wound. Physician #2 said that he was notified about Resident #1's sacral pressure ulcer by his Nurse Practitioner and said that when he went to the Facility the wound was very bad, very deep, appeared infected, involved bone and he debrided it. The Physician said he wanted Resident #1 to start intravenous antibiotics immediately and he was concerned about [CONDITION(S)], however the antibiotics would have taken six to eight hours to arrive from the Pharmacy, so he provided orders to have Resident #1 transferred to the Hospital. During an interview on 3/11/21 at 12:13 P.M., the Director of Nursing (DON) said that Resident #1's pressure injury was brought to her attention on 1/22/21 and said she reviewed the discharge paperwork from the Hospital she saw that it had indicated that Resident #1 had stage two pressure injury to his/her coccyx. The DON said that staff should have called Resident #1's Physician to notify him and obtain treatment orders for the wound at the time of admission and said that the first time staff treated Resident #1's pressure injury was on 1/14/21. On 3/11/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A) Resident #1 was transferred to the Hospital on 1/26/21 and has been discharged from the Facility. B) All residents were assessed for skin issues on 1/28/21. C) Audits were completed of all resident skin check schedules to ensure proper scheduling of weekly skin checks on 1/28/21 D) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . E) Licensed staff were educated on completion of admission and weekly skin checks, new skin issues, obtaining treatment orders, care plan revision on 2/11/21. F) A pressure injury log was developed and will be maintained weekly to track wound progress, interventions and care plan updates on 2/03/21. G) A Nurse was promoted to the role of wound care nurse to champion the wound process on 1/28/21. H) A weekly At-Risk Meeting that involves the Director of Nursing (DON) and the inter-disciplinary team, which includes review of residents with wounds was re-launched on 2/05/21. I) The DON and Wound Care Nurse initiated a weekly wound progress report on 2/12/21. J) The DON and Wound Care Nurse will to analyze pressure injury/wound data weekly and monthly to identify trends and demonstrate outcomes. K) The DON presented wound process improvement to the Quality Assurance Performance Improvement Committee on 2/9/21 and will continue to present wound data at QAPI meetings monthly. L) The DON and /or designee is responsible for overall compliance.

Based on observation, record review, and staff interview, the facility failed to ensure that one sampled Resident (#5) in a total sample of 24 Residents, was provided adequate supervision resulting in a fall with injury. Findings include: For Resident #5 the facility failed to ensure oversight and supervision was provided to the Resident, resulting in the Resident falling on 2/2/15 and sustaining a sub-dural hematoma requiring a craniotomy (surgical opening of the skull). The facility failed to complete a reassessment of the Resident who presented with a change in cognitive/physical condition, which placed the Resident at risk for falls. Resident #5 was admitted to the facility in 1/15 with [DIAGNOSES REDACTED]. Review of the 1/22/15, initial/admission minimum data set (MDS) assessment, indicated that Resident #5 was extensive assistance (resident is involved in the activity but staff provide weight bearing support) of one staff for all activities of daily living. It also indicated the Resident needed limited assistance of one, encouragement or cueing for locomotion/walking off the unit. The Care Area Assessment documentation notes (CAA'S) triggered the Resident for experiencing falls at home and for impaired balance during transitions. Risk factors include the glio[DIAGNOSES REDACTED] with status [REDACTED]. The Resident has generalized fatigue from illness and radiation treatment. The acute care hospital discharge summary dated 12/30/14 indicated that the Resident had an overall general decline postoperatively. The Resident had been very unsteady on his/her feet and had several falls prior to the hospital admission. The Resident's admission fall risk was coded as a 75. This deems the Resident a high fall risk. (The fall risk is a tool which is used to identify Residents who might be at risk for falls. A total score of 46-125 deems Residents at high risk for falls). The policy for fall risk and fall management indicates that evidence based strategies are to be implemented to reduce the risk of falls and fall related injuries for all Residents at high risk for falls. It furthers stated the resident's risk will be assessed upon admission and regularly thereafter using the Morse Fall Scale. Fall risk will be reassessed with [REDACTED]. Fall rounds will be held at least weekly on each unit with interdisciplinary participation to identify residents whose safety needs have changed due to improvements or declines in cognitive, emotional, neurological, or physical function. Discussion will include: -Any Resident admitted with a high risk for falls. -Any medications that may have contributed to the fall -Residents on a functional maintenance plan will be reviewed -Any equipment in need or repaint will be identified and work orders will be placed -Residents who have experienced a fall since the last Fall Rounds on the unit, including changes to the care plan -Residents who have had changes in their functioning (improved or declined) relative to fall risk will be discussed. -If appropriate, the Resident will be screened and/or evaluated by an OT or PT -Based on the discussion at Fall Rounds, each residents' care plan will be revised. The Fall Rounds documentation dated 1/13/15, 1/20/15 and 1/27/15 did not address the Resident as a new admission (admitted to the facility on [DATE]) with a fall risk of 75, which is considered a high risk for falls. Review of the Physical Therapy notes dated 1/7/15, (prior to admission to the facility), indicated that the Resident was able to ambulate with a rolling walker and assist of one. The cognitive issues were identified as short term memory deficits, alert with the ability to follow commands but slow to respond/initiate movements. The initial Occupational Therapist (OT) and Physical Therapist (PT) notes both dated 1/10/15 address the Resident's cognitive status with the short and long term memory as mildly impaired with the ability to follow directions, insight, safety awareness and comprehension as also being mildly impaired. PT progress report on 1/29/15 indicated the resident's balance as unsteady but able to stabilize with staff assistance. The initial Speech-Language evaluation dated 1/12/15 indicated the Resident presented with mild to moderate cognitive-linguistic deficits, decreased attention, memory and reasoning/organization. It indicated that the Resident was given a memory book to increase recall of rehabilitation information. It indicated that the Resident's progress had been limited due to severe fatigue. A nurses note dated 1/23/15 decribed the resident as having more difficulty transferring from sitting to standing position. A nurses note dated 1/29/15 again described the resident as having increased weakness with difficulty transferring at times. The plan of care evaluation/careplan dated 1/12/15 addressing cognition characterized the Resident as having decreased memory and concentration which interferes with functional communication skills and carryover of rehabilitation training. Review of the OT notes from 1/20/15 to 2/2/15 indicated the Resident's current status for Activities of Daily living was supervision to contact guard assistance. The Resident did not meet the goals established by the OT due to the Resident being too fatigued to complete/participate. It also stated that there was decreased insight into deficits. The Activity of Daily Living (ADL) flow sheet log which is completed by the certified nursing assistants (CNA) coded the Resident on 1/29/15 through 2/2/15 as being a limited assistance to totally dependent with assist of one staff member for toileting. Review of the nurses notes' prior to the fall on 2/2/15 described the Resident as very tired and requiring 2 staff members to assist the Resident to stand, pivot and transfer. A nursing note dated 1/23/15 decribed the Resident as having more difficulty transferring from sitting to standing position. A nurses' note dated 1/29/15 again described the Resident as having increased weakness with difficulty transferring at times: "Appetite poor, Increase in weakness, difficulty transferring at times". Review of the facility incident report dated 2/5/15 described the 2/2/15 fall as follows: The report indicated that the Resident put the call light on for assistance to go to the bathroom. 2 CNA's went in and got the Resident out of bed. The Resident was put on the toilet. One CNA stripped the soiled bed. The second CNA began wiping up urine on the soiled floor outside the bathroom doorway. The Resident got up from the toilet without asking for assistance, lost her/his balance and fell forward hitting her/his head on the bathroom wall. The facility incident report indicated that the CNA turned his/her back on the Resident to wipe up the floor making the floor safe, prior to the Resident returning to bed. The CNA was counseled not to turn his/her back on the Resident, even in close proximity. During an interview on 2/25/15 at 3:45 P.M., the Administator and Director of Nurses (DON) said that the CNA was right outside the bathroom door, and the CNA could see the Resident if the CNA had not turned and had his/her back to the Resident. Further investigation and observation of the physical set-up of the Resident's room on 2/25/15 at 4:20 P.M. revealed that the CNA was not outside the bathroom door, but was in fact by the window in the Resident's room. The CNA confirmed his/her location when the fall occurred. This was approximately eleven feet from the bathroom door. The CNA was not in close proximity to the Resident, nor was the Resident in the CNA's visual field. The Resident was sent to the hospital where he/she was diagnosed with [REDACTED]. The facility's incident report had inaccurate information in regard to the actual distance the CNA was to the entrance of the bathroom as well as the CNA's ability to visualize the Resident in the bathroom. The facility failed to communicate the Resident's declining physical and mental condition to his/her caregivers, which resulted in the CNA not providing adequate supervision to prevent a fall with injury.

Based on record review and interview, for 1 of 10 sampled residents (Resident #1), the Facility failed to notify the Physician when, at approximately 8:30 P.M. on [DATE], Resident #1 had an unwitnessed fall and told staff that he/she hit his/her head and his/her head hurt. Approximately 12 hours later, at 8:15 A.M. on [DATE], staff found Resident #1 dead in bed. Findings include: Resident #1's physician's orders [REDACTED]. The Nurse's Progress Note, dated [DATE], indicated at 8:25 P.M., staff found Resident #1 lying on his/her back on the floor. The Progress Note indicated Resident #1 told staff he/she hit his/her head, and he/she complained of a headache. The Progress Note indicated staff administered Tylenol (an [MEDICATION NAME] medication) to Resident #1, with good relief noted. There was no documentation to indicate the Physician was notified of the fall or Resident #1's reports of striking his/her head and complaint of head pain. The Surveyor interviewed Nurse #3 at 12:30 P.M. on [DATE] and at 11:00 A.M. on [DATE]. Nurse #3 said after she discovered Resident #1 on the floor, she placed a call to the Physician's answering service at approximately 9:00 P.M. to have the covering physician on-call call back. Nurse #3 said she provided the service with Resident #1's name but no details about the fall or that Resident #1's head hurt. Nurse #3 said she sent an email to the Nurse Practitioner (NP), regularly scheduled to work from 9:00 A.M. to 5:00 P.M. Monday through Friday, at approximately 10:00 P.M., to follow up with Resident #1 the following morning secondary to a his/her fall. Nurse #3 said she did not receive a call back from the covering Physician. Nurse #3 said when the Nursing Supervisor conducted rounds at approximately 10:30 P.M., she asked the Nursing Supervisor if she knew the name of the Physician. Nurse #3 said she did not place a second call to the answering service to request a call from the Physician. The Surveyor interviewed the Nursing Supervisor at 3:30 P.M. on [DATE]. The Nursing Supervisor said Nurse #3 called her earlier in the evening, on [DATE], to report Resident #1's fall. The Nursing Supervisor said when she was conducting change of shifts rounds, she asked Nurse #3 if she started to complete an incident report and take statements from staff. The Nursing Supervisor said she had no recollection of Nurse #3 asking her the name of the Physician or reporting a problem with the Physician not returning her call. The Surveyor interviewed Nurse #4 at 8:15 A.M. on [DATE]. Nurse #4 said at the change of shift, at 11:00 P.M. on [DATE], staff told her Resident #1 had an unwitnessed fall that evening. Nurse #4 said staff told her Resident #1 complained he/she hit his/her head and his/her head hurt. Nurse #4 said she did not ask if staff informed the Physician. The Nurse's Progress Note, dated [DATE] indicated at 8:11 A.M., Resident #1 was unresponsive to voice, touch or painful stimuli and no respirations were observed; at ,[DATE] A.M. a Code Blue was called and Cardiopulmonary Resuscitation (CPR) was initiated, 911 Emergency Services (EMS) were activated and EMS Paramedics arrived and took over CPR; and at 8:46 A.M. Resident #1 was pronounced dead. The Surveyor interviewed the NP at 10:15 A.M. on [DATE]. The NP said when she checked her email messages on the morning of [DATE], she saw an email from Nurse #3, sent at 10:06 P.M. on [DATE], informing her Resident #1 had fallen and no injuries were noted. The NP said when Resident #1 told staff he/she hit her head and his/her head hurt, following the unwitnessed fall, Resident #1 should have been transferred to the Hospital for evaluation to rule out possible head trauma and/or hemorrhage. The Surveyor interviewed the Medical Director at 12:15 P.M. on [DATE] and at 1:30 P.M. on [DATE]. The Medical Director said he was the Physician on [DATE]. The Medical Director said he was not paged and did not receive a call from the Facility on the evening of [DATE] regarding Resident #1's fall.

Based on record review and interviews, for 1 of 10 sampled residents (Resident #1), the Facility failed to ensure Resident #1, whose [DIAGNOSES REDACTED]. -failed to ensure Resident #1's plan of care was approved by a physician because Resident #1 was never seen by a physician during his/her admission period; -failed to ensure Resident #1's behaviors were accurately documented on his/her Minimum Data Set (MDS) assessment; - failed to ensure a behavioral plan of care was developed, based on an assessment of Resident #1's medical, physical, functional, psychological, emotional, psychiatric, social and environmental symptoms and factors, and that causes were identified and addressed, prior to Resident #1's plan of care being updated to include the use of a an as needed (PRN) antipsychotic medication; -failed to consistently assess Resident #1 following an unwitnessed fall on [DATE], at approximately 8:25 P.M., after which Resident #1 told staff he/she hit his/her head and had head pain; --failed to ensure Resident #1's new complaint of head pain was a reported to a physician; -failed to ensure staff were trained and competent to perform the necessary neurological and pain assessments on a cognitively impaired resident, who did not speak English; -failed to ensure staff (Nurse #4), did not administer [MEDICATION NAME] to Resident #1 (an antipsychotic medication) with the purpose of making him/her fall asleep and remain in bed to prevent him/her from wandering around the unit and reduce his/her risk of falling; -failed to ensure staff woke Resident #1 to perform necessary neurological assessments after administering a sedating antipsychotic; On [DATE], at 8:15 A.M. Resident #1 was discovered dead in bed approximately 12 hours after his/her unwitnessed fall. Findings include: 1. The Facility's policy titled "Neurology Assessment", dated [DATE], indicated: a neurological assessment will be completed on any resident who sustains an injury to the head and/or has an unwitnessed fall which the resident is unable to describe. The procedures included neurological assessments to be completed every 15 minutes for 1 hour, every 30 minutes for the next 4 hours, every hour for the next 2 hours, and every shift for 72 hours following the fall. The Facility's policy titled "Pain Assessment and Management", dated [DATE], indicated: assessment and management of pain in residents who are non-verbal and/or cognitively impaired depends on the observations of the interdisciplinary team; when a resident can not report or rate his/her pain, the nurse will document a pain rating using a pictorial scale of 0 to 10 (0 meaning no pain and 10 the worst pain imaginable); when an [MEDICATION NAME] medication is used PRN, the nurse will document the pain rating scale of 0 to 10 at the time the medication is administered and will follow up in 1 hour to assess the efficacy of the administered dose. The Center for Medicare and Medicaid Services (CMS) Memorandum, dated [DATE], indicated Guidelines for antipsychotic medications in persons with dementia should not be used if wandering and [MEDICAL CONDITION] are the only indications for its use and behavioral interventions must have been attempted, except in the case of an emergency. The Memorandum indicated antipsychotic medications may be considered for elderly residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes have been identified and addressed. Resident #1's physician's orders [REDACTED]. The Nurse's Progress Note, dated [DATE], indicated at 8:25 P.M. staff found Resident #1 lying on his/her back on the floor. The Progress Note indicated Resident #1 told staff he/she hit his/her head and he/she complained of a headache. The Progress Note indicated staff administered Tylenol (an [MEDICATION NAME] medication) to Resident #1, with good relief noted. The Progress Note indicated Resident #1 had no other complaints of pain and no visible injuries were found. Review of Resident #1's medical record, including the Medication Administration Record [REDACTED]"Pain Assessment and Management". The Surveyor interviewed Nurse #3 at 12:30 PM. on [DATE] and at 11:00 A.M. on [DATE]. Nurse #3 said after she discovered Resident #1 fell on the floor, she placed a call to the Physician's answering service at approximately 9:00 P.M. on [DATE] to have the Physician on-call contact her. Nurse #3 said she provided the answering service with Resident #1's name but no details about the fall or that Resident #1's head hurt. Nurse #3 said she sent an email to request the Nurse Practitioner (NP), who was regularly scheduled to work from 9:00 A.M. to 5:00 P.M. Monday through Friday, at approximately 10:00 P.M., follow up with Resident #1 the following morning secondary to his/her fall. Nurse #3 said she did not receive a call back from the Physician. Nurse #3 said she did not place a second call to the answering service to request the Physician contact her. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:00 P.M. on [DATE]. CNA #1 said Resident #1 kept pointing to the back of his/her head saying, in Spanish, throughout the evening of [DATE], his/her head hurt. CNA #1 said she told Nurse #1 that Resident #1 fell and he/she hit his/her head and his/her head hurt. Resident #1's Neurological Assessment Flowsheet indicated assessments began at 8:30 P.M. on [DATE] and ended at 5:00 A.M. on [DATE], were inaccurately completed. The Neurological Assessment Flowsheet indicated between 8:30 P.M. to 9:00 P.M. on [DATE] the assessing nurse (Nurse #1) failed to document Resident #1's pupil response, motor functions and vital signs. The Surveyor interviewed Nurse #1 at 11:00 A.M. on [DATE]. Nurse #1 said CNA #1 told her that Resident #1 fell and that he/she told CNA #1 that he/she hit his/her head and his/her head hurt. Nurse #1 said she did not complete a full neurological assessment on Resident #1 or determine if there was a change in his/her condition during this time period. The Neurological Assessment Flowsheet indicated between 9:15 P.M. to 11:30 P.M. on [DATE] the assessing nurse (Nurse #2) failed to document Resident #1's level of consciousness, pupil response, motor functions and vital signs and failed to assess Resident #1 every 30 minutes. The Surveyor interviewed Nurse #2 at 1:50 P.M. on [DATE]. Nurse #2 said she did not assess Resident #1's motor functions to determine if Resident #1 had any decrease in strength and did not perform a neurological assessment on Resident #1 every 30 minutes. The Medication Administration Record [REDACTED].M., indicated staff administered [MEDICATION NAME] 12.5 milligrams (mg) to Resident #1 and the reason documented by the nurse giving the dose (Nurse #4) was "wandering". The MAR indicated [REDACTED]. the medication had a "good effect" and Resident #1 was asleep. The Surveyor interviewed Nurse #4 at 8:15 A.M. on [DATE]. Nurse #4 said at the change of shift at approximately 11:00 P.M. on [DATE], staff reported Resident #1 had an unwitnessed fall and complained his/her head hurt. Nurse #4 said at this time she observed Resident #1 pacing around the nurses' station and following staff. Nurse #4 said Resident #1 did not appear to be agitated but she was afraid if Resident #1 did not stop wandering around he/she might fall again. Nurse #4 said she administered [MEDICATION NAME] with the intention of having Resident #1 fall asleep and remain in bed to prevent him/her from wandering around the unit and reduce his/her risk of falling. Resident #1's Neurological Assessment Flowsheet indicated between 11:30 P.M. on [DATE] to 5:00 A.M. on [DATE] the assessing nurse (Nurse #4) failed to document Resident #1's level of consciousness, pupil response, motor functions and vital signs and failed to assess Resident #1 every 30 minutes. In addition, the Flowsheet indicated that although Resident #1 slept through assessment periods staff also performed an assessment of pain response. The Flowsheet indicated staff did not assess him/her at 2:30 A.M. or 3:30 A.M. on [DATE]. Nurse #4 said she did not waken the Resident #1 during the night to assess his/her neurological signs. Nurse #4 said she obtained Resident #1's vital signs at 5:30 A.M. but did not perform a neurological assessment. Nurse #4 was unable to demonstrate to the Surveyor how to test for motor function or how to properly assess, with the use of a pen light, for pupil response. The Surveyor interviewed Nurse # 5 at 2:20 P.M. on [DATE]. Nurse #5 said she entered Resident #1's room at approximately 7:50 A.M. on [DATE], to assess his/her vital signs (heart rate, blood pressure and temperature) and neurological signs. Nurse #5 said she observed Resident in bed asleep and made the decision not to wake him/her and to let him/her continue sleeping. Nurse #5 said at approximately 8:10 A.M. on [DATE] CNA #2 called her into Resident #1's bedroom at which time she discovered Resident #1 unresponsive and not breathing. The Nurse's Progress Note, dated [DATE] at 8:11 A.M. indicated Resident #1 was unresponsive and no breathing was observed; Code Blue was called, Cardiopulmonary Resuscitation (CPR) was initiated; 911 Emergency Services (EMS) were called; EMS Paramedics arrived and took over CPR, and at 8:46 A.M. Resident #1 was pronounced dead. The Surveyor interviewed the NP at 10:15 A.M. on [DATE]. The NP said when she checked her email messages on the morning of [DATE], she saw an email from Nurse #3, sent at 10:06 P.M. on [DATE] informing her Resident #1 had fallen and no injuries were noted. The NP said when Resident #1 told staff he/she hit her head and his/her head hurt, following the unwitnessed fall, staff should have communicated this to a physician or NP and transferred Resident #1 to the Hospital for evaluation to rule out possible head trauma and/or hemorrhage. The Surveyor interviewed the Medical Director at 12:15 P.M. on [DATE] and at 1:30 P.M. on [DATE]. The Medical Director said he was the physician on-call on [DATE]. The Medical Director said he was not paged and did not receive a call from the Facility on the evening of [DATE] regarding Resident #1's fall. The Medical Director said he was not made aware of Resident #1's fall until [DATE], when the Facility conducted a Root Cause Analysis in to the events surrounding Resident #1's death. The Medical Director said following Resident #1's unwitnessed fall and complaints that his/her head hurt, staff should have awakened Resident #1 from his/her sleep to complete an accurate neurological assessment.

Based on record review and interviews, the Facility failed for 1 of 10 sampled residents (Resident #1) the Facility failed to ensure acceptable standards of practice were followed when on [DATE] at approximately 8:25 P.M., staff found Resident #1 on the floor following an unwitnessed fall. Resident #1 told staff he/she hit his/her head and his/her head hurt. The Facility failed to ensure staff were trained and competent to perform the necessary neurological assessments on a cognitively impaired resident following an unwitnessed fall, in accordance with the Facility's "Neurology Assessment" policy. Approximately 12 hours later, staff found Resident #1 dead in bed. In addition; The Facility failed to ensure events surrounding Resident #1's unanticipated death on [DATE] were accurately reported to the Office Chief Medical Examiner. Findings include: 1. Pursuant to Massachusetts General Law (M.G.L.) Chapter 112, individuals are the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibility of a Registered Nurse and Practical Nurse respectively. The Regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. The Facility's policy and procedure titled "Neurology Assessment", dated [DATE], indicated a neurological assessment will be completed on any resident who sustains a injury to the head and/or has an unwitnessed fall which the resident is unable to describe. The procedure indicated neurological assessments will be completed every 15 minutes for 1 hour, every 30 minutes for 4 hours, every hour for 2 hours, and every shift for 72 hours. The Neurological Assessment Flowsheet indicated staff were to assess a resident for level of consciousness, pupil response, motor functions, pain response, vital signs, and observe for [MEDICAL CONDITION], headaches, vomiting and paralysis. Resident #1's Nurse's Progress Notes, dated [DATE], indicated at 8:25 P.M., staff found him/her lying on his/her back on the floor in another resident's bedroom. The Progress Note indicated Resident #1 told staff he/she hit his/her head and he/she complained of a headache. The Progress Note indicated staff administered Tylenol (an [MEDICATION NAME] medication) to Resident #1, with good relief noted. The Progress Note indicated Resident #1 had no other complaints of pain and no visible injuries were found. The Progress Note indicated staff initiated neurological assessments on Resident #1. The Neurological Assessment Flowsheet, dated [DATE], indicated assessments beginning at 8:30 P.M. and ending at 5:00 A.M. on [DATE], were inaccurately completed. The Flowsheet indicated between 8:30 P.M. to 9:00 P.M. the assessing nurse (Nurse #1) failed to document assessment findings related to Resident #1's pupil response, motor functions and vital signs. The Surveyor interviewed Nurse #1 at 11:00 A.M. on [DATE]. Nurse #1 said she assessed Resident #1's neurological status at 8:30 P.M., 8:45 P.M., and 9:00 P.M. on [DATE]. Nurse #1 said she had no recollection of Resident #1's pupil response. Nurse #1 said she did not complete a full neurological assessment on Resident #1 or determine if there was a change in his/her condition during this time period. The Neurological Assessment Flowsheet indicated between 9:15 P.M. to 10:30 P.M. on [DATE] the assessing nurse (Nurse #2) failed to document Resident #1's level of consciousness, pupil response, motor functions and vital signs and failed to assess Resident #1 every 30 minutes, per the Neurology Assessment policy. The Surveyor interviewed Nurse #2 at 1:50 P.M. on [DATE]. Nurse #2 said she could not recall if Resident #1's pupils were equal and reacting to light (normal assessment findings) and she did not check Resident #1's motor functions to determine if Resident #1 had any decrease in strength, or changes in function indicative of a possible head injury. Nurse #2 said she did not perform a neurological assessment on Resident #1 every 30 minutes. The Neurological Assessment Flowsheet indicated between 11:30 P.M. on [DATE] to 5:00 A.M. on [DATE] the assessing nurse (Nurse #4) failed to document Resident #1's level of consciousness, pupil response, motor functions and vital signs and failed to assess Resident #1 every 30 minutes. The Flowsheet indicated staff did not assess Resident #1 at 2:30 A.M. or 3:30 A.M. as scheduled, per the Neurology Assessment policy. The Surveyor interviewed Nurse #4 at 8:15 A.M. on [DATE]. Nurse #4 said she did not wake Resident #1 during the night to assess his/her neurological signs. Nurse #4 said she obtained Resident #1's vital signs at 5:30 A.M. but did not perform a neurological assessment. Nurse #4 was unable to demonstrate to the Surveyor how to properly assess, with the use of a pen light, for pupil response or how to test for changes in motor function. Review of Resident #1's medical record indicated there were no other documented neurological assessments. The Surveyor reviewed the educational records of Nurse #1, Nurse #2, and Nurse #4 who were assigned to perform neurological assessments on Resident #1 following the unwitnessed fall on [DATE]. The Self-Assessment Skills Check List, dated [DATE], indicated Nurse #4 checked off she felt very confident she could perform a neurological assessment. However, there was no indication the Facility determined whether Nurse #1, Nurse #2, or Nurse #4 were competent to perform neurological assessments, in accordance with the Facility's policy. The Director of Nurses (DON) said she reviewed Resident #1's Neurological Assessment Flowsheet, dated [DATE] and [DATE], with the Surveyor at 1:30 P.M. on [DATE]. The DON said Resident #1's neurological assessment, following the fall, was incomplete and inaccurate. The DON said the assessment did not reflect Resident #1's pupil response, motor functions, or observations of any change in condition. The DON said the documentation did not indicate staff performed an accurate neurological assessment. The Surveyor interviewed the Medical Director at 12:15 P.M. on [DATE]. The Medical Director said an accurate neurological assessment required nursing staff to wake Resident #1 from his/her sleep and obtain the data at the required times. The Surveyor interviewed the Staff Development Coordinator at 9:20 A.M. on [DATE]. The Staff Development Coordinator said the Facility did not have a formal teaching program on how to perform a neurological assessment. 2. Massachusetts General Law (MGL) Chapter 38: Section 3. Duty to report deaths; failure to report: indicated it was the duty of any person having knowledge of a death which occurs under the circumstances enumerated in this paragraph to immediately notify the office of chief medical examiner (OCME) or the medical examiner designated to the location where the death occurred, of the known facts concerning the time, place, manner, circumstances, and cause of such death: MGL indicated any death under suspicious or unusual circumstances; death associated with diagnostic or therapeutic procedures; sudden death when decedent was in apparent good health; or any person found dead. The Nurse's Progress Note, dated [DATE] indicated at 8:11 A.M., Resident #1 was unresponsive to voice, touch or painful stimuli and no respirations were observed; Code Blue was called and Cardiopulmonary Resuscitation (CPR) was initiated; 911 Emergency Services (EMS) were activated and EMS Paramedics arrived and took over CPR; and at 8:46 A.M., Resident #1 was pronounced dead. The Nurse Practitioner's Progress Note, dated [DATE], indicated the medical examiner was informed of Resident #1's death and declined the case. The Surveyor interviewed the NP at 10:15 A.M. on [DATE] and at 1:35 P.M. on [DATE]. The NP said immediately after Resident #1's death she called the OCME and reported Resident #1's unanticipated death and that he/she had a fall without injury approximately 12 hours earlier. The NP said after the telephone conversation with OCME, nursing staff provided her with new information that when Resident #1 sustained the unwitnessed fall, Resident #1 told staff he/she hit his/her head and complained of head pain. The NP said she did not call the OCME back to report this new information she had obtained.

Based on record review and interview, for 1 of 10 sampled residents (Resident #1) the Facility failed to ensure he/she was not chemically restrained when on 8/20/14, at 12:06 A.M., nursing staff administered an "as needed" (PRN) dose of [MEDICATION NAME] (an antipsychotic medication indicated for the management of [MEDICAL CONDITION], severe depression and manic episodes related to [MEDICAL CONDITION] disorder) to Resident #1. Staff administered the antipsychotic medication with the intention of having Resident #1 fall asleep and remain in bed to prevent him/her from wandering around the unit and reduce his/her risk of falling. Findings include: The Initial Plan of Care titled "Wandering", dated 7/28/14, indicated Resident #1 had a tendency to wander and staff were to keep his/her environment safe to enable him/her to freely move around the unit. Care Plan interventions did not include the use of an antipsychotic medication to manage Resident #1's wandering. The Surveyor interviewed Nurse #3 at 12:30 P.M. on 9/9/14 and at 11:00 A.M. on 10/10/14. Nurse #3 said Resident #1 would follow staff around and required constant redirection. Nurse #3 said Resident #1 could be redirected when spoken to in Spanish, his/her native language, which a lot of staff could speak, and sometimes he/she would ride in the elevator with staff, which had a calming effect on him/her. Resident #1's admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 did not exhibit any behavioral concerns, including wandering or resistance to care. The Psychiatric Consultation note, dated 8/19/14, indicated nursing staff reported Resident #1 had periods of striking out occasionally if he/she "did not get his/her way." The Psychiatric Consultation recommended discontinuation of Resident #1's current antipsychotic medication ([MEDICATION NAME]) and to begin [MEDICATION NAME] 12.5 milligrams (mg) at 9:00 A.M. and 25 mg at 5:00 P.M. and to give [MEDICATION NAME] 12.5 mg PRN up to twice per day. The Psychiatric Consultation note did not specify which behaviors the PRN [MEDICATION NAME] was intended to treat. The Nurse Progress note, dated 8/19/14, indicated the psychiatric consultant evaluated Resident #1 and made recommendations, "due to the wandering and the inability to redirect for safety." Resident #1's NP's telephone order, dated 8/19/14, indicated a new prescription for [MEDICATION NAME] 12.5 milligrams (mg) was to be administered in the morning and [MEDICATION NAME] 25 mg was to be administered at 5 P.M., and [MEDICATION NAME] 12.5 mg was to be given up to twice per day, as needed (PRN) for wandering and agitation. The NP's telephone order indicated Resident #1 had a new [DIAGNOSES REDACTED]. The Surveyor interviewed the NP at 10:15 A.M. on 9/10/14 and at 1:35 P.M. on 9/12/14. The NP said staff reported to her that on different occasions Resident #1 did not sleep well, he/she was restless and constantly wandered around the unit, required a lot of redirection and took up staff time. The NP said she asked the psychiatric consultant to evaluate Resident #1 and she followed their recommendation to prescribe PRN [MEDICATION NAME] to help Resident #1 fall asleep. The Surveyor interviewed Nurse #4 at 8:15 A.M. on 8/10/14. Nurse #4 said at the change of shift report, at approximately 11:00 P.M. on 8/19/14, staff told her Resident #1 had a new order for PRN [MEDICATION NAME]. Nurse #4 said staff also told her Resident #1 had an unwitnessed fall and that he/she hit his/her head and his/her head hurt. Nurse #4 said she observed Resident #1 during the night shift following staff around the unit and spending time at the nursing station. Nurse #4 said Resident #1 did not appear agitated but she was afraid Resident #1 might fall again if he/she continued to wander. Nurse #4 said Resident #1 typically did not sleep well during the night shift and would get out of bed and wander. Nurse #4 said she administered the antipsychotic medication with the intention of having Resident #1 fall asleep and remain in bed to prevent him/her from wandering around the unit and reduce his/her risk of falling. The Medication Administration Record, [REDACTED].M., indicated staff administered [MEDICATION NAME] 12.5 milligrams and the reason documented by the nurse administering the dose was "wandering". Staff indicated at 12:53 A.M. the medication had a "good effect" and Resident #1 was asleep. The Surveyor interviewed the Medical Director at 12:15 P.M. on 9/12/14 and at 1:13 P.M. on 9/15/14. The Medical Director said the PRN dose of [MEDICATION NAME] was prescribed to Resident #1 to stop him/her from wandering and to help him/her sleep.