Every finding on record at Palmer Healthcare Center

Based on observation, interviews, and record reviews, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and reflective of the resident's status at the time of the assessment, for two Residents (#7 and #5), out of a total sample of 15 residents. Specifically,1. For Resident #7, the facility failed to complete a Patient Health Questionnaire-9 (PHQ-9-an assessment for mood and depressive symptoms) Assessment when the Resident had documented psychological disorders.2. For Resident #5, the facility failed to accurately code that the Resident sustained falls with injury on the MDS Assessments dated 5/29/25 and 11/20/25, when the Resident had documented falls with injury within the assessment periods. Findings include: 1. Resident #7 was admitted to the facility in March 2018 with diagnoses including bipolar disorder with psychotic features, schizoaffective disorder, mood disorder, and psychosis. Review of Resident #7's MDS assessment dated [DATE] indicated: -the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a possible score of 15 -the PHQ-9 was not assessed. Review of Resident #7's medical record failed to indicate a PHQ-9 Assessment had been attempted during the assessment period. During an interview on 1/6/26 at 2:23 P.M., the Director of Nursing (DON) said that the PHQ-9 Assessment for the MDS assessment dated [DATE] was not completed but should have been. During an interview on 1/6/26 at 2:27 P.M., the Social Worker (SW) said the PHQ-9 Assessment is done quarterly to look for changes in mood of the Resident. The SW further said that not completing a PHQ-9 Assessment could affect the psychosocial care of the Resident. 2. Resident #5 was admitted to the facility in September 2024 with diagnoses including abnormal gait, weakness, lack of coordination and unsteadiness on feet. a. Review of the Nursing Progress Notes, dated 4/6/25, indicated a Certified Nurse Aide (CNA) found Resident #5 lying on the floor in his/her room with blood under his/her head. The Nurse was alerted, assessed the Resident, and a wound was noted on his/her right head measuring 6 centimeters (cm) by (x) 1 cm. Pressure was applied to the Resident's head wound to stop bleeding and he/she was transferred to the hospital for evaluation. A subsequent Nursing Note, dated 4/6/25, indicated Resident #5 returned to the facility from the hospital with ten staples to the right side of the head. Review of the Health Care Facility Reporting System indicated the Resident's fall with sustained laceration (to the head) was reported to the Department of Public Health on 4/7/25. Review of the MDS Assessment, dated 5/29/25, indicated Resident #5 did not sustain any falls with injury since the last completed assessment (dated 11/8/24). b. Review of the Resident's clinical record indicated the following: -Nursing Progress Note dated 10/18/25: Resident #5 was found lying on the floor in his/her room and sustained a small bump on the back of his/her head and an abrasion to the middle/lower back. -Nursing Progress Note dated 10/20/25: Resident #5 was found by facility staff lying on the floor next to his/her bed. The Resident was assessed by the Nurse and had no injuries . Review of the MDS assessment dated [DATE] indicated the Resident sustained no falls since the last completed assessment (dated 9/26/25). During an interview on 1/6/26 at 12:51 P.M., the DON said the MDS Coordinator and Corporate Consultant reviewed Resident #5's MDS Assessments dated 5/29/25 and 11/20/25, and that both MDS Assessments were coded incorrectly relative to falls.

Based on interviews, and record review, the facility failed to ensure that the Resident Representative had the right to make decisions on behalf of the Resident for one Resident (#17) out of a total sample of 15 residents.Specifically, for Resident #17, the facility failed to ensure that the court-appointed Guardian had the legal authority to elect advanced directives (written instructions, such as a medical order form that records a resident's treatment wishes in the event of a medical emergency) on behalf of the Resident when the Guardian signed Resident #17's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form. Findings include:Resident #17 was admitted to the facility in [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), dementia, failure to thrive, and malignant neoplasm of the kidney. Review of the document titled, Decree and Order of Appointment of Guardian for an Incapacitated Person for Resident #17, dated [DATE], indicated but was not limited to the following:-The Court appointed a Guardian for the Resident.-The powers and duties of the Guardian failed to indicate the authority to elect advanced directives. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #17 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) exam score of five out of a possible 15. Review of Resident #17's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE], indicated but was not limited to the following:-Advanced directives indicated: Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do not use non-invasive ventilation, and Do Not Hospitalize (DNH).-The Resident's Guardian signed the MOLST on [DATE]. Review of Resident #17's [DATE] Physician Order Report indicated:-Advanced directives: DNR, DNI, Do not use non-invasive ventilation, DNH, no dialysis, no artificial nutrition, no artificial hydration, and Guardian in place. Start date [DATE]. During an interview on [DATE] at 2:11 P.M., Nurse #1 said residents with a Guardian are a Full Code (advanced directives indicating to attempt resuscitation and intubate and ventilate) because Guardians do not have the authority to complete a MOLST. Nurse #1 said that Resident #17's advanced directives indicated DNR/DNI/DNH. During an interview on [DATE] at 3:46 P.M., the Director of Nursing (DON) said Resident #17's Guardian completed a new MOLST, indicating DNR/DNI. The DON said Resident #17's advanced directives should have been Full Code but were not Full Code. The DON said the concern with Resident #17 not having advanced directives completed by an authorized party was that the Resident could have required cardiopulmonary resuscitation (CPR) and the facility staff would not have performed the resuscitative treatment when legally they should have.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 11/30/25, Activity Aide (AA) #1 witnessed a potential incident of verbal and physical abuse and did not immediately report the incident as required, therefore placing Resident #1 and other residents at risk for abuse.Findings include:Review of the Facility policy titled Abuse Prevention Program, dated as revised March 2022, indicated that all employees are responsible to immediately report any violation or alleged violations.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/01/25, indicated that on 12/01/25, Activity Aide (AA) #1 reported to the Activity Director that on 11/30/25, she witnessed AA #2 making a comment mimicking a [NAME] sound while touching the loose skin under Resident #1's chin, as well as calling him/her a jackass for knocking a tablet over and calling him/her childish after Resident #1 verbalized being scared but was unable to answer when AA #2 asked him/her why.Review of the Facility's Incident Report, dated 12/01/25, indicated these alleged incidents occurred the previous evening (on 11/30/25).Resident #1 was admitted to the Facility in October 2025, diagnoses included unspecified dementia with anxiety, restlessness and agitation.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 10/30/25, indicated that he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs.Resident #1 was unable to be interviewed due to his/her severe cognitive impairment. During a telephone interview on 12/16/25 at 11:00 A.M., which included review of her written witness statement, dated 12/01/25, Activity Aide (AA) #1 said on 11/30/25 at around 5:30 P.M., (exact time unknown), both she and AA #2 were in the Facility's Dining/Activity room with several residents, including Resident #1.AA #1 said that she was standing in the corner of the room and AA #2 was seated at a table with Resident #1. AA #1 said that AA #2 called out her name, asked her to look, and when she looked over to see what AA #2 wanted, she saw AA #2 flicking the loose skin under Resident #1's neck while laughing and saying, [NAME], [NAME]. AA #1 said she immediately told AA #2 to stop it, said she told him he was being rude, and AA #2 stopped what he was doing.AA #1 said a little while later, AA #2 asked her to get a tablet for another resident seated at the same table as Resident #1. AA #1 said she obtained the tablet, and as AA #2 was setting it up for the other resident, Resident #1 knocked the tablet out of AA #2's hand and she heard AA #2 call Resident #1 a jackass in response. AA #1 said not long after that incident, she heard Resident #1 say he/she was scared, heard AA #2 ask him/her why, and heard him/her reply to AA #2 that he/she did not know why. AA #1 said she heard AA #2 tell Resident #1 he/she was childish and not making sense.AA #1 said she did not report the incident to anyone until the next day. AA #1 said although she told the Activity Director the next morning (12/01/25) that she needed to speak to her, AA #1 said she did not share full details of the incident until around 2:30 P.M. AA #1 said after she reported the incident, the Activity Director told her that this needed to be reported to the DON right away.AA #1 said that she knew the entire interaction between AA #2 and Resident #1 was not right but said she did not think to report it right away.During an interview on 12/16/25 at 12:55 P.M., the Activity Director said that on 12/01/25 at 2:30 P.M., AA #1 reported to her that on 11/30/25 (around 5:30 P.M.) she observed AA #2 laughing and jiggling Resident #1's neck skin while saying, [NAME], [NAME] and reported to her that AA #2 also called Resident #1 a jackass and childish.The Activity Director said AA #1 should have reported these incidents immediately after it happened.During an interview on 12/16/25 at 1:35 P.M., the Director of Nurses (DON) said that on 12/01/25, the Activity Director notified her of an interaction that occurred between AA #2 and Resident #1 on 11/30/25 at around 5:30 P.M. The DON said they immediately conducted an interview with AA #1. The DON said AA #1 reported that she and AA #2 were in the Dining/Activity room the prior evening with several residents, and AA #1 reported she observed AA #2 jiggling Resident #1's neck skin while saying, [NAME], [NAME] and that she heard AA #2 call Resident #1 a jackass and childish.The DON said although she was unable to substantiate an allegation of verbal abuse, she said that AA #1 should have reported these interactions between AA #2 and Resident #1 immediately (on 11/30/25) and should not have waited until the following day.On 12/16/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 12/10/25 which addressed the areas of concern as evidenced by:A) Resident #1 was assessed, and he/she showed no signs of distress or change in behavior as a result of the incident and will continue to be monitored and supported by staff as needed. B) On 12/03/25, the Director of Nurses completed an initial audit of the past 30 days reportable events for compliance with timeliness of reporting of incidents.C) On 12/01/25, AA #1 received re-education titled, Reporting Potential Abuse and received a final, written warning for failing to report the incident timely. D) On 12/02/25, the Staff Development Coordinator and/or their designee, initiated education for facility staff titled, Abuse Policy, Dignity, Customer Service, and Resident Rights. Staff education was completed on 12/12/25. E) On 12/05/25, the Director of Nurses initiated ongoing, weekly audits of reportable events for compliance with timeliness of reporting incidents, which will continue for three months.F) Data from the audits will be discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months or until the committee determines compliance.G) The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her healthcare needs, the Facility failed to ensure he/she was treated in a respectful and dignified manner, when after eliciting the attention of Activity Aide #1, Activity Aide #2 used his fingers to jiggle the loose skin under Resident #1's neck while laughing and saying, [NAME], [NAME]. Activity Aide #2 did this in the presence of other residents and staff members.Findings include:Review of the Facility's policy titled, Resident Rights, dated 05/28/21, indicated Federal and state laws guarantee certain basic rights to all residents of this facility, including the right to be treated with respect, kindness, and dignity.Review of the Facility's policy titled, Dignity, dated 05/28/21, indicated the following:-Residents are treated with dignity and respect at all times.-Demeaning practices and standards of care that compromise dignity are prohibited.Resident #1 was admitted to the Facility in October 2025, diagnoses included unspecified dementia with anxiety, restlessness, and agitation.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 10/30/25, indicated that he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs.Resident #1 was unable to be interviewed due to his/her severe cognitive impairment.During a telephone interview on 12/16/25 at 11:00 A.M., which included review of her written witness statement, dated 12/01/25, Activity Aide (AA) #1 said on 11/30/25 at around 5:30 P.M., (exact time unknown), both she and AA #2 were in the Facility's Dining/Activity room with several residents, including Resident #1.AA #1 said that she was standing in the corner of the room and AA #2 was seated at a table with Resident #1. AA #1 said that AA #2 called out her (AA #1) name and asked her to look. AA #1 said when she looked over to see what AA #2 wanted, she saw AA #2 flicking the loose skin under Resident #1's neck while laughing and saying, [NAME], [NAME]. AA #1 said she immediately told AA #2 to stop it, told him he was being rude, and AA #2 stopped what he was doing.Review of Certified Nurse Aide (CNA) #2's witness statement, obtained via telephone interview by the Director of Nursing (DON) on 12/05/25 at 10:40 A.M., indicated CNA #2 was taking a resident out of the Dining/Activity room, saw that AA #2 was with Resident #1, and that she heard AA #2 make a comment about and started playing with his/her (Resident #1's) neck.Review of CNA #3's written witness statement, dated 12/05/25, indicated that while she did not witness AA #2 flick the loose skin under Resident #1's neck, the statement indicated that she had heard AA #1 tell AA #2, that is not funny.The surveyor was unable to interview CNA #2 or CNA #3 as they did not respond to the Department of Public Health's request for an interview.Review of AA #2's witness statement (sent via an email), dated 12/02/25 timed stamped 10:19 A.M., indicated that on 11/30/25, he was in the activity room with Resident #1, that he attempted to be playful and keep him/her engaged in conversation and that he tickled the loose skin on his/her neck. AA #2's statement indicated Resident #1 did not ask him to stop and that he (AA #2) did not perceive this interaction as inappropriate.The surveyor was unable to interview AA #2 as he was unreachable by telephone, and he did not respond to the Department of Public Health's letter request for an interview. During an interview on 12/16/25 at 12:55 P.M., (which included a review of her written statement, dated 12/02/25), the Activity Director said that on 12/01/25 at around 2:30 P.M., (exact time unknown), AA #1 reported to her that AA #2 had behaved inappropriately towards Resident #1 on 11/30/25 around dinner time.The Activity Director said AA #1 told her that AA #2 called out to her (AA #1) to get her attention on both himself and Resident #1 and that AA #1 told her that she saw AA #2 jiggling Resident #1's loose neck skin with his fingers while saying, [NAME], [NAME]. The Activity Director said based on what AA #1 told her, she felt the situation needed to be reported to the DON right away, and they immediately began an internal investigation.The Activity Director said both she and a representative from Human Resources called AA #2, and they asked him if anything unusual happened during his shift on 11/30/25 and informed him that an abuse allegation was made against him.The Activity Director said when AA #2 said he had no knowledge of any incident, so they asked him specifically about his interaction with Resident #1. The Activity Director said AA #2 told them he was playing with Resident #1's chin flap and that he/she did not tell him to stop.The Activity Director said AA #2 sent his witness statement via email to her, he was suspended immediately pending investigation and was terminated at the conclusion of the investigation for violating Resident #1's rights.During an interview on 12/16/25 at 1:35 P.M., the Director of Nurses (DON) said the Activity Director came to her office on 12/01/25 at around 2:30 P.M. (exact time unknown) and told her that one of the Activity Department employees had concerns over the weekend about how a resident was treated. The DON said she met with the Activity Director and AA #1 and that AA #1 told her she witnessed AA #2 jiggling Resident #1's neck skin while saying the words [NAME], [NAME]. The DON said all staff that were working during the alleged time frame were interviewed, that two CNAs were also aware of the incident had occurred between AA #2 and Resident #1, and after reviewing AA #2's emailed witness statement, it was determined that AA #2 did not treat Resident #1 with dignity and respect and he was terminated.On 12/16/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 12/10/25 which addressed the areas of concern as evidenced by:A) Resident #1 was assessed, he/she showed no signs of distress or change in behavior as a result of the incident, and he/she continues to be monitored and supported by staff as needed. B) On 12/01/25, the Director of Nurses immediately initiated an investigation into the allegation.C) Activity Aide #2 was immediately suspended pending results of the investigation and ultimately terminated from his position effective 12/09/25.D) On 12/01/25, AA #1 received re-education titled, Reporting Potential Abuse and received a final, written warning for failing to report the incident timely.E) On 12/05/25, the Staff Development Coordinator and/or designee, initiated education for facility staff titled, Abuse Policy, Dignity, Customer Service, and Resident Rights, and specific education titled, Dignity.F) On 12/09/25, Certified Nurse Aide #2 received 1:1 education which included a review of the Facility's Dignity policy.G) On 12/05/25, the Director of Nurses initiated weekly observations/audits/interviews of staff members related to identifying and reporting potential abuse or any other infarctions related to dignity, customer service and resident rights.H) Data from the audits will be discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months or until the committee determines compliance.I) The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when 07/01/25, Certified Nurse Aide (CNA) #1 witnessed an incident of verbal abuse and did not report the incident immediately as required, therefore placing Resident #1 and other residents at risk for abuse. Findings include:Review of the Facility policy titled Abuse Prevention Program, dated as revised March 2022, indicated that all employees are responsible to immediately report any violation or alleged violations. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 07/01/25, indicated that on 07/01/25, CNA #1 reported to the Executive Director that she heard CNA #2 (agency CNA) verbally abuse Resident #1 while assisting him/her during lunch. Review of the report indicated the alleged incident had occurred at 12:50 P.M.Review of the Facility Incident Report, dated 07/01/25 indicated that CNA #1 reported an alleged incident of verbal abuse to the facility Executive Director on 07/01/25 at 2:35 P.M. (one hour and 45 minutes after witnessing the alleged abuse). Resident #1 was admitted to the Facility in January 2025, diagnoses included Down Syndrome, unspecified dementia and seizures.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 04/17/25, indicated he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs. On 09/02/25 at 11:00 A.M., the surveyor attempted to interview Resident #1, however he/she was unable to respond to the surveyor's questions, due to his/her severe cognitive impairment. During a telephone interview on 09/02/25 at 02:35 P.M., CNA #1 said that on 07/01/25, both she (CNA #1) and CNA #2 were assisting residents with lunch at the same table in the dining room, where four residents were seated. CNA #1 said that Resident #1 was saying no to CNA #2 while she (CNA #2) was feeding Resident #1 carrots. CNA #1 said that she told CNA #2 that Resident #1 did not feel good and that she should stop feeding him/her. CNA #1 said that CNA #2 responded in a loud voice, while Resident #1 and three other residents were seated at the table, that Resident #1 had been (expletive) drinking soda when his/her brother had visited and was now being a spoiled brat. CNA #1 said that she felt uncomfortable that Resident #1, and/or the other residents seated at the table heard what CNA #2 said about Resident #1 and how she (CNA #2) felt he/she was acting. CNA #1 said she was worried about CNA #2's behavior in front of the residents. CNA #1 said that after the meal, she proceeded to provide care to another resident and that it took a while before she reported the incident to the Executive Director. CNA #1 said that she should have reported the incident immediately. During a telephone interview on 09/02/25 at 01:00 P.M., CNA #2 said that on 07/01/25, while she was assisting Resident #1 with lunch, that Resident #1 said no while she was feeding him/her carrots and that CNA #1 told her put Resident #1's tray on the side table and to assist someone else. CNA #2 said that she then assisted a different resident. CNA #2 said that she had not sworn or made any negative comments in front of Resident #1. During an interview on 09/02/25 at 1:50 P.M., Nurse #1 said that she had not witnessed, and CNA #1 had not reported to her that an incident had occurred in the dining room on 07/01/25 during lunch.During an interview on 09/02/25 at 02:50 P.M., the Director of Nurses said allegations of suspected abuse should be reported immediately. On 09/02/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 07/08/25 which addressed the areas of concern as evidenced by:a) Resident #1 was assessed, he/she showed no signs of distress or change in behavior as a result of the incident. b) On 07/02/25 the Director of Nurses completed an initial audit of the past 30 days reportable events for compliance with timeliness of reporting of incidents. c) On 07/07/25, CNA #1 received re-education titled, Reporting Potential Abuse.d) On 07/07/25 the Staff Development Coordinator or designee-initiated education for facility staff titled, Abuse Policy, Dignity, Customer Service, and Residents Rights. Staff education was completed on 07/21/25.e) On 07/11/25 the Director of Nurses initiated ongoing weekly audits of reportable events for compliance with timeliness of reporting of incidents, weekly audits will be continued for three months. f) The concern for immediate reporting of allegations of resident abuse was discussed by the Quality Assurance Performance Improvement (QAPI) Committee on 08/16/25 and 09/16/25. Ongoing audit results will continue to be discussed at the QAPI Committee monthly meeting for three months. Target date of the QAPI plan is 10/01/25.g) The Director of Nurses and/or designee are responsible for overall compliance.

Based on observation, interview, and policy review, the facility failed to maintain a clean and sanitary environment in the main facility kitchen to prevent contamination and the spread of foodborne illnesses. Specifically, the facility staff failed to ensure that: 1) equipment in the facility kitchen was clean and free of dust and debris. 2) hair restraints were worn to prevent potential physical contamination of food/fluids. 3) the facility dish machine was appropriately tested for temperature and sanitation requirements by Dietary Staff when the minimum sanitation requirements were not met, putting the facility residents at risk for contamination and foodborne illnesses. Findings include: Review of the facility policy titled Kitchen Sanitation, dated [DATE], indicated the food service area is maintained in a clean and sanitary manner. The policy included the following: -All kitchen, kitchen areas and dining areas are kept clean, free from garbage and debris . -All utensils, counters, shelves and equipment are kept clean . -All equipment, food contact services and utensils are cleansed and sanitized using heat or chemical sanitizing solutions. -Dishwashing machines are operated according to manufacturer's instructions. Review of the facility policy titled Hair Restraint, dated [DATE], indicated: >compliance to local and federal food service codes requires that anyone within the kitchen, who will have close contact with the preparation or service of food, food storage areas, equipment will keep hair effectively/appropriately restrained to include facial hair. >The purpose of hair restraint is to prevent hair from contacting food and food equipment surfaces, and to deter food service employees from touching their hair. >The policy also included the following: -The Food Service Director (FSD) will provide disposable hair nets and beard guards at all times. -Hair nets will be located just outside, or just inside, of the entrances of the kitchen. Review of the Dish machine Instructions, located on the facility dish machine, included the following: -Testing Parts Per Million (PPM) on Low Temperature Dish Machine: -Run dish machine ,d+[DATE] cycles. -Ensure machine is at the appropriate temperatures: Wash 120 or higher degrees Fahrenheit (F), Rinse 120 or higher degrees F. -Use Precision Chlorine test paper directly after machine finishes rinse cycle. -Ensure hands are dry and test strips are not expired. -With dry hands, place test strip against the rinsing arm inside of the dish machine for 1 second. -Match the color of the strip (should turn dark purple color) with the index on the test strip tube. -PPM has to be between ,d+[DATE] PPM per manufacturers guidelines. -If the temperature and/or PPM are not within standards, do not run dishes through the machine. Contact FSD or Maintenance immediately . During an initial kitchen tour on [DATE] at 7:30 A.M., the surveyor observed the following: -two fans observed in the kitchen that were dust laden -shelf under the portable air conditioner unit was dusty -utensil rack with clean kitchen utensils which was located over the cooks preparation area was dusty -clear stacked storage containers which were not dry inside and had clear evidence of moisture During an interview on [DATE] at 7:34 A.M., Dietary Aide #4 said the clear containers that had been stacked and were not thoroughly dried were from the previous night. Dietary Aide #4 said the containers should not have been stacked while wet and there would be a concern for mold and bacterial growth. During a follow-up visit to the facility kitchen on [DATE] at 1:42 P.M., the surveyor observed the following: -the [NAME] was preparing food for dinner and did not have a hair restraint in place. During an interview at the time, the [NAME] said she should have put on a hair net prior to working in the kitchen. -utensil rack with clean kitchen utensils which was located over the cooks preparation area remained dusty. -Dietary Aide #2 was observed running the dish machine after lunch. During an interview of the process for checking the temperatures and sanitation requirements, Dietary Aide #2 said the temperature was checked after running ,d+[DATE] racks of dishes through the machine. Dietary Aide #2 said the chemical sanitizer should also be checked when using the dish machine but she had not checked it yet. Dietary Aide #2 proceeded to take a test strip and test the water inside the dish machine after a rack of dishes had commenced and compare the color on the strip to the guidance on the test strip tube. The color of the test strip was observed to be black and Dietary Aide #2 said the PPM was reading 200 which was too high. Dietary Aide #2 further said that she was never educated on when to check the chemical sanitizer and had already run two of the three lunch trucks with resident dirty dishes/trays through the machine. At this time, Dietary Aide #1 who was assisting with the dish machine said they should not continue to use the machine and should contact the FSD and maintenance. On [DATE] at 2:09 P.M., the surveyor, Maintenance Worker #1, the FSD and Executive Director, re-checked the facility dish machine using the test strips in the kitchen. After checking the water with a test strip in the dish machine, Maintenance Worker #1 showed the results obtained on the test strip which was observed to have no color (indicating there was no chemical sanitizer present). Upon inspection of the test strip tube, the surveyor observed there was no expiration date listed. The FSD said he would check his office to find a new tube of test strips in order to re-check the chemical sanitizer to determine if the dish machine could be used. During a follow-up interview on [DATE] at 3:51 P.M., the FSD said he checked the dish machine test strips and they were expired. The FSD said he was able to find additional unopened test strips which were not expired and the dish machine was re-checked and still indicating there was no chemical sanitizer present. The FSD said the dish machine temperatures and chemical sanitizer should be checked prior to running dishes through to ensure it was at the appropriate levels. The FSD further said that hair restraints should be worn by all staff when in the kitchen. The FSD said the fans should be cleaned monthly and were not routinely being cleaned. The FSD said he was currently working on a kitchen cleaning schedule to ensure areas were sanitary and free of dust/debris.

Based on observation, interview, record and policy review, the facility failed to ensure that one Resident (#3) out of a total sample of 17 residents was free from accidental risk of injury or entrapment. Specifically, the facility failed to ensure the scoop mattress (a mattress with raised edges on all four sides to prevent accidental rolling out of bed) being used for Resident #3 was compatible with the bed frame when there was a significant gap between the scoop mattress and foot board, placing the Resident at risk for injury or entrapment. Findings include: Review of facility policy titled Bed Safety, dated 5/28/21, indicated: -Our facility shall strive to provide a safe sleeping environment for the resident. -The residents sleeping environment shall be assessed by the interdisciplinary team (IDT), considering resident safety, medical conditions, comfort, freedom of movement, as well as input from the resident's family regarding sleeping habits and bed environment. -The facility shall identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g. [exempli gratis (for example)] altered mental status). -The facility shall provide inspection by maintenance staff of all beds . to identify risks and problems including potential entrapment risks. Resident #3 was admitted to the facility in June 2020 with a diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #3 had severe cognitive impairment as evidenced by a score of zero out of a possible total score of 15 on the Brief Interview for Mental Status (BIMS) exam. Review of Resident #3's comprehensive medical record indicated appointment of Guardianship (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) for incapacitated person, effective 1/12/23. On 9/24/24 at 8:15 A.M., the surveyor observed Resident #3 lying in bed on a scoop mattress with a large gap space between the foot board and the end of the mattress. On 9/24/24 at 1:47 P.M., the surveyor observed Resident #3 lying in bed on a scoop mattress with a large gap space present at the foot of bed. On 9/25/24 at 8:37 A.M., the surveyor observed Resident #3 lying in bed on a scoop mattress with a large gap space present at the foot of bed. The surveyor measured the gap space area on the Resident's bed which was nine inches from the edge of mattress to the foot board. During an interview on 9/25/24 at 10:22 A.M., Certified Nurses Aide (CNA) #1 said Resident #3 could move around in bed independently and had fallen out of bed in the past. CNA #1 said the facility took away the air mattress the previous week because Resident #3 did not like it and replaced the air mattress with the scoop mattress instead. CNA #1 said the scoop mattress that was in place was shorter than most other mattresses that were used in the facility. Review of Resident #3's September 2024 Physician's orders indicated that the air mattress had been discontinued from use on 9/24/24. During an interview and observation on 9/25/24 at 11:10 A.M., Maintenance Staff #1 said the maintenance staff were responsible for changing mattresses at the facility and were not notified of the Resident's mattress change from over the weekend. Maintenance Staff #1 said the scoop mattress that was placed on Resident #3's bed was not compatible with the bed frame and was too small. Maintenance Staff #1 said the small scoop mattress had created a big gap at the foot of the bed which was concerning and could place Resident #3 at risk for being hurt or entrapped. During an interview on 9/26/24 at 9:47 A.M., the Director of Nursing (DON) said a weekend staff Nurse had changed out the mattress for Resident #3. The DON could not provide evidence that an audit for safety had been completed at the time of the mattress change. The DON said there was no facility policy for bedframe or mattress audits, but audits did occur quarterly by the maintenance department. The DON said a whole house audit of mattress safety was last completed on 9/3/24, and was not scheduled to occur again until 12/3/24.

Based on observation, interview, record and policy review, the facility failed to provide supervision and an environment free of accident hazards for one Resident (#1), out of a total sample of 17 residents. Specifically, the facility failed to ensure that Resident #1 was provided with supervision, when the Resident who was determined as being at risk for elopement was observed outside of the facility in close proximity of a parking lot without staff supervision. Findings include: Review of the the facility policy titled Wandering and Elopement, dated 6/11/21, indicated: -the facility strives to promote resident safety by maintaining a process to screen all residents for risk of elopement and implement preventative strategies for those identified at risk. The policy also included the following: -If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Resident #1 was admitted to the facility in March 2018, with diagnoses including Bipolar Disorder with psychotic features (a mood disorder that features extreme shifts in mood that include emotional highs [mania or hypomania] and lows [depression], during which hallucinations or delusions can occur), Dementia with behavioral disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as Depression, Anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances), hearing loss, bilateral Glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called the optic nerve [which sends visual information from the eye to the brain]) and Presbyopia (the gradual loss of the eye's ability to focus on nearby objects). Review of the Activities Care Plan, initiated 6/5/24, indicated the Resident needed a quiet relaxing environment and included the following intervention: -Offer Resident patio time when weather is permitting . can go on the patio without staff supervision (dated 6/5/24) Review of the Elopement Risk Assessment, dated 8/17/24, indicated Resident #1 was identified as at risk for elopement based on the following factors: -Verbally abusive -Psychiatric diagnosis Further review of the Elopement Risk Assessment included the following interventions: -Activities -Redirection -Special Care Unit . secured unit -Identification band on the Resident -Photograph posted Review of the Minimum Data Set (MDS) Assessment, dated 8/22/24, indicated Resident #1: -had moderate difficulty hearing -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 7 out of 15 -utilized a walker -required substantial/maximum assistance of staff with ambulating 50 feet Review of the Elopement Care Plan, initiated 8/27/24, indicated Resident #1 was at risk and included the following interventions, dated 8/27/24: -Complete elopement assessment quarterly and as needed. -Complete Resident elopement sheet and put in the elopement book located at the nurses station. -Provide activities and assist with redirecting the Resident from attempting to leave the building. On 9/24/24 at 10:57 A.M., the surveyor observed Resident #1 seated in a chair on the patio located outside of the facility. The surveyor observed that the Resident's walker was positioned next to him/her and that there were no staff members outside the facility in the Resident's vicinity. The surveyor also observed that there was an open gate from the patio which lead to the sidewalk, a ramp and then a parking lot and the main road located near the facility. During an interview on 9/24/24 at 10:59 A.M., Certified Nurses Aide (CNA) #2 said the facility assesses residents to ensure they were able to go outside. CNA #2 said if Resident #1 wanted to go outside, the staff would use the keypad located inside the facility near the door (which led to the patio) to unlock the door and then open the door to allow the Resident outside. CNA #2 said the Resident ambulates with his/her walker and knows how to ring the doorbell on the outside patio door when he/she wanted to come back into the facility. CNA #2 said the door was locked from the outside of the building, so the doorbell was required in order to alert the staff that the Resident wanted to come back inside the facility. Review of the facility's Elopement Book, located at the nurses station, included a photograph and physical characteristics description of Resident #1 and indicated that he/she was an elopement risk. On 9/25/24 at 11:56 A.M., the surveyor observed Resident #1 seated in a chair outside on the patio with a walker positioned next to him/her. The surveyor did not observe any staff on the patio at the time. On 9/26/24 at 1:02 P.M., the surveyor and the Director of Nursing (DON) observed the facility door that lead to the patio. There were no residents on the patio at the time as it was raining, and the gate that lead from the patio, sidewalk and then ramp to the facility parking lot was observed to be open. The DON said that facility staff, visitors and vendors use this entrance to the facility. The DON said in order to enter the facility, they (person) would need to ring the doorbell located outside the door and staff would unlock the door using the keypad inside of the building to allow entrance. The DON said residents were able to go outside and sit without staff assistance but would need staff to unlock the door to let them back into the facility. The DON further said the patio gate should be closed when residents are outside to ensure the residents safety. During a follow-up interview on 9/26/24 at 3:23 P.M., the DON said the residents used to have scheduled time outside that was supervised by staff, but this had been stopped for quite a while. The DON said although there are staff located in the activity/dining room (which was in view of the patio), there were often a lot of residents in the activity/dining room with activities/events occurring so supervision of the residents who were seated outside may not be occurring. The DON said Resident #1 was considered an elopement risk and should be supervised by staff to ensure his/her safety. The DON said the gate on the patio was also a concern as it was open and could be unlatched by residents when closed.

Based on observation, interview, record and policy review, the facility failed to provide treatment and care in accordance with professional standards relative to the proper setting of pressure reducing and relieving devices for two Residents (#37and #2) who were at risk of skin breakdown. Specifically, the facility failed to: 1. For Resident's #37, maintain the pressure-reducing air mattress settings as ordered by the Physician. 2. For Resident #2, to ensure the Physician's order for an air mattress was implemented for the Resident who was bed bound, identified as being at increased risk for skin breakdown, and had a history of skin breakdown. Findings include: Review of the facility policy titled Support Surface Guideline, dated 5/28/21, indicated the following: -The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. -Redistributing support surfaces prevent skin breakdown, promote circulation and provide pressure relief or reduction. -Support surfaces are modifiable. Individual resident needs differ. -Elements of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution, moisture control, shear reduction, heat dissipation/temperature control, friction control, infection control, flammability, and life expectancy. 1. Review of the Panacea Air Ease Mattress Owner's Manual, dated 2022 - 2024, indicated the following: -Firmness dial: Turn the dial to adjust the pressure within the mattress, clockwise to increase pressure; counterclockwise to decrease pressure. -The recommended pressure settings correspond to the user weight values around the dial. Resident #37 was admitted to the facility in August 2021, with diagnoses including Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language) and Epilepsy (also known as seizure disorder - is a brain disorder that causes recurring seizures). Review of the Minimum Data Set (MDS) Assessment, dated 7/25/24, indicated the Resident had the following: -Brief Interview for Mental Status (BIMS) assessment score of zero out of 15, indicating the Resident had severe cognitive impairment. -was dependent on staff for all activities of daily living (personal hygiene, grooming, dressing, toileting, transferring and eating). -was dependent for mobility (the ability to change and control the body position). -weight was 137 pounds (lbs) and had weight gain of five percent or more in the last month or ten percent or more in the last six months. -presence of one, unhealed, stage two pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister). -used a pressure-reducing device in bed and received pressure injury care. Review of the Physician's orders, dated September 2024, indicated the following: -Air mattress set to 135, check for correct setting and function every shift, start date 8/22/24. Review of the Medication Administration Record (MAR), dated September 2024, indicated the following: -Air mattress set to 135 - check for correct setting and function every shift. -checks for correct setting and function was documented as being done every shift for 9/1/24 through 9/25/24. Review of the Care Plan, titled Risk for Alteration in Skin Integrity, revised 8/23/24, indicated the approach was to use an Air Mattress per MD (Physician) order. Review of the Wound Care Consultation, dated 7/26/24, indicated the following: -Follow-up on pressure ulcer to right heel. Left heel is resolved with intact epithelial tissue. -Recommend nursing to apply skin prep to bilateral heels every shift. Keep LAL (air mattress) in place. On 9/24/24 at 9:37 A.M., the Resident was observed lying in bed and a Panacea Air Ease Mattress was in place with the setting dial set to 85 pounds. The surveyor observed a sticker on the air mattress pump indicating to set the dial to 135 pounds. On 9/25/24 at 9:56 A.M., the Resident was observed lying in bed, and an air mattress was in place with the setting dial set to 85 pounds. During an observation and interview on 9/25/24 at 10:29 A.M., the surveyor and Nurse #1 observed the Panacea Air Ease Mattress in place on Resident #37's bed. Nurse #1 said the bed was set wrong and should be set for 135 pounds. Nurse #1 further said that she had only worked at the facility for six weeks and she was not aware the Resident had a history of pressure ulcers. During an interview on 9/25/24 at 10:29 A.M., the Director of Nursing (DON) said Resident #37's air mattress should have been set for 135 pounds and not 85 pounds. The DON further said that when a Resident was prescribed an air mattress, their weight was obtained, and a label is put on the pump indicating what the setting should be. The DON said the Nurses should be checking and correcting the setting if needed every shift. 37400 2. Resident #2 was admitted to the facility in December 2022, with diagnoses including Adult Failure to Thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity,) and Protein-Calorie Malnutrition (insufficient intake of both energy and protein). Review of the Panacea Air Element Mattress Owner's Manual indicated the following under Operations: -The pressure adjustment knob controls the air pressure in the mattress. Turning the know clockwise will increase the pressure; counterclockwise decreases the pressure. -Higher pressures will support heavier residents. -The pressure should be adjusted according to individual comfort levels. -You can generally check if the pressure is suitable for a resident by sliding one hand beneath the air cells at level of the resident's buttocks. The air cells will alternately inflate and deflate. You should feel slight contact with the buttocks when the air cells beneath the buttocks deflate. Review of the Skin Integrity Care Plan, initiated 12/14/22, indicated the Resident was at risk for alteration in his/her skin related to chronic incontinence, cognitive impairment, Moisture Associated Skin Damage (MASD: inflammation or skin erosion caused by prolonged exposure to a source of moisture) and history of venous ulcers (caused by problems with blood flow/circulation). Further review of the Skin Integrity Care Plan included the following intervention: -Air mattress to bed, see the Physician's order for the setting, initiated 12/30/22. Review of the MDS Assessment, dated 8/29/24, indicated Resident #2: -had clear speech, was able to make self understood, understands others. -was dependent on staff for positioning. -was at risk for pressure ulcers (localized skin and soft tissue injuries that develop due to prolonged pressure) and had a pressure reducing device in place for his/her bed. Review of the September 2024 Physician's orders included the following: -Bed bound per patient request, initiated 4/21/23 -Air mattress to be set at 120/150 (pounds or lbs.). See arrow on the device and check for function/setting every shift, initiated 8/22/24 On 9/24/24 at 9:51 A.M., the surveyor observed Resident #2 lying in bed with an air mattress in place and set to 210 lbs. The surveyor observed an arrow sticker on the setting box of the air mattress was pointing at the line between 120 and 150 lbs. On 9/25/24 at 8:28 A.M., the surveyor observed Resident #2 lying upright in bed. The air mattress was observed set at 210 lbs. An arrow sticker was observed on the setting box of the air mattress and was pointing at the line between 120 and 150 lbs. During an interview at the time Resident #2 said the mattress was uncomfortable. Review of the September 2024 Monitoring Administration Record included the following Physician's Order: -Air Mattress to be set at 120/150 (lbs.). See arrow on the device. Check for the function and setting every shift. Further review of the Monitoring Administration Record indicated the nursing staff verified that the air mattress was at the correct setting on 9/24/24 and 9/25/24. During an interview on 9/25/24 at 2:31 P.M., Nurse #2 said Resident #2 had reddened blanchable (skin turns white when pressure is applied and is a sign that the patient's position needs to be changed as there is potential for capillary damage if pressure is not relieved) areas on his/her back and required staff assistance with care and repositioning. Nurse #2 said the Resident had an air mattress in place that the nursing staff check every shift to ensure it was at the correct setting. Nurse #2 said the Nurse would check to ensure the Resident's air mattress was functioning and set at the correct setting. When the surveyor relayed observations from 9/24/24 and 9/25/24, Nurse #2 said she was unaware that the mattress was not at the correct setting. Nurse #2 further said that the Resident's mattress was set to his/her weight, and if it not set appropriately, it could put the Resident at risk for skin breakdown. During an interview on 9/25/24 at 4:19 P.M the DON said she was made aware that Resident #2's air mattress was not set to the Physician's ordered setting.

Based on observation, interview, record and policy review, the facility failed to provide reasonable accommodation of resident needs for one Resident (#207), out of a total sample of 17 residents. Specifically, the facility failed to provide Resident #207, who was identified as being at risk for falls, with access to his/her call bell at all times to allow the Resident to call for staff assistance when needed. Findings include: Review of the facility policy titled, Call Bells, dated 5/28/21 indicated the following: -Purpose: to have a communication system to allow residents to call for assistance. -Place call bell/light within reach of resident . Resident #207 was admitted to the facility in September 2024, with diagnoses including Parkinson's Disease (a progressive degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood), and urinary frequency. Review of the Brief Interview for Mental Status (BIMS) Assessment, dated 9/20/24, indicated the Resident was cognitively intact as evidenced by a score of 13 out of a total score of 15. Review of the Rehabilitation Screen, dated 9/20/24, indicated the Resident was able to transfer and ambulate with a walker and the assistance of one staff member. Review of the Fall Risk assessment, dated 9/20/24, indicated the Resident was at risk for falls. Review of the Fall Risk Care Plan, dated 9/21/24, indicated an approach was to keep the call bell in reach of the Resident. On 9/26/24 at 8:42 A.M., the surveyor observed the Resident sitting in his/her room in a wheelchair next to the bed with the overbed table in front of him/her. The surveyor observed that the Resident's call bell was hanging behind the bed and was not within reach. The Resident said he/she was comfortable in the wheelchair and that he/she had stayed in the wheelchair too long the previous day. When the surveyor asked the Resident how staff would be notified if he/she wanted to get out of the wheelchair, the Resident said he/she would press the button. The Resident was observed to look around the room, reach toward the bed, and said that he/she would wheel out to the room door to get help but that it might take him/her a month to do so. On 9/26/24 at 9:12 A.M., the surveyor observed the Resident was sitting in his/her room in a wheelchair and eating their breakfast meal. The surveyor observed that the call bell was still hanging behind the bed, and was not within reach of the Resident if he/she needed to call for staff assistance. During an interview on 9/26/24 at 11:06 A.M., the Director of Nursing (DON) said call bells should always be in reach of the Residents in their rooms.

Based on observation, record and policy review, and interview, the facility failed to ensure respect (regard for the feelings, wishes, rights, and traditions of others) and dignity (the state or quality of being honored or respected) for one Resident (#3), out of total sample of 17 residents. Specifically, for Resident #3, the facility had video monitoring in the Resident's bedroom without consent (agreement to do something), with video images of the Resident's body visible on a monitor screen in the Unit nursing station placing Resident #3 at risk for an undignified existence. Findings include: Review of facility policy titled Dignity, dated 5/28/21, indicated: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of wellbeing .and feelings of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. -The facility culture supports dignity and respect .by honoring choices, preferences, values, and beliefs. This begins with admission and continues throughout the residents stay. -Individual needs and preferences .are identified though the assessment process. -Residents private space and property are respected at all times. Resident #3 was admitted to the facility in June 2020, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Minimum Data Set (MDS) Assessment, dated 7/11/24, indicated Resident #3 had severe cognitive impairment as evidenced by a score of zero out of a total score of 15 on the Brief Interview for Mental Status (BIMS) exam. Review of Resident #3's comprehensive medical record indicated appointment of Guardianship (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) for incapacitated person, effective 1/12/23. On 9/24/24 at 8:15 A.M., the surveyor observed Resident #3 lying in bed covered by bed sheets/blankets, a dresser at the foot of the bed and a video camera located on top of the dresser that was on and pointed at the Resident's bed. On 9/24/24 at 11:03 A.M., the surveyor observed an image of Resident #3 lying in bed playing on a video monitor screen display located behind the nurses station. On 9/24/24 at 2:19 P.M., the surveyor observed that the privacy curtain of Resident #3 was pulled closed partially around the Resident's bed. The surveyor observed that Resident #3 was lying in bed and was uncovered and undressed from the waist up, exposing his/her chest. The surveyor observed the video camera located on top of the dresser was on and aimed at the Resident's bed. On 9/24/24 at 2:25 P.M., the surveyor observed the video monitor screen display behind the nurses station playing the image of Resident #3 lying in bed with his/her chest exposed. Review of Resident #3's comprehensive medical record did not indicate: -Assessment of need for video monitoring. -Physician order for video monitoring. -Consent for video monitoring. -Comprehensive, person-centered care plan for video monitoring. During an interview on 9/24/24 at 2:34 P.M., Activity Assistant #1 said that the video monitor was in place because Resident #3 sometimes rolls out of bed to put themselves on the floor. Activity Assistant #1 said the video monitor helped the staff watch Resident #3 from the nurses station. Activity Assistant #1 said the video monitor in the Resident's room had been in place for several months, and the monitor did not record. During an interview on 9/24/24 at 3:00 P.M., the Director of Nursing (DON) said she was unaware of how long the video monitor had been in place or why it was being used for Resident #3. The DON said that she was unable to provide evidence that an assessment had been completed, a consent had been obtained from the Resident's Guardian, a Physician order was in place, or that a comprehensive person-centered care plan had been developed for the video monitoring of Resident #3. During a follow-up interview on 9/25/24 at 8:00 A.M., the DON said Resident #3 has had the video monitoring in place since February 2024 per the Nursing Progress Note dated 2/18/24. The DON said Resident #3 did not have the ability to make his/her own choices due to Dementia. The DON further said the facility did not have a policy on video monitoring and the Resident's Guardian was not asked to provide consent for the use of video monitoring of the Resident. The DON said before the video monitor was put into place, the facility should have obtained consent for video monitoring from the Guardian, obtained an order from Resident #3's Physician and developed a comprehensive person-centered care plan related to the video monitoring. The DON said video monitoring without consent was a dignity concern, because video monitoring did not respect Resident #3's private space.

Based on observation, interview, record and policy review, the facility failed to provide food that was designed to meet the individual needs of one Resident (#2) out of a total sample of 17 residents. Specifically, the facility failed to ensure that Resident #2 was provided with the Physician's prescribed diet consistency of mechanical soft consistency (altered diet in which foods difficult to chew are chopped, ground, shredded, cooked or altered in some way to make them easier to chew and swallow) when the Resident was offered regular consistency items not allowed on his/her diet and pureed (texture modified diet where foods have been altered so that they have a smooth, cohesive, pudding-like consistency) meal items that was not ordered or the Resident's preference. Findings include: Review of the facility policy titled Therapeutic Diet Orders, dated 6/15/20, indicated it was the policy of the facility to assure that residents receive and consume foods in the appropriate form .as prescribed by the Physician and/or as assessed by the interdisciplinary team (IDT) to support the resident's treatment, plan of care in accordance with his/her goals and preferences. The policy also included the following: -therapeutic diets will be based on the individual needs of the resident and must be prescribed by the Physcian or delegate . -will be provided to residents in the appropriate form. Review of the facility Diet Manual, titled Diet Manual: A Nutritional Handbook and Training Guide for Long Term Care, dated 2/10/21, included the following under Ground Diet: -for individuals who had difficulty chewing or swallowing regular textured foods -foods that are difficult to chew are chopped, ground, shredded, cooked or altered in some way to make them easier to chew or swallow --Breads and cereals are allowed on this menu -meats should be very tender, finely chopped or ground and well moistened . -regular bread items should be finely chopped into 1/8 inches (in) . -well cooked, moistened, boiled, baked or mashed potatoes, well cooked noodles in sauce (chopped to 1/8 in) . -vegetables should be soft, well cooked, and easily mashed with a fork . -allowed fruits include soft, canned, or cooked fruits or ripe soft bananas, which are finely chopped to 1/8 in . -poached, scrambled eggs and cottage cheese are acceptable -danish pastry, sweet rolls, pancakes, french toast, breads, well moistened with syrup or sauce to form a slurry -avoid: any sticky foods peanut butter . Resident #2 was admitted to the facility in December 2022, with diagnoses including Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity) and Protein-Calorie Malnutrition (insufficient intake of both energy and protein), and Dysphagia (difficulty swallowing). Review of the Speech Language Pathology (SLP) Discharge Summary, dated 6/2/24, indicated Resident #2 was evaluated for swallowing and analysis of diet texture and made the following recommendation upon discharge from therapy: -Resident unable to follow verbal cues and safety precautions needed to further advance diet for soft salad sandwiches . Review of the Resident Food Preference Assessment Form, dated 6/10/24, indicated Resident #2 did not like the texture consistency of his/her diet . Review of the Minimum Data Set (MDS) Assessment, dated 8/29/24, indicated Resident #2 understands, was able to make self understood, and was on a mechanically altered (altered texture to allow for easier chewing or swallowing) diet. Review of the Nutritional Assessment, dated 8/30/24, indicated Resident #2 was: -on a mechanically altered diet and disliked the diet texture -had weight loss over six months that was not significant -considered a moderate nutritional risk Review of the September 2024 Physician's orders included the following, initiated 5/4/24: -Diet: Regular -Consistency: Dysphagia Mechanical Soft (Level 2) -Liquids: thin liquids with meals On 9/24/24 at 9:51 A.M., the surveyor observed Resident #2 lying in bed. During an interview at the time, the Resident said he/she was on a puree diet and hated it. The Resident said the food was crappy, watery and mixed together and he/she did not like that. On 9/25/24 at 8:28 A.M., the surveyor observed the Resident lying upright in bed. An overbed table was positioned in front of him/her and a breakfast tray that contained a pureed brown colored scoop of food (pureed pancake) and ground sausage. During an interview at the time, the Resident said the food was horrible, was like glue, and that he/she was not even sure what the brown mound of food (while pointing to it) was on his/her plate. Review of the Resident's meal ticket included the following: Regular-Ground diet. On 9/25/24 at 12:18 P.M., the surveyor observed Resident #2 lying in bed. An overbed table was positioned in front of him/her and a lunch tray was present and contained ground meat, a pureed orange substance (sweet potato), cooked scoop of spinach and a cup of pureed pineapple. During an interview at the time, the Resident said he/she was unable to eat the food and had requested a sandwich from the facility staff. The surveyor observed the Staff Development Coordinator (SDC) get a peanut butter and jelly sandwich with no crust for Resident #2 at this time. During an interview on 9/25/24 at 1:46 P.M., Certified Nurse Aide (CNA) #1 said the Resident was on a modified diet and often does not eat his/her food. CNA #1 said other staff bring in special items for him/her like the Vienna sausages and tuna packets for him/her to eat. CNA #1 said when the Resident doesn't eat, he/she will stack the food on his/her plate and return it to the kitchen. On 9/26/24 at 8:54 A.M., the surveyor observed Resident #2 lying in bed with breakfast tray positioned in front of him/her on an overbed table. The Resident's breakfast plate contained a pile of finely ground up pumpkin spice muffin and a small container of finely ground up fruit. During an interview at the time, the Resident said he/she was very upset about the food provided and did not understand why the muffin and fruit were ground up the way it was. On 9/26/24 at 1:22 P.M., the surveyor observed Dietary Aide #1 deliver a lunch tray for Resident #1 at the nurses station. Nurse #2 was present at the nurses station and was observed to check the lunch tray. A small container of egg salad was observed on the plate and a wrapped peanut butter and jelly sandwich with no crust. Nurse #2 said she did not think Resident #1 was able to have the peanut butter and jelly sandwich and removed it from the plate. Dietary Aide #1 said she would provide another small container of egg salad. During an interview on 9/26/24 at 1:23 P.M., Dietary Aide #1 said the cook was responsible for placing the Resident's food on the plate. Dietary Aide #1 said if a staff member requests food items for a resident, she checks with the cook to ensure the food is appropriate prior to sending it to the unit to be given to the resident. During an interview on 9/26/24 at 3:51 P.M., the Food Service Director (FSD) said he was familiar with Resident #2 because he/she would pile uneaten food items on his/her meal plate. The FSD said he was unaware of any diet concerns expressed by the Resident and said his/her current diet was Dysphagia Mechanical Soft which was the Ground Diet in the facility diet manual. The surveyor relayed observations from 9/25/24 and 9/26/24 and the Resident's concerns about the meal items provided. The FSD said the pancake provided on 9/25/24 should have not been pureed, it should been cut up and moistened. The FSD also said that the muffin provided on 9/26/24 should also have been moistened and not ground up on the plate. The FSD said the pureed orange food item for lunch on 9/25/24 was sweet potato. The FSD said he was not sure if the nursing staff are provided education on the diets provided in the facility and that sandwiches were not allowed on the Resident's diet, especially sandwiches which contain peanut butter which was sticky. During an interview on 9/26/24 at 5:15 P.M., the Staff Development Coordinator (SDC) said the nursing staff check meal trays and distribute them to residents. The SDC said she was not aware of any diet education that was provided to nursing staff about the facility used diet consistencies.

Based on record review and interview, the facility failed to ensure the Food Service Director (FSD) held the required qualifications. Specifically, the facility failed to ensure there was a full-time Registered Dietitian (RD) when the FSD: - was not a certified dietary manager. - was not a certified food service manager. - did not have a similar national certification in food service management and safety. - did not have an Associate's degree or higher in food service management or in hospitality. - did not have two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. Findings include: Review of the list of key personnel, provided by the facility, indicated a FSD was in place. During an interview on 8/10/23 at 7:41 A.M., the Regional FSD said he was covering for the facility's FSD because she was on vacation. He said the RD for the facility worked part-time. The Regional FSD provided a certificate held by the FSD. Review of the certificate indicated the FSD completed a course that included the safe handling of food. When the surveyor asked if the FSD had completed a Food Service Manager Program or held any other degrees that would meet the regulation, the Regional FSD said he would have to look into it. During an interview on 8/10/23 at 9:10 A.M., the Regional FSD provided the surveyor with the FSD's resume which indicated the FSD had been in the role of facility FSD since October 2022. The Regional FSD was unable to provide any evidence that the facility FSD held the required qualifications - was a certified dietary manager or food service manager, had a national certification in food service management and safety from a national certifying body, held an Associate's degree or higher in food service management or in hospitality, or had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. During an interview on 8/10/23 at 10:09 A.M., the Regional FSD said that it would be up to his manager to decide if the regulation had been met and that he was unaware if the facility's FSD met the qualifications.

Based on record review, policy review and interview, the facility failed to ensure that it provided discharge planning services with respect for the wishes of one Resident (#11) out of a total sample of 17 residents. Specifically, -For Resident #11, the facility failed to provide referrals and education based on the activated (made active) Health Care Proxy's (HCP-the legal document you use to tell medical providers who should make decisions about your care if you're not competent to do so) expressed desire to transfer the Resident to another skilled nursing facility closer to their home. Findings include: Resident #11 was admitted to the facility in March 2023 with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of the facility policy on Discharge Plan, dated 5/8/21, indicated that residents transferring to another skilled nursing facility . will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. Review of Resident #11's Social Services progress note dated 3/17/23, indicated that the Resident's HCP requested referrals to skilled nursing facilities that were closer to their family home and that Social Services staff would place the referrals during the week of 3/17/23. Further review of the progress notes indicated that no referrals had been made and that a discussion regarding transfer to another facility did not occur until 8/9/23, after the surveyor brought it to the attention of the Social Services Department, which was 145 days after the initial discussion on discharge placement. Review of Resident #11's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that he/she was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Further review of the MDS indicated that Resident #11 and his/her family's overall expectation was for the Resident to be discharged to another facility/institution. During an interview on 8/8/23 at 1:21 P.M., Resident #11's HCP told the surveyor that they had requested referrals to transfer the Resident to a skilled nursing facility closer to their family. The HCP further said that they had informed staff of their wishes and nothing had been done to assist them. During an interview on 8/9/23 at 2:10 P.M., Social Worker (SW) #1 said that the facility staff had not provided education or referrals based on Resident #11's and their family's wishes for a transfer to a facility closer to their family's home.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired and unable to make his/her needs known, the Facility failed to ensure staff consistently implemented measures related to abuse prevention as identified in their Abuse Policy when 1) on 05/18/23 after being made aware of an allegation of potential physical abuse of Resident #1 by Nurse #1, Nurse #2 did not immediately report the allegation per facility policy, therefore placing other residents at risk for potential abuse, and 2) for two out of three sampled employee personnel files (Nurse #2 and Nurse #3) the Facility failed to ensure a Massachusetts Nurse Aide Registry (NAR) background check was conducted, in accordance with facility policy, before they were allowed to work. Findings include: 1.) Review of the Facility Policy titled Abuse Prevention Program, dated as revised 03/01/22, indicated all staff will be responsible for the proactive identification of any event that may potentially be abuse or would lead a reasonable person to conclude that there was a potential for abuse. The Policy indicated that all staff are responsible for identifying and reporting immediately to their supervisor any witnessed abuse or allegation they are told about by residents, families, visitors, or other staff. Resident #1 was admitted to the Facility in April 2021, diagnoses included Alzheimer's disease and unspecified psychosis. Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 05/18/23, indicated his/her cognitive skills for daily decision making were severely impaired. The Assessment also indicated Resident #1 transferred and ambulated in his/her room and on the unit, independently, without any assistive devices. During an interview on 06/27/23 at 3:20 P.M., Certified Nurse Aide (CNA) #1 (which also included a review of her written witness statement dated 06/13/23) said that on 05/18/23, while she stood at the nurses station and looked down the South Wing, sometime between 7:00 P.M. and 8:00 P.M., she saw Nurse #1 place her hands on Resident #1's chest, and forcefully push him/her away. CNA #1 said she reported the incident to Nurse #2. Review of Nurse #2's written Witness Statement, dated 06/13/23, indicated that on 05/18/23, at approximately 7:30 P.M., she witnessed Nurse #1 place her hands around Resident #1's neck and that it looked like she (Nurse #1) had grabbed or tried to choke him/her, while yelling at him/her. Nurse #2's statement indicated she never reported the incident to the supervisor or facility administration. During an interview on 06/28/23 at 9:20 A.M., Nurse #3 said that on 06/13/23, while she was working at a different facility with Nurse #2, said Nurse #2 told her that when she worked the evening shift [at Resident #1's Facility] on 05/18/23, she witnessed Nurse #1 grab Resident #1, by the neck. Nurse #3 said that Nurse #2 told her that she had gone on vacation without ever reporting the incident to a supervisor or to facility administration. Nurse #3 said the phone number for the on call supervisor was posted on both the clipboard and at the nurses station on the unit at Resident #1's Facility, and that Nurse #2 should have called the supervisor immediately to report the incident. Nurse #3 said she immediately called the Facility's Unit Manager on 06/13/23 and reported what Nurse #2 had alleged. During an interview on 06/27/23 at 2:30 P.M., the Unit Manager said she received a phone call from Nurse #3 on the morning of 06/13/23, about an alleged incident that had occurred on 05/18/23, involving Nurse #1 and Resident #1. The Unit Manager said she immediately reported the incident to the Director of Nurses (DON). During an interview on 06/27/23 at 2:50 P.M., the Administrator said that facility administration had not been notified of the alleged incident involving Nurse #1 and Resident #1, that occurred on 05/18/23, until the morning of 06/13/23, when the Unit Manager reported the abuse allegation (to the former Director of Nurses) after receiving a phone call from Nurse #3. The Administrator said the investigation was initiated on 06/13/23 and the Department of Public Health was notified of the alleged incident within two hours. The Administrator said that Facility policy required staff to immediately report any allegations of suspected abuse to their supervisor, the DON, or the administrator. The Administrator further said that the staffing agency that referred Nurse #2 was notified of her failure to report an allegation of abuse and she no longer worked at the Facility. 2.) Review of the Facility Policy titled Abuse Prevention Program, dated as revised 03/01/22, indicated the following: -All potential employees will be screened to rule out a history of abuse, neglect, or mistreatment of residents. -The Facility does not knowingly hire individuals who have been found guilty of abusing residents by a court of law; had a finding entered in the state nurse aide registry concerning abuse; and/or had disciplinary action taken regarding resident abuse. -The Facility checks state nurse aide registries for all prospective employees (Massachusetts and other states in which the person is known to have worked). -The Facility documents the results of all screening activities including the name of the person who obtained the information and the date the information was obtained. Review of Staffing Agency #1's Contract with the Facility, dated 11/21/19, indicated that the Staffing Agency ensured all healthcare professionals had up to date licenses and background checks. During an interview on 06/27/23 at 8:10 A.M. and 4:00 P.M., the Director of Nurses (DON) said Nurse #2 was an agency staff member and Nurse #3 was employed by the Facility. During the interview, the Surveyor requested that the DON provide personnel information and evidence of background checks for Nurses #2 and #3. Review of Nurse #2's personnel file indicated that she was hired by Agency #1 and worked her first shift at the Facility on 05/18/23. Review of the personnel records provided by the Facility indicated there was no documentation to support the Facility and/or the Agency checked her status on the Massachusetts NAR. Review of Nurse #3's personnel file indicated that she was hired by the Facility on 03/02/23. Review of the personnel records provided by the Facility indicated there was no documentation to support the Facility having checked her status on the Massachusetts NAR. The DON said that Nurse #2 should have had NAR checks completed by the agency, but that the agency was unable to provide any documentation to support that a NAR check had been completed. The DON said the Facility had not checked Nurse #3's status on the Massachusetts NAR, upon hire, because they were not aware the checks had to be performed on Nurses.

Based on record review and interview, the facility failed to ensure its staff documented each instance of staff COVID-19 testing for three Employees (#1, #2, and #3) out of a total sample of eight Employees, when the facility was experiencing an outbreak of COVID-19. Specifically, the facility failed to ensure its staff documented that testing had been conducted, and the results of the testing recorded, for: 1) two Employees (#1 and #2) prior to their return to work after having tested positive for COVID-19, and 2) one Employee (#3), during outbreak testing. Findings include: Review of the COVID-19 testing policy provided by the facility, dated 9/7/20, included that employees were to conduct testing in accordance with Department of Public Health guidelines and Centers for Medicare and Medicaid Services (CMS) requirements. During an interview on 1/18/23 at 9:00 A.M., the Infection Preventionist (IP) said the facility was experiencing an outbreak of COVID-19 which began 12/28/22. The IP said all employees were required to be tested for COVID-19 every 48 hours, prior to the start of their shift. She also said employees who were out of work due to testing positive for COVID-19 were allowed to return to work on day six after testing positive, as long as they had a negative test on day five. The IP said the dates and results of staff tests were to be recorded on the facility's staff testing log. 1. The facility failed to ensure its staff documented that COVID-19 testing was conducted and results recorded for Employees #1 and #2 prior to allowing them to return to work, after they tested positive for COVID-19. Review of the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health (DPH) memorandum, titled Guidance for Health Care Personnel with SARS-CoV2 Infection or Exposure, dated 10/13/22, included the following: - An isolating health care personnel (HCP) who had COVID-19 symptoms could return to work: - After 5 days had passed since the first positive test was taken; AND - Symptoms had substantially improved, including being fever-free, for 24 hours; AND - The HCP received a negative test (antigen) on Day 5 or later. Further review of the document also included that an isolating HCP who had been asymptomatic and isolating may return to work after 5 days once the HCP received a negative test on day five or later. a) Review of the facility's Respiratory Surveillance Line List for staff, dated 12/28/22, included that Employee #1 tested positive for COVID-19 on 12/28/22. >Review of Employee #1's timesheet for dates 12/30/22 through 1/12/23 indicated Employee #1 returned to work on 1/4/23 (on day seven after having tested positive for COVID-19). >Review of the facility's employee testing logs did not indicate Employee #1 had been tested , and was negative for COVID-19 prior to his/her return to work on 1/4/23. During an interview on 1/18/23 at 12:15 P.M., the IP said Employee #1 tested negative for COVID-19 at the facility on 1/3/23, but the date and result of the test were not recorded on the facility's testing log as required. b) Review of the facility's employee schedules indicated Employee #2 worked at the facility on the following dates: -1/10/23 -1/11/23 -1/12/23 -1/13/23 -1/14/23 >Review of the facility's employee COVID-19 testing logs did not indicate Employee #2 was ever tested for COVID-19 between 1/10/23 and 1/14/23. During an interview on 1/18/23 at 3:45 P.M., the IP said Employee #2 had not tested for COVID-19 between 1/10/23 and 1/14/23 because he/she had been positive for COVID-19 within the last 30 days. The IP said she could not recall the exact date the Employee tested positive, but she would find out. During an interview on 1/19/23 at 4:10 P.M., with the Administrator and the IP, the Administrator said Employee #2 tested positive for COVID-19 on 1/4/23. The IP said Employee #2 worked on 1/10/23 and that she tested the Employee prior to allowing him/her to return to work. The IP said Employee #2 tested negative, but the date and result of the test were not recorded on the facility's testing log, as required. 2. For Employee #3, the facility failed to ensure its staff documented one instance of COVID-19 testing, and the result of the test, when the facility was experiencing an outbreak of COVID-19 and the Employee worked at the facility. Review of the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health (DPH) memorandum, titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, Including Visitation Conditions, Communal Dining, and Congregate Activities, dated 10/13/22, indicated that once a new case of COVID-19 was identified, the facility should: - Once the facility has completed the requisite initial outbreak testing, the facility should test staff .every 48 hours on the affected units until the facility goes seven days without a new case or a DPH epidemiologist directs otherwise. Review of Employee #3's timesheet for dates 12/30/22 through 1/12/23 indicated that he/she worked at the facility on the following dates: -1/6/23 -1/9/23 -1/10/23 >Review of the employee COVID-19 testing logs indicated Employee #3 was tested for COVID-19 on 1/6/23, but no other test was documented for the Employee again until 1/10/23 (more than 48 hours from the previous test). During an interview on 1/18/23 at 7:50 A.M., Employee #3 said the facility had been experiencing an outbreak of COVID-19 and that all staff were required to test every 48 hours. Employee #3 said he/she tested every 48 hours at the facility, even on his/her days off. Employee #3 said if employees did not test negative for COVID-19 every 48 hours, they would not be allowed to work. During an interview on 1/18/23 at 12:15 P.M., the IP reviewed the facility's COVID-19 testing logs with the surveyor and said Employee #3 should have been tested on [DATE] (48 hours after his/her previous test on 1/6/23), and prior to the start of his/her shift on 1/9/23, but there was no documented evidence this had been done as required. The IP also said the system used to document and track employee COVID-19 testing needed to be tightened up.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a walker and physical assistance of two staff members for transfers, the Facility failed to ensure staff consistently implemented and followed interventions from his/her Comprehensive Care Plan, and provided an appropriate level of staff assistance to ensure safety during transfers. On 10/26/22, Certified Nurse Aide (CNA) #1, who admitted to being in a rush that day, attempted to transfer Resident #1 from his/her bed to his/her wheelchair by herself. CNA #1 did not use an assistive device (walker) and did not obtain assistance from another staff member for Resident #1's transfer, per his/her Care Plan. CNA #1 was aware Resident #1 required two staff members for transfers, but transferred him/her alone placing the Resident #1, as well as herself, at risk of injury. Findings include: Review of the Facility's Care Plan Policy, dated 05/28/21, indicated that the care plan is based on the resident's comprehensive assessment. Resident #1 was admitted to the Facility in June 2022 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/08/22, indicated Resident #1 required extensive physical assistance of two staff members for transfers, and had significant cognitive impairment. Review of Resident #1's Comprehensive Care Plan, dated as edited 05/16/22, indicated Resident #1 required the use of a walker and physical assistance of two staff members for transfers. Review of Resident #1's Resident Profile, dated 02/10/22, (located in the CNA Assignment Book), indicated that he/she required the use of a walker and physical assistance of two staff members for transfers. Review of the Facility's Internal Investigation Report, undated, indicated that on 10/26/22 at approximately 10:30 A.M., a CNA (later identified as CNA #)1 reported that during a transfer from bed to wheelchair, the Resident (#1) began to tighten his/her grip on her until only his/her fingernails were in her (CNA #1's) back. The Report indicated CNA #1 asked Resident #1 to stop because she could not focus on the transfer anymore. The Report indicated that Resident #1 got very upset, and CNA #1 was observed by another staff member (later identified as Nurse #1), as she (CNA #1) shook her finger in Resident #1's face and yelled That is not [OBSCENITY] ing okay; you hurt me. During an interview on 11/08/22 at 11:45 A.M., CNA #1 said that the level of assistance for all residents is listed on their Resident Profiles in the CNA Assignment Book. CNA #1 said she and Resident #1 were close, she knew him/her well, and said she felt that even though Resident #1 could not use his/her legs during a transfer, and was already a little agitated, that she would transfer him/her by herself, especially since it was such a hectic morning. CNA #1 said she frequently worked with Resident #1 and said he/she got upset when his/her routine was altered. CNA #1 said she had Resident #1 wrap his/her arms around her back, then she grabbed his/her pants and quickly tried to transfer Resident #1 from his/her bed to his/her wheelchair. CNA #1 said Resident #1 got upset, freaked out, and sunk his/her nails into her (CNA #1's) back. During an interview on 11/08/22 at 12:57 P.M., Nurse #1 said the level of assistance a resident requires for transfers was determined by licensed staff, and said it was listed on the Resident Profile, which was kept in the CNA Assignment Book. Nurse #1 said Resident #1 required the use of a walker and physical assistance of two staff members for transfers. Nurse #1 said that on 10/26/22, CNA #1 had not used a walker or two staff members to transfer Resident #1, as his/her Resident Profile indicated. During an interview 11/18/22 at 9:49 A.M., the Director of Nurses (DON) said Resident #1 required the use of a walker and physical assistance of two staff members for transfers. The DON said CNAs use the Resident Profiles located in the CNA Assignment Books to determine the level of assistance required to transfer a resident safely. The DON said Resident #1's Resident Profile indicated he/she required a walker and physical assistance of two staff members for transfers. The DON said CNA #1 transferred Resident #1 alone and without a walker or another staff member to help her, but should not have.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who has a history of [CONDITION(S)] with significant cognitive impairment, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 10/26/22, while attempting to transfer Resident #1 by herself, Certified Nurse Aide (CNA) #1 instructed Resident #1 to wrap his/her arms around her back, CNA #1 then grabbed Resident #1 by his/her pants, lifted him/her up, Resident #1 then freaked out and dig his/her fingers/fingernails into CNA #1's back. CNA #1 then proceeded to yell and point her finger at Resident #1, while using profanity. Findings include: Review of the Facility's Residents Rights Policy, dated 05/28/21, indicated that all employees shall treat residents with kindness, respect, and dignity. Resident #1 was admitted to the Facility in June 2022 diagnoses included Wernicke's [CONDITION(S)] ([CONDITION(S)] brain disorder), intracerebral hemorrhage (brain bleed), and [CONDITION(S)]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/08/22, indicated Resident #1 had significant cognitive impairment. Review of the Report submitted by the Facility via the Health Care Facility System (HCFRS), dated 10/26/22, indicated that on 10/26/22 at 10:30 A.M., Resident #1 and CNA #1 were involved in a physical and verbal altercation. Review of the Facility's Internal Investigation Summary, undated, indicated that on 10/26/22, CNA #1 was observed by another staff member (later identified as Nurse #1), as she (CNA #1) shook her finger in Resident #1's face and yelled That is not [OBSCENITY] ing okay; you hurt me. The Summary indicated that during an interview with the Executive Director, CNA #1 said she may have used hand gestures, but did not think she pointed the gestures in Resident #1's face. Review of CNA #1's Written Witness Statement, dated 10/26/22, indicated she (CNA #1) started to transfer Resident #1 from his/her bed to his/her wheelchair, when Resident #1 got nervous and angry, then tightened his/her grip on her until his/her fingernails were in her (CNA #1's) back. The Statement indicated CNA #1 could not complete the transfer to the wheelchair safely, so she returned Resident #1 to his/her bed. The Statement indicated that CNA #1 told Resident #1 that he/she could not do that to her (CNA #1) and that it was not okay. During an interview on 11/08/22 at 11:45 A.M., Certified Nurse Aide (CNA) #1 said she had frequently provided care for Resident #1 and knew him/her well. CNA #1 said Resident #1 got upset when his/her routine was altered. CNA #1 said on 10/26/22, it was a hectic morning and said it was easier for her to transfer Resident #1 by herself instead of getting another staff member to help. CNA #1 said she was rushing which caused Resident #1 to get upset. CNA #1 said as she attempted to transfer Resident #1 from his/her bed to his/her wheelchair, Resident #1 freaked out, yelled, and sunk his/her finger nails into her (CNA #1's) back. CNA #1 said she did not shake her finger in Resident #1's face and said she didn't think she had sworn in his presence, but was not sure. Review of Nurse #1's Written Witness Statement, dated 10/26/22, indicated that she (Nurse #1) entered Resident #1's room when she heard CNA #1 yell. The Statement indicated she saw CNA #1 shaking her finger in Resident #1's face and heard her yelling, That is not [OBSCENITY] ing okay; you hurt me. During an interview on 11/08/22 at 12:57 P.M., Nurse #1 said on 10/26/22. she was helping CNA #2 in the room next to Resident #1's room and heard yelling. Nurse #1 said she and CNA #2 went into Resident #1's room and saw CNA #1 standing in front of Resident #1 (who was in bed) and that CNA #1 was pointing her finger in Resident #1's face and saying words to the effect of, That's not [OBSCENITY] ing okay. Review of CNA #2's Written Witness Statement, dated 10/26/22, indicated CNA #2 heard CNA #1 yell at Resident #1 saying, don't [OBSCENITY] ing grab my skin like that again. The Statement also indicated that CNA #2 saw CNA #1 shake and point her finger in Resident #1's face as she screamed at him/her. During an interview on 11/09/22 at 12:34 P.M., CNA #2 said she and Nurse #2 heard CNA #1 yelling and went into Resident #1's room to see what was going on. CNA #2 said when they entered Resident #1's room, he/she was sitting at the edge of his/her bed, and CNA #1 was shaking and pointing her finger in Resident #1's face and she (CNA #1) was yelling at him/her. CNA #2 said CNA #1 said, words to the effect of, You can't [OBSCENITY] ing touch me like that. During an interview on 11/09/22 at 12:27 P.M., Housekeeper #1 said that on 10/26/22, she was cleaning Resident #1's bathroom when she heard CNA #1 scream, ouch. Housekeeper #1 said she looked out into Resident #1's room and saw him/her sitting on his/her bed, and CNA #1 was standing in front of him/her. Housekeeper #1 said CNA #1 was very angry and was yelling at Resident #1 telling him/her to calm down. During an interview on 11/18/22 at 9:49 A.M., the Director of Nurses (DON) said that on 10/26/22, Nurse #1 immediately reported to her that she (Nurse #1) had observed CNA #1 shake and point her finger in Resident #1's face, yell at him/her, and swear in his/her presence. The DON said when CNA #1 was interviewed by Administration, CNA #1 said she may have sworn in front of Resident #1, and may have used hand gestures. The DON said CNA #1 was immediately suspended pending an investigation, and was then terminated upon completion of their investigation based on her behavior. During an interview on 11/08/22 at 2:25 P.M., Executive Director (ED) said in response CNA #1's behavior, she had been terminated. The ED said initially there was question of a physical altercation as well because it was reported that CNA #2 saw CNA #1's hand on Resident #1's shoulder during the incident, but it was later determined that CNA #1 had been steadying Resident #1, who was seated at the edge of his/her bed.

Based on observation, record review and interview, the facility failed to ensure staff provided treatment and repositioning to prevent a pressure ulcer injury from worsening for one Resident (#23) out of 2 applicable sampled residents. Findings include: Resident #23 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment, dated 2/24/22, indicated the Resident required extensive assist of two for both bed mobility and transfers and was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. Review of a progress note, dated 4/10/22, indicated the Resident had a large blister on the back of the right heel measuring 6 centimeters (cm) x 8 cm with a small opening that was draining serous sanguineous drainage (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells). Review of the nurse practitioner's (NP) progress note, dated 5/5/22, indicated the Resident had a right heel deep tissue injury which had yellow slough (yellow/white material in the wound bed; it is usually wet, but can be dry. It generally has a soft texture and consists of dead cells that accumulate in the wound exudate) surrounding edges of black eschar (dry, dead tissue) to the center. Refer to wound clinic for evaluation and treatment, will most likely need debridement (removal of dead tissue) continue Santyl (used to removed dead tissue) daily and offload the area. Monitor for signs and symptoms of infection. Review of the May 2022 Treatment Administration Record (TAR) indicated the following: Cleanse area to the right heel with normal saline, pat dry, apply a nickel thick layer of Santyl to wound bed, cover with non-adherent gauze and wrap loosely with kling. The treatment was signed off as being administered from 5/6/22 through 5/10/22, each day it was documented that the drainage was foul smelling. On 5/6/22 the drainage was documented as moderate (with no other description), on 5/7/22 it was moderate bloody and serosanguineous, on 5/8/22 through 5/10/22 it was heavy bloody, serosanguineous. Review of a progress note, dated 5/11/22, indicated the right heel wound had 90% slough and 10% granulation, foul odor noted, heavy amounts of purulent (a thick and milky discharge that often indicates infection) drainage. Surrounding tissue macerated (break down from moisture). New order to cover wound with ABD pad rather than non-adherent pad for maximum absorption. Review of the National Library of Medicine, Patient Safety and Quality: An Evidenced Based Handbook for Nurses: Pressure Ulcers, indicated the following: Clinical signs that the pressure ulcer may be infected include malodorous, purulent exudate; excessive draining; bleeding in the ulcer; and pain. Review of the May 2022 TAR indicated the following: Cleanse area to right heel with normal saline, pat dry, apply a nickel layer of Santyl to wound bed, cover with ABD pad and wrap loosely with kling. The treatment was signed off as being administered on 5/11/22 and 5/13/22 through 5/19/22. Each day it was documented as the drainage being foul smelling. On 5/14/22 and 5/15/22 the type of drainage was not specified. On 5/11/22, 5/18/22, 5/19/22 the drainage was documented as purulent. On 5/19/22 at 1:06 P.M., the surveyor observed the wound and dressing change with the infection control nurse, nurse #1 and the nurse practitioner. The infection control nurse removed the right heel dressing and said there was a moderate amount of blood tinged, foul smelling, purulent drainage. The NP said there was an odor to the wound (or drainage) that she had not noticed before. The NP said she would order an antibiotic and an x-ray of the right heel to rule out [CONDITION(S)] (bone infection). During an interview on 5/19/22 at 1:43 P.M., with the infection control nurse and the NP, the NP said she hadn't seen the wound since 5/5/22 because she was told last week it was getting better and didn't need to see it. She said another practitioner must have given the order for the ABD pad which was started on 5/11/22. She said that the last time she saw the wound there was no odor and while the size of the wound had improved, the odor wasn't there before. She said she wasn't notified personally of the wound drainage and odor but maybe a colleague was. The infection control nurse said that she spoke with the physician to get the order for the ABD pad. She said that at that point she told him about the deterioration of the wound and he didn't want to order anything. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/19/22 at 1:51 P.M. with the NP and the infection control nurse, the NP said she wasn't updated on 5/11/22 and didn't give the treatment order. The infection control nurse said she must have made an error when she entered it and instead of using the physician's name she used the NP's name. The surveyor asked for evidence that someone had been updated about the status of the wound on that day. The infection control nurse referenced the progress note she entered on 5/11/22 and said there was nothing there to say who she spoke with to obtain the new treatment order or that anyone was updated about the wound drainage and foul odor. The infection control nurse said she thought the the wound looked better (on 5/19/22). When the surveyor asked why the NP would be ordering an x-ray and antibiotic if the wound had in fact improved, she had no response. During an interview on 5/19/22 at 2:35 P.M., the Director of Nurses (DON) said that she knew there were signs of infection with the wound but there were also improvements as far as the type of tissue and the wound size. She said she was under the impression that the NP knew about the foul odor because it was documented before. During an interview on 5/20/22 at 7:44 A.M., the physician said he was aware that the infection control nurse wanted to change the treatment to something more absorbent. He said he was not told that there was heavy drainage, only that the dressing was keeping the wound too saturated. He said he didn't remember the last time he saw the Resident, but the NP sees him/her regularly. He said if he had been told there was purulent drainage or heavy drainage he would have gone to see the wound himself because those are signs of an infection and would have needed an intervention. He said that his understanding was there was a problem with the dressing and not the wound itself. Review of the May 2022 Certified Nurse Aide (CNA) flow sheets indicated the Resident was to be repositioned every two hours and 17 of the 19 days had no repositioning documented for the 11:00 P.M. - 7:00 A.M. shift. Further review indicated 4 out of 19 days had no repositioning documented for the 7:00 A.M.- 3:00 P.M. shift and 5 out of 19 days had no repositioning documented for the 3:00 P.M. -11:00 P.M. shift. Review of both the May 2022 TAR and the May 2022 CNA flow sheets indicated no evidence of off loading pressure to the right heel as the NP had indicated in her 5/5/22 progress note listed above. During an interview on 5/20/22 at 9:17 A.M., the DON reviewed the CNA flow sheets and said the Resident was supposed to be repositioned every 2 hours and it looked like he/she was hardly repositioned in May on the 11:00 P.M. -7:00 A.M. shift. She said that the off loading to the right heel should have been documented on the May 2022 TAR but said she didn't see it on there. She said she thought it was on there and it was her mistake that it wasn't.

Based on observation, record review and interview, the facility failed to ensure staff notified the physician about signs of a wound infection for one Resident (#23) out of two applicable sampled residents. Findings include: Resident #23 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a progress note, dated 4/10/22, indicated the Resident had a large blister on the back of the right heel measuring 6 centimeters (cm) x 8 cm with a small opening that was draining serous sanguineous drainage (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells). Review of the nurse practitioner's (NP) progress note, dated 5/5/22, indicated the Resident had a right heel deep tissue injury which had yellow slough (yellow/white material in the wound bed; it is usually wet, but can be dry. It generally has a soft texture and consists of dead cells that accumulate in the wound exudate) surrounding edges of black eschar (dry, dead tissue) to the center. Refer to wound clinic for evaluation and treatment, will most likely need debridement (removal of dead tissue) Continue Santyl (used to removed dead tissue) daily and offload the area. Monitor for signs and symptoms of infection. Review of the May 2022 Treatment Administration Record (TAR) indicated the following: Cleanse area to the right heel with normal saline, pat dry, apply a nickel thick layer of Santyl to wound bed, cover with non-adherent gauze and wrap loosely with kling. The treatment was signed off as being administered from 5/6/22 through 5/10/22, each day it was documented that the drainage was foul smelling. On 5/6/22 the drainage was documented as moderate (with no other description), on 5/7/22 it was moderate bloody and serosanguineous, on 5/8/22 through 5/10/22 it was heavy bloody, serosanguineous. Review of a progress note, dated 5/11/22, indicated the right heel wound had 90% slough and 10% granulation, foul odor noted, heavy amounts of purulent (a thick and milky discharge that often indicates infection) drainage. Surrounding tissue macerated (break down from moisture). New order to cover wound with ABD pad rather than non-adherent pad for maximum absorption. Review of the May 2022 TAR indicated the following: Cleanse area to right heel with normal saline, pat dry, apply a nickel layer of Santyl to wound bed, cover with ABD pad and wrap loosely with kling. The treatment was signed off as being administered on 5/11/22, 5/13/22 through 5/19/22. Each day it was documented as the drainage being foul smelling. On 5/14/22 and 5/15/22 the type of drainage was not specified. On 5/11/22, 5/18/22, 5/19/22 the drainage was documented as purulent. Review of the National Library of Medicine, Patient Safety and Quality: An Evidenced Based Handbook for Nurses: Pressure Ulcers, indicated the following: Clinical signs that the pressure ulcer may be infected include malodorous, purulent exudate; excessive draining; bleeding in the ulcer; and pain. On 5/19/22 at 1:06 P.M., the surveyor observed the wound and the dressing change with the infection control nurse, nurse #1 and the nurse practitioner. The infection control nurse removed the right heel dressing and said there was a moderate amount of blood tinged, foul smelling, purulent drainage. The NP said there was an odor to the wound (or drainage) that she had not noticed before. The NP said she would order an antibiotic and an x-ray of the right heel to rule out [CONDITION(S)] (bone infection). During an interview on 5/19/22 at 1:43 P.M., with the infection control nurse and the NP, the NP said she hadn't seen the wound since 5/5/22 because she was told last week it was getting better and didn't need to see it. She said another practitioner must have given the order for the ABD pad which was started on 5/11/22. She said that the last time she saw the wound there was no odor and while the size of the wound had improved, the odor wasn't there before. She said she wasn't notified personally of the wound drainage and odor but maybe a colleague was. The infection control nurse said that she spoke with the physician to get the order for the ABD pad. She said that at that point she told him about the deterioration of the wound and he didn't want to order anything. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/19/22 at 1:51 P.M. with the NP and the infection control nurse, the NP said she wasn't updated on 5/11/22 and didn't give the treatment order. The infection control nurse said she must have made an error when she entered it and instead of using the physician's name she used the NP's name. The surveyor asked for evidence that someone had been updated about the status of the wound on that day. The infection control nurse referenced the progress note she entered on 5/11/22 and said there was nothing there to say who she spoke with to obtain the new treatment order or that anyone was updated about the wound drainage and foul odor. The infection control nurse said she thought the wound looked better (on 5/19/22). When the surveyor asked why the NP would be ordering an x-ray and antibiotic if the wound had in fact improved, she had no response. During an interview on 5/20/22 at 7:44 A.M., the physician said he was aware that the infection control nurse wanted to change the treatment to something more absorbent. He said he was not told that there was heavy drainage, only that the dressing was keeping the wound too saturated. He said he didn't remember the last time he saw the resident, but that the NP sees him/her regularly. He said if he had been told there was purulent drainage or increased drainage he would have gone to see the wound himself because those are signs of an infection and would have needed an intervention. He said that it was his understanding there was a problem with the dressing and not the wound itself.

Based on records reviewed and interviews, for one of 3 sampled residents (Resident #1), the facility failed to ensure that Resident #1 was free from physical restraint. During the 11:00 P.M. to 7:00 A.M. shift from 03/30/17 to 03/31/17, Certified Nurse Aide (CNA) #1 and CNA #2 manually restrained Resident #1 on multiple occasions to prevent him/her from walking down the Facility's West wing, that CNA #2 allegedly attempted to remove Resident #1 from a room by pulling on his/her arms, and that Nurse #1 allegedly was aware of at least some of CNA #1's and CNA #2's actions, but did not intervene to protect Resident #1. Nurse #1 also used the medication cart to block Resident #1's access of the Facility's West wing, and was observed pointing and waving her finger in Resident #1's face. Findings include: The Abuse policy, effective 11/28/16, indicated that all employees would be provided with written documentation and an educational program regarding abuse prohibition practices. The policy indicated that the programs would contain information including the appropriate methods to deal with aggressive residents or harmful reactions of residents. The policy indicated that any resident who became assaultive toward other residents or staff members would be placed on a one to one monitoring until the aggressive behaviors subsided; and, the supervision should be documented. The Restraints policy, dated 01/01/14, did not address the use of manual restraint of residents by staff members. Resident #1 was admitted to the Facility in April 2016 with [DIAGNOSES REDACTED]. Resident #1's clinical record indicated that he/she had been moved from a room on one unit, to a room on the other unit on 03/30/17, the date the alleged incidents began. The Surveyor interviewed the Human Resources (HR) Manager at 9:54 A.M. on 04/19/17. The HR Manager said there were multiple video cameras throughout the interior and exterior of the Facility. The HR Manager said that on 03/31/17, she reviewed recordings from the previous night (03/30/17 into 03/31/17) based on Nurse #1's report of a resident fall and behavior issues with another resident. The HR Manager said that while reviewing the footage, she observed CNA #1 manually restraining Resident #1, and immediately notified the Director of Nurses (DON). The Surveyor and the HR Manager reviewed the recorded footage from 5 of the Facility's video cameras, from the night of 03/30/17 into 03/31/17. The HR Manager said the time stamp on the footage was approximately 45 minutes behind; all documented footage times were as noted on the recordings and in military time for consistency purposes. Observations from the footage included, but were not limited to: - At approximately 23:06 on 03/30/17, Nurse #1 moved the medication cart to block access to the West wing. Resident #1 approached the cart and attempted to get by, but Nurse #1 did not move the cart, and appeared to use her body to prevent Resident #1 from moving the cart. Resident #1 became increasingly agitated, as evidenced by jerking movements of his/her head and arms and walker, and an attempt to hit CNA #1 with his/her walker. - At approximately 23:14, Resident #1 and CNA #1 walked down the West wing hallway. Nurse #1 pushed the medication cart at Resident #1 and CNA #1, blocking further access to the hallway. Resident #1 again became agitated, as evidenced by jerking movements of his/her head and arms and walker, and attempts to squeeze between the cart and the wall to get around the cart. CNA #1 then grabbed Resident #1 by the arms, and Resident #1 and CNA #1 begin to struggle. During the struggle, multiple items were knocked off of the cart and Resident #1 lost his/her left slipper sock. CNA #1 grabbed Resident #1's arms from behind and then wrapped her arms around Resident #1, under the armpits and around the chest. CNA #1 then physically forced Resident #1 in the opposite direction of the cart, towards the dining area; Resident #1 struggled with CNA #1, in what appeared to be an attempt to get free. - At approximately 23:21, Resident #1 was seen walking back towards West wing. CNA #1 wrapped an arm around Resident #1 from the front. Resident #1 appeared agitated, as evidenced by jerking movements of his/her head and arms, and he/she and CNA #1 appeared to exchange words. CNA #1 then grabbed Resident #1's arms, let go, and attempted to use her body to block Resident #1's path. CNA #1 grabbed Resident #1 again, and Resident #1 slapped at CNA #1 and attempted to move away from her. CNA #1 grabbed Resident #1 under the armpits and around the chest from behind, and physically forced Resident #1 into the dining room. Resident #1 appeared visibly upset. - At approximately 23:26, Resident #1 exited the dining room and approached Nurse #1. Nurse #1 was observed jabbing and waving her finger in Resident #1's face, while CNA #1 clenched the back of Resident #1's clothing in her fist. Nurse #1 and CNA #1 appeared to both grab Resident #1, Nurse #1 with one hand and CNA #1 with both hands. CNA #1 again grabbed Resident #1 under the armpits and around the chest from behind, and physically forced Resident #1 in the opposite direction while his/her feet slid along the floor. CNA #1 was then observed physically carrying Resident #1, as evidenced by Resident #1's bent legs and his/her feet not touching the floor, approximately 20 feet around the nurses' station while Nurse #1 walked behind them; this observation was confirmed with the HR Manager. - At approximately 01:28 on 03/31/17, CNA #2 appeared to be talking to Resident #1, who became physically agitated, as evidenced by jerking movements of his/her walker, slamming the walker down on the floor, and throwing the walker. CNA #2 grabbed Resident #1's arms and they appear to struggle before CNA #2 put her arms around Resident #1 from behind. Resident #1 grabbed the hallway handrail and appeared to struggle to get free from CNA #2, as evidenced by what appeared to be attempts to pry CNA #2's hands off of him/her. Nurse #1 arrived while CNA #2 and Resident #1 were struggling, uprighted Resident #1's walker, and then pulled up a wheelchair, and Resident #1 was seated in it by CNA #2. - At approximately 01:31, Nurse #1 was observed leaning close to Resident #1's face while Resident #1 was seated in the wheelchair, in the hallway. Resident #1 kicked his/her feet out, tapped his/her feet, and waved his/her right arm in an angry manner, as evidenced by a clenched fist and quick, jerking movements of his/her arm. Nurse #1 continued to speak with Resident #1, who continued to appear agitated, as evidenced by slapping his/her hands down on his/her own legs. CNA #1 attempted to wheel Resident #1 away, and Resident #1 grabbed the hallway handrail with both hands and would not let go. Resident #1 then forcibly pushed himself/herself out of the wheelchair, which rolled rapidly back into the hallway wall. CNA #1 gave Resident #1 a walker, and attempted to physically block Resident #1's attempt to walk down the West wing by stepping in front of him/her. Resident #1 became agitated, jerking his/her walker back and forth, and moving his/her head in quick, jerking motions. CNA #1 grabbed Resident #1's walker, but then let go. As Resident #1 began to walk forward, CNA #1 stepped in front of him/her repeatedly. - At approximately 01:39, Resident #1 had entered a resident room, but his/her left arm and leg, and part of his/her body were visible. CNA #2 grabbed Resident #1's left arm with two hands, and appeared to be pulling on Resident #1's arm in an attempt to remove Resident #1 from the room. Resident #1 appeared to be puling backward, in response to CNA #2 pulling on his/her arm. CNA #2 let go of Resident #1's arm, and he/she remained in the room. The Surveyor interviewed CNA #1 at 11:55 A.M. on 05/01/17. CNA #1 said that when she arrived at the start of her 11:00 P.M. to 7:00 A.M. shift on 03/30/17, Nurse #1 told her and CNA #2 that the nurse on the prior shift reported that Resident #1 was not allowed to go down onto the West wing because he/she had threatened Resident #3 three times. CNA #1 said Resident #1's room had been changed from a room on the West wing, to one on the south wing, but would not stay in the room. CNA #1 said Resident #1 said he/she wanted to go see Resident #3. CNA #1 said that at one point, Resident #1 became extremely agitated, was banging his/her walker on the ground and threw a cup of juice. CNA #1 said she wrapped her arms around Resident #1's torso area, to move him/her away from the area so he/she would not hurt himself/herself. CNA #1 said Resident #1 also attempted to throw himself/herself on the floor, and so she lifted Resident #1 up and carried him/her to his/her room. CNA #1 said she had not been trained by the Facility to use the physical holds she used on Resident #1, and was not trained to pick residents up and carry them like she did to Resident #1. CNA #1 said she was trained to lower residents to the floor if they were falling. CNA #1 said she had not dealt with a situation before like what occurred with Resident #1. CNA #1 said Nurse #1 was present during both incidents and did not assist her in any way, even when CNA #1 yelled to her for help with Resident #1 or when she picked Resident #1 up. CNA #1 said Nurse #1 did not tell CNA #1 to stop holding Resident #1, or to put Resident #1 down after CNA #1 picked him/her up. CNA #1 said she did not know if Nurse #1 medicated Resident #1 to calm him/her, or if she notified anyone of Resident #1's behaviors. The Surveyor interviewed Nurse #1 at 12:06 P.M. on 05/08/17. Nurse #1 said she received report from the out-going nurse that Resident #1 was really irate, not his/her normal self, that he/she had threatened another resident. Nurse #1 said Resident #1 was normally calm and could usually be redirected, but could not be redirected that night. Nurse #1 said she was aware CNA #1 picked Resident #1 up so that his/her feet were not physically touching the floor, and said CNA #1 did it to keep Resident #1 from falling after he/she lost his/her balance. Nurse #1 said she did not know if CNAs were trained to pick residents up in that manner. Nurse #1 said she did not intervene as she did not feel that CNA #1 acted inappropriately. Nurse #1 said she did not attempt to medicate Resident #1 to calm him/her, and did not notify anyone of Resident #1's behaviors. Nurse #1 said she was not aware of any interactions between CNA #2 and Resident #1, but said that she did not feel that any staff acted inappropriately that night. The Surveyor interviewed CNA #2 at 9:28 A.M. on 05/11/17. CNA #2 said that when she arrived to work on 03/30/17, she was told not to let Resident #1 go into his/her old room on the West wing, that he/she was moved to a new room after striking and threatening Resident #3. CNA #2 said that as she walked to another resident's room after assisting CNA #1 with Resident #2, she saw Resident #1 walking towards the West wing. CNA #2 said she attempted to verbally redirect Resident #1, but Resident #1 became angry and threw his/her walker. CNA #2 said Resident #1 began to fall backward, so she grabbed Resident #1 from behind and yelled for assistance. CNA #2 said Nurse #1 arrived with a wheelchair, and she seated Resident #1 in the wheelchair. CNA #2 said neither she nor CNA #1 physically removed Resident #1 from any room. CNA #2 said she did not recall ever grabbing Resident #1's arms, and/or attempting to pull Resident #1 out of a room. CNA #2 said she was told that video camera footage showed her doing that, but she was not given the opportunity to view the footage and so could not comment. CNA #2 said Resident #1's behavior that night was not unusual, that Resident #1 had a known history of assaultive and threatening behavior. CNA #2 said she was not trained by the Facility to manually restrain residents, that staff was told manually restraining residents constituted abuse. CNA #2 said she did not manually restrain Resident #1, she tried to prevent Resident #1 from falling. The Surveyor interviewed the Director of Nurses (DON) at 1:55 P.M. on 04/19/17. The DON said Facility CNAs were not trained to manually restrain a resident for any reason. The DON said that the holds performed by CNA #1 and CNA #2 observed in the video camera footage were not acceptable Facility practice. The DON said CNAs were trained to lower residents to the floor in the event a resident began to fall, not hold them or pick them up. The DON said Nurse #1 should have stopped CNA #1 and CNA #2's interactions with Resident #1, notified someone such as the physician, a supervisor, or herself, of Resident #1's behaviors, and transferred Resident #1 to the hospital if necessary.

Based on records reviewed and interviews, for one of 3 sampled residents (Resident #2), the facility failed to ensure that the services provided by Nurse #1 were in accordance with Facility policy and acceptable standards of practice. Sometime after 2:00 A.M. on 03/31/17, Certified Nurse Aide (CNA) #1 notified Nurse #1 that Resident #2 had an unwitnessed fall. Nurse #1 documented that she completed neurological assessments on Resident #2 after his/her fall in accordance with facility policy, but admitted that she did not complete the neurological assessments. Nurse #1 also documented that she conducted safety checks on Resident #2 every 15 minutes from after the fall until the end of her shift, which was inconsistent with video camera footage showing Nurse #1 seated in an area not in the sightline of Resident #2 or his/her room, for more than 2 hours. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility's Neurological Checks policy, dated 01/01/14, indicated that neurological signs would be checked and documented by the licensed staff as indicated, on the Neuro Nursing Assessment Sheet; checks would be implemented and documented for all residents sustaining a head injury, unwitnessed fall or a change of consciousness; checks would include: the resident's level of consciousness/orientation, bilateral (both sides) pupil reaction, bilateral hand grasps, behavioral changes, nausea/vomiting, and the taking of blood pressure, pulse and respiration; and, checks would be completed every 15 minutes for the first one hour, every hour for the next 4 hours, every shift for the remaining 24 hours, and longer if the resident remained unstable. The Accident/Incident Report and Investigation Form, dated 03/31/17 and signed by Nurse #1, indicated that Resident #2 fell in his/her room at approximately 2:15 A.M. on 03/31/17. The form indicated that Resident #2 was found seated on the floor next to his/her bed, and that the fall was unwitnessed. The Neurological Assessment form, dated 03/31/17, indicated that during the 11:00 P.M. to 7:00 A.M. shift, assessments were completed at 2:15 A.M., 2:30 A.M., 2:45 A.M., 3:00 A.M., 4:00 A.M., 5 A.M., and 6:00 A.M. The initials for those assessments were illegible. The Frequent Check Sheet, dated 03/31/17, indicated that Resident #2 was checked on the 11:00 P.M. to 7:00 A.M. every 15 minutes from 2:30 A.M. until 6:45 A.M. by a person with initials matching those of Nurse #1. The Nursing Progress Note, dated 03/31/17 and signed by Nurse #1, indicated that Resident #2 was found sitting on the floor with his/her back against the bed. The note indicated that neurological checks were started. The Facility's internal investigation into an incident involving Resident #1 indicated that Resident #2 fell on the same shift, 11:00 P.M. on 03/30/17 to 7:00 A.M. on 03/31/17. The investigation indicated that after Resident #2's fall, Nurse #1 documented she conducted neurological assessments on Resident #2. The investigation indicated that Nurse #1 told the Director of Nurses (DON) that she only did neurological assessments for the first hour, and then asked CNA #1 to do the neurological assessments. The investigation indicated that CNA #1 told the DON that she checked Resident #2's vital signs evert 15 minutes, but did not do neurological assessments. The Surveyor and the HR Manager reviewed the recorded footage from 5 of the Facility's video cameras, from the night of 03/30/17 into 03/31/17. The HR Manager said the time stamp on the footage was approximately 45 minutes behind; all documented footage times were as noted on the recordings and in military time for consistency purposes. Observations from the footage included, but were not limited to: - At approximately 01:25 A.M. on 03/31/17, Nurse #1, CNA #1 and CNA #2 entered what was identified as Resident #2's room. - At approximately 01:29, Nurse #1 exited Resident #2's room. - At approximately 01:40, Nurse #1 re-entered Resident #2's room. - At approximately 01:44 A.M., Nurse #1 again exited Resident #2's room. - At approximately 01:52 A.M., Nurse #1 pushed a rolling over-the-bed table and a chair down the hallway of the West wing. Nurse #1 stopped approximately halfway down the hallway and sat down in the chair. - At approximately 03:10 A.M., Nurse #1 got out of the chair and entered a room further down the hallway on the West wing, towards an emergency exit. - At approximately 04:00 A.M., Nurse #1 exited the room she entered as noted at 03:10 A.M. The Surveyor interviewed CNA #1 at 11:55 A.M. on 05/01/17. CNA #1 said that on 03/31/17 at approximately 2:45 A.M., she heard Resident #2 yell for help. CNA #1 said she observed Resident #2 on the floor of his/her room, sitting with his/her back against the bed. CNA #1 said Nurse #1 asked her to check Resident #2's vital signs after Nurse #1 did an initial assessment. CNA #1 said she checked Resident #2's vital signs, but could not recall how many times. CNA #1 said Nurse #1 did not ask her to conduct neurological assessments on Resident #2. CNA #1 said neurological assessments were the responsibility of nurses. CNA #1 said she thought Nurse #1 did 15 minute safety checks on Resident #2, but was not sure. The Surveyor interviewed Nurse #1 at 12:06 P.M. on 05/08/17. Nurse #1 said Resident #2 was found on the floor by CNA #1, sitting with his/her back against the bed. Nurse #1 said she did an assessment prior to staff moving Resident #2, including vital signs and neurological assessment. Nurse #1 said that after an unwitnessed fall, she was supposed to check the resident's vital signs every 15 minutes for one hour, then every 30 minutes for 2 hours, then every hour, but was not sure of the timing and duration of the checks. Nurse #1 said she checked Resident #2's vital signs every 15 minutes for one hour, then every 30 minutes for one hour. Nurse #1 said she had to perform resident treatments, and so asked CNA #1 to perform the other vital signs checks. Nurse #1 said she did not know if Facility policy allowed for CNAs to check residents' vital signs following a fall. Nurse #1 said she signed all of the documentation for Resident #2's vital sign checks and other checks, but did not perform all of the checks she signed for. The Surveyor interviewed the DON at 1:55 P.M. on 04/19/17. The DON said that on 03/31/17 after Resident #2's unwitnessed fall, Nurse #1 documented that she conducted neurological assessments every 15 minutes for an hour and then every hour for 4 hours, but was observed on video camera footage to only enter Resident #2's room on 2 occasions within 20 minutes of his/her fall. The DON said that at no time between approximately 01:45 A.M and 04:04 A.M. (as timestamped on the video camera footage), did Nurse #1 leave the West wing, and so could not have done any safety checks or neurological assessments on Resident #2 as he/she resided in another area of the Facility. The DON said that when she interviewed Nurse #1, Nurse #1 told her that CNA #1 was a nursing student and so she asked CNA #1 to do the neurological assessments. The DON said Facility CNAs were not approved to perform neurological assessments on the residents for any reason, whether the CNA was a nursing student or not, because neurological assessments were to be conducted by nurses only. The DON said it also was not Facility practice to allow the CNAs to check residents' vital signs. The DON said Nurse #1 documented and said she conducted the neurological assessments on Resident #2 after his/her unwitnessed fall. The DON said Nurse #1 also documented that she performed 15 minute safety checks on Resident #2 after his/her fall. The DON said that on video camera footage, Nurse #1 was seen sitting outside of a room on the West wing for hours. The DON said that where Nurse #1 sat would make it impossible for her to visualize Resident #2 in his/her room, as his/her room was in another area of the Facility. The DON said that when she asked Nurse #1 about the documented 15 minute checks, Nurse #1 told her that she knew Resident #2 was stable anyway, or words to that effect. Observations by the Surveyor on the date of survey indicated that Nurse #1 could not have visualized Resident #2's room from where she was recorded sitting in the early morning of 03/31/17 due to the physical layout of the Facility. There was no documentation at the time of survey that Nurse #1 conducted neurological assessments of Resident #2 after an unwitnessed fall, in accordance with Facility policy; or, that Nurse #1 accurately documented when or if neurological assessments and 15 minute safety checks were conducted, and by whom. Nurse #1 was observed sitting in an area of the Facility that would put her visually and physically inaccessible to Resident #2, for more than 2 hours, during which she documented the completion of neurological assessments and 15 minute safety checks. On 04/19/17, the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A. Nurse #1, CNA #1 and CNA #2 were no longer involved in resident care at the Facility. B. All staff re-education on the Facility's Abuse policy was completed by 04/03/17 by the DON and/or Facility educator. C. Nursing staff re-education on the Facility's Falls Prevention policy was completed by 04/03/17 by the DON and/or Facility educator. D. Nursing staff re-education on the Facility's Neurological Checks policy was completed by 04/03/17 by the DON and/or Facility educator. E. Video camera footage is to be randomly reviewed by the DON, HR manager, or Maintenance Director for any further incidents. F. The incident had not yet been reviewed by the QAPI committee, but had been reviewed by administrative staff, including the Administrator. G. The DON said she was responsible for ensuring compliance.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 3 of 8 applicable residents (#1, #11, and #12) out of a total sample of 13 residents. Findings include: 1. For Resident #1, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program for the resident. The facility also failed to follow the resident's plan of care relative to assuring the resident's bed alarm was properly connected on 8/8/13 when the resident got out of the bed, fell and sustained a fracture. Resident #1 was admitted to the facility in 4/2013 with [DIAGNOSES REDACTED]. Review of a Nursing Note of 4/27/13, indicated that at 6:45 A.M., the resident slid self out of bed. Review of the investigation indicated the resident was unable to state what happened and the fall was unwitnessed. The resident was found on the floor at the bedside (the investigation did not include from which side of the bed the resident was found). The resident had a bed alarm on the bed which sounded and alerted the staff. The cause was determined to be that the resident was confused, and attempted to self transfer from the bed. Interventions included to keep the bed in a low position, and to place bolsters at the end of the bed. Review of the Initial MDS (Minimum Data Set) assessment dated [DATE], indicated the resident had minimal difficulty hearing; unclear speech; was sometimes understood; could sometimes understand others (simple, direct communication only); had severely impaired cognition as evidenced by the BIMS (Brief Interview for Mental Status) score of 4; had difficulty focusing attention; little interest or pleasure in doing things; down and depressed; poor appetite, trouble concentrating, and rejected care. The resident required extensive assistance of two for bed mobility; transfers; toilet use; did not ambulate; and was totally dependent with assist of one for locomotion on and off the unit in the wheelchair. The resident was always incontinent of bladder; frequently incontinent of bowel; had a fall in the last month prior to admission to the facility; had a fall in the last 2 - 6 months prior to admission to the facility; had a fracture related to a fall in the 6 months prior to admission to the facility; had 1 fall with no injury since admission to the facility, and received antipsychotic medication. The plan of care for the resident being at risk for falls/injury recent decline in status with progression of dementia incorrectly dated (4/30/30), included the following interventions: - Fall Risk Assessment on admission, quarterly and with change in status, - Monitor resident physical environment - well lit and free of clutter, - Report to Physician any noted side effects and adverse reactions to medications, - Anticipate needs, redirect to promote safety and decrease restlessness, - Check skin daily for new areas of bruising and report, - Monitor lab work, - Monitor behavior, - Keep nails trimmed, - Use simple one step direction, - Assist of 2 for transfers and toileting with walker and gait belt, - Pressure alarm in bed and chair, and - Bed bolsters Review of a Nursing note of 5/4/13 indicated that at 1:26 P.M., the resident was found on the floor beside the chair on his/her left side. The resident complained of back pain and sustained a 4.4 x 5 cm (centimeter) bruise on the right elbow. Review of the investigation revealed the resident was in the day/dining room, and had been eating and sitting and standing consistently from the chair prior to the fall. The investigation further indicated that the chair alarm sounded, but very faintly. A statement obtained by an Activity Aide present in the day/dining room, who did not witness the fall, indicated that she did not hear the alarm because it was very noisy in the dining room. A statement obtained on 5/14/13 from a CNA (Certified Nursing Assistant) present in the day/dining room also did not witness the fall but stated, "Alarm was so faint so you could not hear it going off, with all the talking and loud noise in the dayroom." The CNA replaced the alarm box after the fall. A Quarterly MDS assessment dated [DATE], indicated the resident had difficulty focusing attention; little interest or pleasure in doing things; trouble concentrating, and rejected care. The resident required extensive assistance of two for locomotion off unit; bed mobility; transfers; toilet use; walking in corridor; did not ambulate in room; was totally dependent with assist of 2 for locomotion on the unit; utilized a wheelchair and walker; failed to identify that the resident had a fall with injury (except major) in Section J1800, and J1900B (on 5/4/13); and received antidepressant medication. On 8/14/13 the plan of care for falls was modified indicating: - Assist of 1 for transfers and toileting with walker and gait belt Review of a Nursing Note of 8/18/13 indicated the resident was found lying on his/her right side on the floor. The resident complained of right hip and right leg pain and was unable to move the right leg. The resident was transported to the hospital for evaluation which revealed a right hip fracture. Review of the investigation indicated the unwitnessed fall occurred at approximately 1:35 P.M. Review of the investigation indicated the resident had gotten out of bed unassisted, did not utilize his/her walker (was an assist 1 for transfers and toileting with walker and gait belt), and that the bed alarm did not sound. Review of an "Employee Witness Statement for Falls Involving Malfunctioning Alarms" form dated 8/18/13, completed by a Licensed Nurse, indicated the alarm did not sound, "not connected properly." On 8/22/13, the facility had an in-service training on the proper use of safety alarms. The resident returned to the facility at 3:10 P.M. (on 8/22/13) with multiple bruises on his/her hands and arms, and a right elbow skin tear. The resident had surgical repair of the right hip fracture with a right leg incision 2.5 cm requiring 5 staples for closure, and a right hip incision 13 cm requiring 18 staples for closure, and a right lower leg incision 2 cm requiring 3 staples for closure. The bruise on the right hip measured 16 cm x 4 cm. The resident's plan of care for falls was updated on 8/22/13 to include the following: - Motion Sensor, - Air mattress - check function every shift, - Walker at bedside, - Assist of 2 WBAT (weight bearing as tolerated) with rolling walker and gait belt, and - Frequent checks. Review of a Nursing Note of 8/23/13, indicated a new order was obtained for the pain relieving medication Oxycodone. Review of the Significant Change in Status MDS Assessment completed on 8/29/13 following the resident's fractured right hip, identified the resident had moderate difficulty with hearing; severely impaired cognition and now scored 2 on the BIMS; felt down, depressed, and hopeless; rejected care; no longer ambulated in the corridor; required total dependence of one assist for locomotion in the room with the wheelchair; had functional limitation in range of motion on one side (lower extremity); was on a scheduled pain medication regimen; received prn (as needed) pain medications; had indicators of pain daily; had a fall in the last month; had a fall in the last 2 - 6 months, had a fracture related to a fall in the 6 months prior to admission/entry or reentry; received antidepressant medications, and received Occupational and Physical Therapy skilled services. Review of the "CNA Care Card" last updated on 9/11/13, indicated the resident was a physical assist (two person assist) for transfers and ambulation with the walker and gait belt. The resident also utilized safety alarms in the bed and wheelchair, and sat in a lower chair in the dining room with a seat cushion, Dycem (non skid material) and lumbar support. On 9/18/13 at 10:45 A.M., the surveyor observed the resident being ambulated by a Physical Therapy Assistant in the hallway on the unit with the walker and a gait belt. On 9/19/13 at 2:20 P.M., the surveyor observed the resident lying in the bed with the body pillow on the right side of the bed, and the left half side rail up. During interview on 9/19/13 at 2:25 P.M., CNA #1 said the resident was ambulated with the CNA's to and from destinations with 2 assists, "She/he frequently tries to get up so we have to watch her/him. She/he is a fall risk." On 9/23/13 at 8:30 A.M., the surveyor observed the resident in the unit dining/day room waiting for his/her breakfast. The resident was sitting in a straight back chair with a pressure pad alarm. On 9/23/13 at 10:45 A.M., the surveyor observed the resident in the unit dining/day room sitting in a straight back chair with a pressure pad alarm. The resident stood up from the chair 3 times between 10:45 A.M. and 10:48 A.M. The alarm sounded each time, and an activity aide ran to the resident and sat the resident back down in the chair. During interview on 9/23/13 at 11:00 A.M., CNA #3 said that it was the resident's usual behavior to stand up from the chair frequently and set the alarm off. "Usually I will try to toilet the resident if (he/she) keeps trying to get up." On 9/23/13 at 3:25 P.M., the surveyor observed the resident lying in bed on his/her back looking around the room. The body pillow was to the right side of the resident with a wedge cushion, left half side rail up, pressure alarm on, and sensor alarm on. During discussion on 9/23/13 at 3:30 P.M., the Director of Nursing said that the investigation regarding the fall and the fracture of 8/18/13 was difficult to determine. The CNA insisted she connected the resident's alarm, despite investigation by the charge nurse following the incident concluding that the alarm was not connected properly. 2. For Resident #11, the facility failed to provide individualized interventions and adequate supervision to prevent falls in order to provide an effective falls program for the resident. The facility also failed to follow the resident's plan of care relative to assuring the resident was wearing proper footwear. Resident #11 was admitted to the facility in 10/2012 with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE], indicated the resident scored (10), "Total score of 10 or above represents HIGH RISK." Review of the Quarterly MDS assessment dated [DATE], indicated the resident had moderately impaired cognition as evidenced by the BIMS score of 12; felt down, depressed, and hopeless and was over eating; was independent with ADL'S (Activities of Daily Living) with the exception of requiring extensive assistance of one person physical assist for dressing, personal hygiene, and bathing; had no falls; had a significant weight gain (not a Physician prescribed regimen), and was receiving antianxiety and antidepressant medications. Review of the current plan of care for falls/injury for status [REDACTED]. - Fall Assessment on admission, quarterly, with changes in status, and after fall, - Monitor resident physical environment - well lit and free of clutter, - Report to Physician any noted side effects and adverse reactions to medication, - Anticipate needs, redirect to promote safety and decrease restlessness, - Monitor behavior, - Psychiatric services as needed, - Keep nails trimmed, - Use simple one step directions, - Offer pain medication if restless, - Offer snack if restless, and - Call light in reach. Review of the Nursing Progress Note of 7/24/13 at 10:30 A.M., indicated that when the resident attempted to sit down in a recliner in the hallway, the recliner moved back causing the resident to fall, landing on his/her buttocks. New interventions included to keep gerichairs out of the hallways and staff spoke with the resident to remind her/him not to sit in the chairs in the hallway, encourage to sit in dayroom. A "Rehabilitation Screening Request" was submitted, and on 7/24/13 recommendations of the screen indicated, "Reviewed safety with resident. New slipper socks non-skid provided. Encourage wearing sneakers when possible." Review of a Nursing Progress Note of 7/24/13, indicated that at 7:30 P.M., the resident's roommate notified the nurse the resident was on the floor in the bedroom. Upon entering the room the resident was kneeling on the floor leaning on the roommates bed. The resident stated that when trying to get up out of bed his/her legs would not stand and he/she fell forward onto the floor on knees. New interventions included a bed alarm and 1 assist with ambulation and transfers. Review of a Fall Risk assessment dated [DATE], indicated the resident scored (12), "Total score of 10 or above represents HIGH RISK." On 8/2/13, a "Rehabilitation Screening Follow Up", completed by Physical Therapy (PT) indicated the resident: ambulated 40 feet with a cane and continual supervision/contact guard; was unsteady on feet with decreased bilateral lower extremity strength, and decreased standing balance. Recommendations for Trial care and PT to screen. A PT evaluation was performed. The bed alarm pad was discontinued on 8/3/13. Review of a Nursing Progress Note of 8/31/13 indicated the resident reported to the nurse that he/she had rolled out of the bed onto the floor when reaching for a piece of paper on the floor. The resident denied hitting head, but was complaining of back pain. Tylenol was administered. The resident did not know the exact time the incident occurred, but stated it was in the middle of the night, and that he/she got self up off the floor. New interventions included to keep the resident's cane within reach, and to provide the resident with a reacher. The resident was still working with Physical Therapy at this time for strengthening. Review of a Nursing Progress Note of 9/7/13 indicated the resident fell at 8:05 A.M., trying to get out of bed. The resident sustained [REDACTED]. Review of the investigation revealed that upon assessment of the resident's footwear, the nurse indicated the resident's footwear had no grips on the bottom of the shoes, and that the bottoms of the shoes were completely frayed. The note also indicated there was a thick layer of soft dust covering the bottom of the shoes. The shoes were removed from resident's room, slipper socks applied, and alarms placed. During discussion on 9/23/13 at 11:00 A.M., the Acting Unit Manager (UM) said she was not sure if the resident's cane was by the bed prior to the fall of 9/7/13. This intervention was put into place after the 8/31/13 fall, and it was not investigated after this fall. The UM also said she was unaware the resident had shoes like the ones described in the investigation, despite rehab (rehabilitation) recommendations following the (7/24/13) fall, to utilize non-skid socks (provided for the resident), and to encourage sneakers when possible. The plan of care for falls indicated that new shoes were requested from the resident's family member on 9/7/13. New interventions also included non-skid strips to the door side of the bed, one half siderail to the door side of the bed, bed pressure alarm (per rehab screen), one assist transfer/ambulation, and again to keep the cane next to the bed. Review of a Fall Risk assessment dated [DATE], indicated the resident scored (15), "Total score of 10 or above represents HIGH RISK." On 9/11/13, a trial walker was added to the plan of care for falls. Review of a Nursing Progress Note incorrectly dated 9/18/13, (investigation report and therapy screening requests should have been dated 9/19/13), indicated that on 9/19/13 at 5:45 A.M., the resident was found on the floor on the right side of the bed. The bed alarm did not sound. The resident was sitting against the bed with his/her back against the bed. (Pressure alarm had slid down between the resident's back and the bed (ineffective intervention).The resident stated that he/she was trying to stand up, slipped and lowered self to the floor. No injuries were noted from the fall. The nurse observed the resident was wearing regular socks at the time of the fall, and not non-skid slipper socks as planned. Review of a Fall Risk assessment dated [DATE], indicated the resident scored (18), "Total score of 10 or above represents HIGH RISK." The surveyor observed the resident on 9/23/13 at 8:20 A.M. sitting in the family room eating breakfast sitting in a straight back chair with a pressure pad alarm in the chair. The resident stood up from the chair and the alarm sounded. Staff were alerted and approached the resident who requested to go back to bed. During interview on 9/23/13 at 10:30 A.M., CNA #2 said the resident seemed more confused lately, and has been falling more frequently. CNA #2 also said the resident did not like the alarms, and when he/she wanted to get up and do something, the resident would ask the roommate to come and sit on the bed alarm, to prevent the alarm from sounding. On 9/23/13 at 10:45 A.M., the surveyor observed the resident being assisted out of the bathroom ambulating with a walker and the assist of a CNA. The resident had slipper socks on. Three non-skid strips were observed on the door side of the bed. The bed pad alarm was applied to the bed and connected by CNA #3. During an interview on 9/23/13 at 10:50 A.M., CNA #3 said the resident just started falling. I think he/she watches the roommate walk around and wants to do the same. Sometimes when coming out of the bathroom he/she will park the walker on the window side of the bed and try to walk all the way around the bed without it. We have to remind him/her not to do that, and to use it all the way around the bed. On 9/23/13 at 3:20 P.M., the resident was observed in the Unit Dining/Day room playing Bingo. The walker was to the left of the straight back chair. During discussion with the Acting Unit Manager on 9/23/13 at 11:00 A.M., and the Director of Nursing at 11:45 A.M., (after review of the documentation of the 9/7/13 and 9/18/13 falls), the Director of Nursing said the care plan was not being followed regarding appropriate foot wear for the resident. 3. For Resident #12, the facility failed to provide adequate supervision and devices to prevent 4 unwitnessed falls from 6/27/13 to 9/10/13. Resident #12 was admitted to the Facility in 3/2012, and readmitted after a hospitalization in 4/2013 with [DIAGNOSES REDACTED]. The resident's Fall Risk Assessments of 4/12/13, 6/27/13, 7/5/13, 8/4/13, 8/24/13 and 9/10/13 indicated the resident was a high risk for falls with scores of 12, 15, 21, 24, 24, and 23 respectively (10 or above indicates high risk for falls.) The Care Plan for the resident to be free of significant injury/falls due to a recent decline in status, status [REDACTED]. - Fall Risk Assessment upon admission, quarterly and with change of status, - Monitor resident's physical environment - well lit and free of clutter, - Report to Physician any noted side effects and adverse reactions to medication, - Anticipate needs, redirect to promote safety and decrease restlessness, monitor behavior, - Use simple one step direction, - Assist of 1 for transfers, ambulation and toileting, - Pressure alarm on bed and chair. The resident's Significant Change MDS Assessment of 4/24/13 for decline in status indicated the resident had scored 5 out of 15 on the BIMS (severely impaired cognitively), had no communication issues, felt tired and had trouble concentrating on things, refused care at times, required limited assist of one for transfers, ambulation, and toilet use, extensive assist for dressing, hygiene and bathing, was continent of bowel and bladder, had no falls, was administered daily antidepressants and antianxiety medication, received oxygen and intravenous administration. Nursing Notes and the Incident Report of 6/27/13 at 12:40 A.M., indicated the nurse heard a loud sound in the dining room and found the resident supine on the floor with complaints of a headache and back pain. X-rays were ordered with negative findings. The resident was placed on the pain relieving medication Ultram. The investigation indicated that staff left the resident alone in the dining room, and had not followed the care plan to anticipate the resident's needs, promote safety and assistance when the resident attempted to self transfer. There was no mention of the chair alarm being in place at the time of the fall. Staff were inserviced to provide supervision when the resident was restless in the late evenings. The Care Plan was updated on 7/15/13 to include: - Assist of 1 for transfers, ambulation and toileting with gait belt/RW (Rolling Walker), - Call light in reach, - Ensure proper footwear, - Pressure alarm in bed (only), - When out of bed needs to be in supervised area, - RW kept at bedside. The resident's Significant Change MDS Assessment of 7/18/13 for further decline in status indicated the resident rarely made self understood, sometimes understood others, had short and long term memory problems, was moderately impaired cognitively, had altered level of consciousness, refused care, required extensive assist of one for transfers, ambulation, and toilet use, limited assist for eating, was frequently incontinent of bladder, and had one fall since the last assessment. Nursing Notes and the Incident Report of 8/4/13 at 6:55 A.M., indicated the alarm sounded and staff found the resident on the floor on the side of the bed after attempting to self transfer to the bathroom. No injury was noted. The Care Plan was updated on 8/5/13 to place the RW at the bedside and to wake the resident to offer toileting daily at 6:30 A.M. Nursing Notes and the Incident Report of 8/24/13 at 4:00 A.M., indicated the alarm sounded and staff found the resident kneeling on the floor on the side of the bed after attempting to self transfer to the bathroom. No injury was noted. The care plan was updated on 8/27/13 to include: - Walker on bathroom side, - Frequent checks if sick, - Non-skid strips on the bathroom side (of bed), - 1/2 side rail on bathroom side, - Alarm between mid back and shoulders. Nursing Notes and the Incident Report of 9/10/13 at 4:45 A.M., indicated that staff heard a loud slap and found the resident on the dining room floor next to a chair. The resident complained of hip pain and sustained an ecchymotic area on the left side of the face. X-rays indicated no fractures. The investigation indicated that staff did not provide supervision when left alone in the dining room as planned. The Care Plan was updated on 9/10/13 to: - Keep walker at side in dining room, - Chair alarm, - Motion sensor in room, - Supervision at all times when out of bed. On 9/23/13, from 8:17 A.M. to 9:10 A.M., the surveyor observed the resident asleep in bed with the head of the bed elevated, a wall sensor alarm behind the bed, a rolling walker positioned on the corridor side of the bed rather than the bathroom side of the bed as planned, and the non-skid floor strips on the bathroom side of the bed was an ineffective intervention because the bed was over the strips. . At Surveyor inquiry at 9:15 A.M. on 9/23/13, Acting Unit Nurse Manager (AUM) went to the resident's bedroom with the surveyor. The AUM repositioned the resident in bed, however, the sensor alarm did not sound as planned. The surveyor and the AUM also observed the resident's walker placed on the wrong side of the bed, and that the non-skid floor strips were partially covered by the position of the bed over them. During interview on 9/23/13 at 11:30 A.M., the Director of Nursing said that inadequate supervision and devices (chair alarm) had not been effective to prevent unwitnessed falls in the dining room on the nighttime shift, and that other bedroom interventions had not been effectively employed this date when observed by the AUM.

Based on observation, record review, and staff interviews, the facility failed to follow the plan of care regarding fall interventions for 3 residents (#1, #11 and #12) out of a total sample of 13 residents. Findings include: 1. For Resident #1, the facility failed to follow the resident's plan of care relative to assuring the resident's alarm was sounding loud enough to be heard by staff on 5/4/13, and that the bed alarm was connected properly on 8/18/13. Resident #1 was admitted to the facility in 4/2013 with [DIAGNOSES REDACTED]. The plan of care for the resident being at risk for falls/injury recent decline in status with progression of dementia incorrectly dated (4/30/30), included the following interventions: - Assist of 2 for transfers and toileting with walker and gait belt, - Pressure alarm in bed and chair. Review of a Nursing Note of 5/4/13 indicated that at 1:26 P.M., the resident was found on the floor beside the chair on his/her left side. The resident complained of back pain and sustained a 4.4 x 5 cm. (centimeter) bruise on the right elbow. Review of the investigation revealed the resident was in the day/dining room, and had been eating, then sitting and standing consistently from the chair prior to the fall. The investigation further indicated the chair alarm sounded, but very faintly. A statement obtained by an Activity Aide present in the day/dining room, but did not witness the fall, indicated that she did not hear the alarm because it was very noisy in the dining room. A statement obtained on 5/14/13 from a CNA (Certified Nursing Assistant) present in the day/dining room, but also did not witness the fall, indicated, "Alarm was so faint so you could not hear it going off, with all the talking and loud noise in the dayroom." The CNA replaced the alarm box after the fall (ineffective intervention). On 8/14/13 the Plan of Care for Falls was modified indicating: - Assist of 1 for transfers and toileting with walker and gait belt Review of an investigation of 8/18/13 indicated the resident got out of bed unassisted at approximately 1:35 P.M., did not utilize his/her walker, and the bed alarm did not sound. The resident was found lying on his/her right side on the floor. The resident complained of right hip/leg pain and was unable to move the right leg. The resident was transported to the hospital for evaluation which revealed a right [MEDICAL CONDITION]. Further investigation by a Licensed Nurse revealed the bed alarm was not connected properly. On 9/19/13 at 2:20 P.M., the surveyor observed the resident lying in the bed with the body pillow on the right side of the bed, and the left half side rail up. During interview on 9/19/13 at 2:25 P.M., CNA #1 said the resident was ambulated with the CNA's to and from destinations with 2 assists. CNA #1 said the resident frequently tries to get up unassisted, so we have to watch her/him, and that the resident is at risk for falls. On 9/23/13 at 10:45 A.M., the surveyor observed the resident in the unit dining/day room sitting in a straight back chair with a pressure pad alarm. The resident stood up from the chair 3 times between 10:45 A.M. and 10:48 A.M. The alarm sounded each time, and an activity aide ran to the resident and sat the resident back down in the chair. During interview on 9/23/13 at 11:00 A.M., CNA #3 said that it was the resident's usual behavior to stand up from the chair frequently and set the alarm off. "Usually I will try to toilet the resident if (he/she) keeps trying to get up." During discussion on 9/23/13 at 3:30 P.M., the Director of Nursing said that the investigation regarding the fall and the fracture of 8/18/13 was difficult to determine. The CNA insisted she connected the resident's alarm, despite investigation by the Charge Nurse following the incident concluding the alarm was not connected properly. Please refer to F323. 2. For Resident #11 the facility failed to follow the resident's Plan of Care for Falls in regards to ensuring proper footwear was being worn. Resident #11 was admitted to the facility in 10/2012 with [DIAGNOSES REDACTED]. Review of the current Plan of Care for Falls/Injury for status [REDACTED]. - Fall Assessment on admission, quarterly, with changes in status, and after a fall, - Monitor resident's physical environment - well lit and free of clutter, - Report to Physician any noted side effects and adverse reactions to medication, - Anticipate needs, redirect to promote safety and decrease restlessness, - Monitor behavior, - Psychiatric services as needed, - Keep nails trimmed, - Use simple one step directions, - Offer pain medication if restless, - Offer snack if restless, and - Call light in reach. Review of a Nursing Progress Note of 7/24/13 at 10:30 A.M., indicated the resident fell on to buttocks after trying to sit on a gerichair in the hallway. Rehabilitation notes following the fall indicated that new slipper socks were given to the resident, and that the resident would be encouraged to wear sneakers when possible. Review of a Nursing Progress Note of 9/7/13, indicated the resident fell at 8:05 A.M., while trying to get out of bed. Review of the investigation revealed the resident had unsafe shoes on his/her feet, despite the intervention following the fall of 7/24/13. Upon assessment of the resident's footwear, the nurse indicated the resident's shoes had no grips on the bottom, and that the bottoms of the shoes were "completely frayed." The nurse also indicated that a thick layer of soft dust was covering the bottom of the shoes. The shoes were removed from resident's room, and non-skid slipper socks were applied. Review of a Nursing Progress Note incorrectly dated 9/18/13 (per investigation report and therapy screening requests should have been dated 9/19/13) indicated that at 5:45 A.M. on 9/19/13, the resident was found on the floor on the right side of the bed. The resident said that he/she was trying to stand up, slipped and lowered self to the floor. No injuries were noted from the fall. The nurse observed that the resident was wearing regular socks (no grips) at the time of the fall, despite the plan of care for non-skid socks or to ensure proper footwear in place. On 9/23/13 at 10:45 A.M., the surveyor observed the resident being assisted out of the bathroom ambulating with a walker and the assist of a CNA. The resident had slipper socks on. Three non-skid strips were observed to the door side of the bed. The bed pad alarm was applied to the bed and connected by CNA #3. During discussion on 9/23/13 at 11:45 A.M., the Director of Nursing said that the care plan was not followed regarding appropriate footwear for the resident during the falls of 9/7/13 and 9/18/13. Please refer to F323. 3. For Resident #12, the facility failed to follow the care plan by providing adequate supervision and devices (chair alarm, wall sensor alarm, Rolling Walker positioning, and non-skid strip availability) to prevent 4 unwitnessed falls from 6/27/13 to 9/10/13. Resident #12 was admitted to the Facility in 3/2012, and readmitted after a hospitalization in 4/2013 with [DIAGNOSES REDACTED]. The Care Plan for the resident to be free of significant injury/falls due to a recent decline in status, status [REDACTED]. - Monitor resident's physical environment-well lit and free of clutter, - Anticipate needs, redirect to promote safety and decrease restlessness, monitor behavior, - Assist of 1 for transfers, ambulation and toileting, - Pressure alarm in chair. Review of Nursing Notes and the Incident Report of 6/27/13 at 12:40 A.M., indicated the nurse heard a loud sound in the dining room and found the resident supine on the floor with complaints of a headache and back pain. X-rays were ordered with negative findings. The investigation indicated that staff had left the resident alone in the dining room and not followed the care plan to anticipate the resident's needs, promote safety and assistance when the resident attempted to self transfer. There was no mention of the chair alarm being in place at the time of the fall. Staff were inserviced to provide supervision when the resident was restless in the late evenings. The Care Plan was updated on 7/15/13 to include: - Assist of 1 for transfers, ambulation and toileting with gait belt/RW (Rolling Walker), - When out of bed needs to be in a supervised area. The Care Plan was again updated on 8/27/13 to include: - Walker on bathroom side, - Non-skid strips on the bathroom side (of bed). Review of Nursing Notes and the Incident Report of 9/10/13 at 4:45 A.M., indicated staff heard a loud slap, and found the resident on the dining room floor next to a chair. The resident complained of hip pain, and sustained an ecchymotic area on the left side of the face. X-rays indicated no fractures. The investigation indicated that staff did not provide supervision when the resident was left alone in the dining room per updated Care Plan of 7/15/13. The care plan was updated on 9/10/13 to provide a motion sensor in room. On 9/23/13, from 8:17 A.M. to 9:10 A.M., the surveyor observed the resident asleep in bed with the head of the bed elevated, wall sensor alarm behind the bed, rolling walker positioned on the corridor side of the bed rather than the bathroom side of the bed per Care Plan, and the non-skid strips on the bathroom side of the bed were ineffective because the bed was positioned over the strips. At Surveyor inquiry at 9:15 A.M. on 9/23/13, Acting Unit Nurse Manager (AUM) went to the resident's bedroom with the surveyor. The AUM repositioned the resident in bed, however, the sensor alarm did not sound as planned. The surveyor and the AUM also observed the resident's walker placed on the wrong side of the bed, and that the non-skid floor strips were partially covered by the position of the bed over them. During interview on 9/23/13 at 11:30 A.M., the Director of Nursing said that care planned supervision and devices (chair alarm) had not been effective to prevent unwitnessed falls in the dining room on the nighttime shift, and that other bedroom interventions had not been effectively employed this date, as planned, when observed by the AUM and surveyor. Please refer to F 323.

Based on record review, observation and interviews, the facility failed to ensure that 1 resident (#3) out of 6 applicable Residents with pressure sores, in a total sample of 17 Residents, did not develop avoidable heel pressure sores and prevent infection of these pressure sores. After Resident #3 sustained a [MEDICAL CONDITION] at the facility, upon readmission, Resident #3 developed facility acquired heel pressure sores (a stage 4 pressure sore, the right heel bone was visible) and an unstagable pressure sore, a full thickness tissue loss covered with dead tissue on the left heel). In addition, Resident #3 developed facility acquired [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) infections of both pressure sores of the heels. Consultations with both the Vascular and Wound Care Physicians have recommended a right above the knee amputation. Findings included: Resident #3 was admitted to the facility in 11/08. This Resident's [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. Review of an annual Minimum Data Set (MDS) assessment, dated 7/6/11, the Brief Interview for Mental Status indicated a severe cognitive impairment, and the Resident was an extensive assist of one for bed mobility, transfers, ambulation, locomotion on and off the unit, and toilet use. Under Section M 0150, the Resident is at risk for pressures. Under M 210, the Resident does not have one or more unhealed pressure ulcer(s) at Stage 1 or higher. Review of the nurse's note of 9/14/11 at 6:00 P.M., indicated the Resident had an unwitnessed fall in the Family Room while waiting for supper. The Resident complained of right hip pain and was transferred to the Community Hospital. Review of the Community Hospital Discharge Summary of 9/23/11 indicated this Resident was diagnosed with [REDACTED]. Review of the clinical record indicated this Resident was transferred back to the facility on [DATE] at 4:30 P.M. Review of the facility's policy "Skin Maintenance Program" stated, under "A. Preventing Pressure Ulcers: The most common risk factors for pressure ulcer development include: - Immobility - Less than optimal nutritional status - Exposure to friction and shearing forces - Overly moist or overly dry skin - Diminished sensory perception 1. All residents and patients are assessed upon admission for risk of developing skin breakdown. If a total of 15 or less is scored, the patient is considered at risk. 2. A written preventive plan must be developed and implemented using the following interventions: .... c. Promotion of good mobility and positioning f. Avoid injury; ...Use protective devices (i.e. elbow pad, heel protector, etc.)." Review of this Resident's Norton Plus Skin Risk Assessment on 9/23/11 indicated a score of 6, this Resident was at high risk for pressure ulcer development. Written next to the score of 6 was, "No heel bows (heel protectors) alt (altered) fall risk and at present time initial attempts to climb out of bed and anticipate ambulating status with physical therapy (foot ware)." (Physical and Occupational Therapy cannot start ambulation without an ambulation/mobility order, an ambulation/mobility order was not written for 43.5 hours). Review of the skin care plan of (7/10/11) indicated this Resident is at risk for skin impairment related to decreased cognition, incontinence, decreased mobility. The area of the care plan, that indicated the need/problem area, was updated on 9/23/11, that this Resident was readmitted with skin tears on arms and buttocks, and had a surgical site from an ORIF. Review of the preprinted skin care plan interventions for skin impairment (done prior to this Resident's [MEDICAL CONDITION]) were as follows: -The Certified Nurses Aides (CNA) were to monitor skin daily and report redness, irritation or breakdown to the nurse. - Apply barrier cream to hips, buttocks, and coccyx every shift. - Maintain activity/mobility - Pressure reducing mattress on bed (the mattress this Resident had from admission in 2008). - On 9/23/11, one intervention was added: two assist to transfer, weight bearing as tolerated and transport in the wheelchair (the physician's verbal order for mobility was not obtained until 9/25/11 at 12:00 noon) Review of the undated Admission physician's orders [REDACTED]. According to the Fundamentals of Nursing, 7th edition, under Effects of Immobility, on page 1068, stated that, "early ambulation after illness or surgery is an essential measure to prevent complications." Under Immobility, on page 857, it stated: "Immobility refers to a reduction in the amount and control of movement a person has. Normally people move when they experience discomfort due to pressure on an area of the body. Healthy people rarely exceed their tolerance to pressure. However, paralysis, extreme weakness, pain or any cause of decreased activity, can hinder a person's ability to change position independently and relieve pressure, even if the person can perceive the pressure." Review of the Nurse's Note of 9/23/11 at 8:15 P.M., indicated that this Resident arrived via stretcher, was alert and responsive, and had the abduction pillow (between the legs to keep the hip away from the midline of the body) in place. Review of the Admission/Re-admission Skin Assessment sheet of 9/23/11 at 10:15 A.M., indicated that there were three open areas: on the left inner arm, on the penis and on the right buttocks. There were no pressure sores or open areas on the heels, on the right great toe nor on the coccyx. Review of the Physician's Admission Order sheet of 9/23/11 indicated that this Resident was to have an abductor pillow between legs at all times in bed. Review of the Treatment Administration Record (TAR) from 9/23/11 to 9/29/11 indicated there were no documented treatments to off load the heels to prevent pressure ulcers. Review of the weekly skin sheet, dated 9/29/11, "no new findings." Review of the Nurse's Note of 9/24/11 at 8:00 P.M., indicated that a call was placed to the Community Hospital (where this Resident was discharged ) on the Surgical Floor to ask the weight bearing status of this Resident. The Nurse's Note stated, "They stated they would call back." Review of the physician's orders [REDACTED]. Review of the Nurse's Note of 9/25/11 at 12:30 P.M., indicated that the nurse called the Community Hospital again, regarding weight bearing status. A staff member at this Hospital stated this Resident should be weight bearing as tolerated. Review of the CNA flow sheets indicated for the skin care interventions from 9/23/11 to 9/30/11, there were 1's and 5's documented. A number 1- meant house barrier cream to hips, buttocks and coccyx and 5 meant pressure reducing surface on bed/chair. The skin care interventions were left blank, (considered not done) for the day shift on 9/24/11, 9/25/11 and 9/28/11. Review of the Physical Therapy note of 9/30/11 (without a time) indicated this Resident was given passive range of motion and heel cord stretches of the right lower extremity. This Resident complained of pain when the heel was touched. Nursing was notified. Review of Nurse's Note of 9/30/11 at 3:00 P.M., stated, "While working c (with) resident the nurse dark area on (this Resident's) right heel and came got this nurse. It measured right 9 cm (centimeters), x (by) 7 cm, the area is not open dark under unstagable area. While doing the right the nurse looked at the left and noted the same thing the area L (left) measured 5 cm x 4.5 cm again not open unstagable. Due to resident's recent ORIF of (his/her) right hip and using the wedge in bed it's very hard to elevate heels off of the bed. NO (new order) place heel bows on when in bed, elevate as much as possible and skin prep to bilat (bilaterally) heels TID (three times a day)." Review of the pressure ulcer record on 9/30/11 for the right heel indicated, 9/30/11 was documented as the "date of origin" (the date it was found). The measurements were 7 cm in length, by 9 cm in width, with no depth. Under comments, this was a new unstagable ulcer and was necrotic underneath. Review of the pressure ulcer record on 9/30/11 for the left heel indicated, 9/30/11 was documented as the "date of origin". The measurements were 5 cm in length, by 4.5 cm with, with no depth. Under comments, it was a new area on the left heel which was non-blanchable and necrotic. Review of significant change MDS assessment, dated 9/30/11, indicated this Resident was an extensive assist of two for bed mobility, transfers, toileting and ambulation in room and corridor did not occur. Under Section M 0150, this indicated at risk for pressures. Under M 210, the resident has one or more unhealed pressure ulcer(s) at Stage 1 or higher. Under section M0300, there are 2 unstagable pressure ulcers due to coverage of the wound bed with slough and/or eschar. Under section 0610, the dimensions of the largest pressure sore was 7 cm in length, by 9 cm in width, and dashes were put in the pressure ulcer depth box to indicate no depth. Under section M0610, the description of the most severe type of tissue present in any pressure sore bed was a 4, which indicates necrotic tissue (Eschar) black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges. Review of the Care Area Assessment Summary of 10/4/11 indicated this Resident triggered for pressure ulcers; this Resident had a decline; status [REDACTED]. This Resident has two unstagable areas on heels; see treatment sheets. Review of the pressure ulcer record on 10/10/11 for the right heel indicated, the measurements were 9.4 cm in length, by 10 cm in width, with no depth. Under comments, area remains dark brown intact with necrotic tissue areas, it measures larger in size, continue to elevate off the bed. Review of the pressure ulcer record on 10/10/11 for the left heel indicated, the measurements were 5 cm in length, by 5 cm in width, with no depth. Under comments, area remains dark and intact no change in size (the length had increased in size from the 9/30/11 measurement by 0.5 cm, although it was unchanged from the 10/3/11 measurement). Review of the interdisciplinary progress note of 10/24/11 indicated during wound rounds this Resident had an unstagable area on the tip of the right great toe that measured 0.5 cm, by 1 cm, thought to be from the blankets resting on his/her foot. A bed cradle was put into place. Review of the pressure ulcer record for the right great toe indicated, 10/24/11 was documented as the "date of origin". The measurements were 0.5 cm in length, by 1 cm in width, with no depth. Under comments, it was a new area on the tip of the right great toe, it was unstagable dark in color, intact and a bed cradle was obtained. Review of the skin impairment care plan indicated this care plan was updated on 10/24/11 and the intervention was to have a bed cradle to keep blanket off feet. Review of the wound clinic documentation from the Community Hospital indicated this Resident was evaluated on 11/2/11 for the bilaterally heel ulcers. This Resident had pain in necrotic areas of the heels intermittently. During debridement of the heels there was purulent drainage. Wound cultures were taken and the Resident was empirically treated with an antibiotic. This Physician indicated that the bilateral heel ulcers, were probably pressure related. Review of the pressure ulcer record of 11/7/11 for the right great toe indicated, that the measurements were 0.9 cm in length, by 1.8 cm in width, with no depth. Under comments, the area remains intact yet necrotic, dark in color, no odor, tender to touch, continue with bed cradle, and the Resident received an air mattress. Review of the nurse's note of 11/8/11 indicated that an air mattress with increased pressure relieve was put on this Resident's bed. Review of the wound clinic documentation from the Community Hospital indicated on 11/9/11, the results from the wound cultures (done on 11/2/11) indicated that the culture grew out [MEDICAL CONDITION] infection, and this Resident was started on Bactrim DS (double strength-an anti-infective medication). Review of the pressure ulcer record of 11/14/11 for the right great toe indicated that, the measurements were documented as 1 cm in length, by 1.1 cm in width, with no depth. Under comments, remains the same in color, smaller in width, and to continue with the bed cradle. Review of the wound clinic documentation from the Community hospital on [DATE], indicated this Resident had necrotic heels, which were debrided bilaterally in the operating room due to both infected heels with full-thickness necrosis of the skin. The left heel was debrided, and the total size of the defect was 2.5 cm with extension down to the periosteum (the fibrous membranes which enclose the covering of bone). The right heel encompassed the entire heel and measured 6.5 cm length, by 5 cm width, and this heel was also debrided. Both heel ulcers extend focally down to the periosteum but not to exposed bone. Review of the pressure ulcer record of 11/21/11 for the right heel indicated that, the measurements were 7 cm in length, by 8.3 cm in width, with a depth of 0.3 cm. Under comments, "the area had exacerbated, see attached note." The attached note indicated the heel area is tender. (This was the last entry on the wound sheet copied 11/30/11 at 10:30 A.M., prior to the Surveyor observing the measurements on 12/1/11). Review of the pressure ulcer record of 11/21/11 for the left heel indicated, the measurements were 5.7 cm in length, by 6 cm in width, and 0.7 cm depth. Under comments, see attachment. The attachment indicated that the wound has granulation tissue around edges, necrotic tissue in the middle as well as slough. (This was the last entry on the wound sheet copied 11/30/11 at 10:30 A.M., prior to the Surveyor observing the measurements on 12/1/11). Review of the pressure ulcer record of 11/28/11 for the right heel and the left heel indicated this resident went to the wound clinic for debridement. Reviewed on 12/1/11 at 10:30 A.M. (at the Director of Nurses (DON) request) the "Moderate to High Pressure Injury Protocol For Dementia Resident With [MEDICAL CONDITION]" developed by the DON, which was started today 12/1/11. It stated the following: "In the case of a Dementia resident who sustains a [MEDICAL CONDITION], the plan of care will presume and prepare for increased risk of a pressure injury during the recovery period... A specialty mattress (a company brand name) is recommended to be in place on their admission day... Heel prevention protocol will be followed. HEELS WILL BE FLOATED AS MUCH AS POSSIBLE AT ALL TIMES, OTHER THAN AMBULATION." Review of the consultation from the Vascular Physician dated 12/5/11 indicated that the Resident: - has a right foot with significant ischemia (decreased blood supply) compared to the left which has good circulation; - has bilateral femoral-tibial arterial disease, resulting in severe ischemia of the right lower leg; - has a nonhealing ulcer on his heel; - was not a candidate for bypass surgery because he/she is non-ambulatory and severely demented; - should probably undergo right above the knee amputation. Review of the Wound Clinic Physician's note of 12/12/11 indicated an order for [REDACTED]. Interview with the Physical Therapy Assistant (PTA) on 11/29/11 at 12:45 P.M., she stated, "When I was doing range of motion (with this Resident), this Resident's heel was tender, I believe I was the person who first discovered the heel, and told the Nurse, on 9/30/11; (the Resident) complained of pain and I told Nursing." Review of the facility's Pressure Ulcer Definition and Stages sheet on the Pressure Ulcer Measurement book indicated the following applicable stages. There are 4 stages plus an unstagable category: - Stage 1 through 4 increasing in severity and unstagable. - Stage 4 is full thickness loss with exposed bone, tendon or muscle. - Unstagable is full thickness tissue loss in which the base of the ulcer is covered by slough or eschar (forms of dead matter/necrotic tissue). The Surveyor observed on 11/30/11 from 7:45 A.M. to 8:05 A.M., from 9:10 A.M. to 9:25 A.M., that this Resident was in bed and the bed blanket was under the bed cradle, directly on the Resident's feet and toes, not off loaded from the right great toe. The bed blanket would need to be draped over the bed cradle to be effective and relieve pressure. The Surveyor observed on 11/30/11 at 10:30 A.M., that this Resident was in the Shower Room in the shower chair with plastic bags covering his feet to keep them dry. The Surveyor observed on 12/1/11 from 7:05 A.M. to 10:00 A.M., that this Resident was in bed, the bed blanket was resting on his/her feet, and the bed cradle was not on the bed. The Surveyor observed the right heel pressure ulcer dressing for Resident #3 on 12/1/11 at 10:15 A.M., performed by CN #2. Present in the room were CN #1, and a Wound Nurse Consultant from an equipment company (She was evaluating the wound for a wound vac to be placed on the right heel wound). This Resident was on contact precautions secondary to a recently infected right heel wound [MEDICAL CONDITION]. The Wound Nurse Consultant gave a black canvas bag to CN #1 which contained a wound vac. CN #1 was handed this canvas bag which was going to be used for Resident #3's right heel pressure ulcer. CN #1 placed this canvas bag on top of a comforter, in a recliner chair, by the foot of the roommate's bed (this is a 3 bed room). When the Surveyor asked CN #1, "Who's recliner chair is that?" CN #1 responded that it belonged to Resident #3's roommate. CN #1 stated, "It (the canvas bag containing the wound vac machine for Resident #3 should not be in that chair (Resident #3's roommates chair," and removed it from the chair. CN #2 donned a gown, gloves and goggles prior to entering this Resident's room and washed hands just prior to the dressing change, gloved hands, and removed the dirty dressing from the right heel. She then pressed the foot pedal on the container to open it, and threw this dressing with a large amount of sero-sanginous dressing, which was foul smelling, into a room trash receptacle, and the dressing touched this trash container lid prior to landing in a clear plastic bag in the trash receptacle. The right heel wound was washed with normal saline which was poured on Q-tips and 4 by 4 gauze pads. The contaminated Q-tips and 4 by 4 gauze pads were also placed in the trash receptacle. When the Surveyor asked CN #2 to measure and stage this pressure ulcer, she said it was 7.6 cm in length, 6.5 cm in width, and the deepest part of wound was 1.5 cm at 4 o'clock. She staged this wound as unstagable. The wound edges were macerated. The Wound Nurse Consultant indicated there was 60% to 80% slough in the wound bed. The Surveyor said that the right heel bone could be seen so it is a stage 4 pressure sore and it is not unstagable. CN #2 then asked the Wound Nurse Consultant if it was a stage 4 pressure sore (CN #2, who does most of the wound treatments, had not correctly staged the wound). The Wound Nurse Consultant responded that the bone is visible, and when you can see bone it is a stage 4 pressure sore. The Wound Nurse indicated that this Resident was not a candidate for the Wound Vac, because of the amount of slough (there was too much) in the wound bed, and because an X- ray of the heel would have to be done to rule out osteo[DIAGNOSES REDACTED] before the wound vac could be used (which she indicated was their standard protocol). The current treatment for [REDACTED]. CN #2 washed hands prior to proceeding to perform the left heel dressing change. The left heel dressing had a large amount of sero-sangouinous drainage. CN #2 washed hands after disposal of this dirty dressing (into the foot pedal trash receptacle, which had a moderate amount of sero-sangunous drainage). CN #2 washed the left heel wound with normal saline on Q-tips and 4 by 4 gauze pads. The measurements were 3.4 cm in length by 2.6 cm in width and the deepest part of the wound was 1.5 cm at 10 o'clock. [MEDICATION NAME] Gel was applied to the wound, followed by an [MEDICATION NAME] cover, then a non-stick pad, and then it was wrapped with Kling. CN #2 then measured the right great toe, which had a necrotic area on the tip of this toe, which measured 0.6 cm by 1.1 cm This Resident declined to have the coccyx dressing change today, 12/1/11, because he/she was tired. On 12/2/11 at 3:20 P.M., CN #2 entered the the conference room and asked the Surveyor for the wound measurements written down (by the Surveyor on 12/1/11) for the heel pressure sores. CN #2 stated, "I found wound measurements of the heels, I had taken on 11/29/11, in my pocket and I forget to document the measurements on the wound sheets." CN #2, had the right Pressure Ulcer Record in her hand and in front of the Surveyor wrote in the following measurements: Under date, she wrote 11/29/11 right heel measured 16.5 cm in length, by 7.5 cm in width, by 1.1 in depth with no tunneling, under comments, the area is larger status [REDACTED]. Under date 11/29/11, left heel measured 5 cm in length, by 5.5 cm in width, by 1.8 cm in depth. Discussion followed with CN #2 regarding how she had measured the length of the right heel ulcer, because the length of the wound she had taken on 11/29/11 was 16.5 cm in length and the measurement obtained on 12/1/11 at 10:15 A.M. was 7.6 cm in length (measured by CN #2 and observed by this Surveyor). CN #2 indicated that the 16.5 cm, was not just the size of the open area of the pressure sore but, included the length of the wound and the surrounding skin which had a darker pigmentation. The Surveyor indicated that the 16.5 cm in length was not an accurate measurement of the wound size (length), the open area of the wound. The measurement for the length is the measurement of the size of the open wound from one edge to the other. CN #2 included a measurement of the peri-wound tissue, which CN #2 described as being discolored but intact. The size of this skin discoloration added to the length of the open pressure sore is an inaccurate measurement. The Surveyor discussed with CN #2 that the pressure ulcer measurements from 11/29/11, she documented today (12/1/11) were late entries, but it was not documented as a late entry. CNA #2, stated, "Then I will have to add a nurse's note." She also stated, "I do not see why I have to enter this as a late entry, it was done on 11/29/11, I just did not document it then." Interview with CN #2 on 12/1/11 at 10:00 A.M., The Surveyor asked why this Resident no longer had a bed cradle on his/her bed. CN #2 explained that this Resident was supposed to have the bed cradle to keep the pressure from the bed blankets off the right great toe. CN #2 found the bed cradle stored on top of this Resident's television and against the wall. While she was placing this bed cradle on the floor, she indicated she would call maintenance to put it back on this Resident's bed. As she was walking away from the bed cradle, she placed it on the floor. The Surveyor stated, "Are you aware that you contaminated the bed cradle by putting it on the floor, and you would not want it on the Resident's bed, especially in lieu of this Resident having problems with wound infections?" CN #2 stated, "I will wash it now, with a bleach wipe, it probably needs to be washed." When the Surveyor asked what type of mattress this Resident had on this Resident's bed prior to these pressure ulcers, she said, "On admission, everyone (referring to the Residents) has a pressure redistribution mattress, which this Resident had on his/her bed since admission." Interview with CN #1 on 12/6/11 at 8:55 A.M. indicated that Resident #3 was readmitted on [DATE] at 4:30 P.M. CN #1 also stated that the undated Physician's admission orders [REDACTED]. Usually, Ambulation/Mobility orders are filled out on admission, so the mobility status for the Resident can be followed and maintained. CN #1 indicated that there were no Ambulation/Mobility orders until (9/25 at 12:00 noon) 43.5 hours after this Resident was admitted . Interview with CN #2 on 12/6/11 at 11:10 A.M., indicated that, for the skin impairment care plan, there were no new interventions added from 9/23/11 (re-admitted post hip Fx) through 9/29/11 (the day prior to the development of bilateral heel ulcers) to off load the heels for a Resident with limited mobility. This Resident was positioned with an abductor pillow between legs at all times while in bed, which decreased the mobility of the lower extremities. Interview with CN #1 on 12/6/11 at 11:10 A.M., indicated that at the time of admission of 9/23/11 there were no pressure sores on the heels, right great toe or the coccyx. The Surveyor asked CN #1 if she was aware that this Resident was prone to pressure sores of the heels after the [MEDICAL CONDITION], and in lieu of wearing an abductor device while in bed. She respond that she was aware that this Resident was at increased risk for the development of pressure ulcers, especially the heels. The Surveyor asked, "Were this Resident's heels off loaded (the use of pressure relieving devices and/or elevation of the heels off the bed) prior to the development of the heel pressure sores?" She stated, "No, he/she was a fall risk and we were afraid (this Resident) would get up out of bed with the heel devices on and fall." The Surveyor asked, "So, no additional interventions were added to the skin care plan to off load the heels prior to the development on 9/30/11 of the bilateral heel pressure ulcers." She responded, "No, we did not want him/her to fall." Review of the care plan with CN #1 indicated after the [MEDICAL CONDITION] on 9/14/11 and prior to the development of the heel pressure sores on 9/30/11, the only update to the skin care plan intervention was on 9/23/11 for 2 persons to assist this Resident with transfers to the wheelchair, and for toileting and weight bearing as tolerated. CN #1 questioned the accuracy of this intervention, since an activity status, mobility and weight bearing as tolerated were not ordered by the physician until 9/25/11 (2 days after this care plan intervention was written). During an interview with CN #1 on 12/6/11 at 11:50 A.M., the Surveyor asked if this Resident had any vascular lower extremity issues and she responded, "No, (this Resident) had a Vascular Consult on 12/5/11 (pointing to this consult) and there is no vascular issues of his/her legs." However review of the consultation from the Vascular Physician dated 12/5/11, indicated that the Resident's right foot has significant ischemia (decreased blood supply). In addition, that this Resident has bilateral femoral-tibial arterial disease, resulting in severe ischemia and should probably undergo a right above the knee amputation. Interview with CN #1 on 12/12/11 at 2:50 P.M., regarding the Norton Skin Risk Assessment this Resident had a score of 6, indicating he/she was at high risk for pressure ulcer development. The Surveyor asked why wasn't the protocol followed for heel protectors, esp. since the Resident scored a 6 on the Norton Scale (at high risk for pressure sore development)? CN #1 indicated that she wrote the note on the Norton Scale that this Resident was at high risk for falls, and she felt that this Resident should not wear heel bows (protectors) and that this Resident was trying to get out of bed. The Surveyor said to CN #1 that there was no documented episodes from 9/23/11 to 9/30/11 (when the pressure sores were found) of this Resident trying to get out of bed. CN #1 responded, "No, but he/she was trying to get out of bed and we did not want him/her to fall again." The Surveyor pointed out that this Resident had a wedge pillow between his/her legs and he/she couldn't get up very easily with this in place. When the Surveyor said that this Resident was a high risk for pressure sore development of the heels. CN #1 did not say anything. During an interview with CN #1 on 12/12/11 at 3:00 P.M., the Surveyor asked to see where the Certified Nursing Assistants (CNA) were documenting the care plan intervention "CNA to monitor skin during care daily and report any redness, irritation or breakdown to nurse." CN #1 indicated these skin checks are not documented, only if they found areas on the skin during direct care to report the areas to the Nurse. When the Surveyor asked, on the CNA flow sheets, what does the category "Skin Care" mean? CN #1 indicated these were the skin care interventions they were doing. When CN #1 was asked, what a number 4 meant as a category? she indicated it meant float heels in bed/protection in bed, and from 9/23/11 to 9/30/11, there were no 4's in his/her skin care documentation boxes. There were 1's and 5's documented and for Resident #3, CN #1 indicated that, 1 meant house barrier cream to hips, buttocks and coccyx and 5 meant pressure reducing surface on bed/chair. CN #1 indicated that the skin care interventions were left blank, (considered not done) for the day shift on 9/24/11, 9/25/11 and 9/28/11. During an interview with Nurse #6 on 12/13/11 at 3:20 P.M., the Surveyor asked if she did the weekly skin check of 9/29/11 and she said, "I did." She was then asked, when and how do you do the weekly skin checks? She stated, "It depends on his/her shower day. The skin check was done 9/29/11 for (Resident #3) because that was his/her shower day. I did the skin check, I am pretty sure he/she was in the shower chair (sitting) in the shower, but I am not sure but he usually is. I would have checked him/her in the shower chair and I checked both heels." When the Surveyor asked if there was adequate lighting, she responded, "I think so." Surveyor asked do you use a flashlight for inspecting his/her heels in the shower? She said, "No, but I could. It is probably difficult to assess heels in the shower chair, I have to get down on the floor to do this. I should probably assess him/her in bed. In the shower chair, I can't pick his/her leg up that high to look because of the fracture." The facility failed to ensure that Resident #3, did not develop avoidable heel pressure sores and prevent infection of these pressure sores. This resident sustained [REDACTED]. In addition, this Resident developed facility [MEDICAL CONDITION] infections of both pressure sores of the heels. Consultations with both the Vascular and Wound Care Physicians have recommended a right above the knee amputation.

Based on staff interviews and record review, there were recurrent deficient practices related to falls and pressure sores, identified during this annual recertification survey and last year's recertification survey. In addition, there were recurrent deficient practices related to pressure sores during a complaint survey (on 12/10/10) at the level of harm, and this annual recertification survey for pressure sores at a substandard level of care. The facility failed to ensure that the quality assurance program identified issues, developed and implemented plans of action for care and services provided to the residents, and evaluated that the plans were effective. Findings included: Interview with the Director of Nurses on 12/13/11 at 2:45 P.M., revealed that there were several areas of concern identified regarding falls with a scope and severity of harm, for the last two surveys: the survey of 1/19/11 and this survey 12/13/11. For Resident #3, six unwitnessed falls were sustained between between 1/20/11 and 11/19/11. One fall resulted in a [MEDICAL CONDITION] with multiple complications and another fall resulted in a hematoma on the right shoulder and a bruise under the right axilla. Please Refer to F323. Interview with the Director of Nurses on 12/13/11 at 2:50 P.M., revealed that there were several areas of concern identified regarding pressure sores for Resident #3 at a substandard level of care, for the development of pressure sores and subsequent infections of the pressure sores. The complaint survey (of 12/10/10), also cited the facility for pressure sore development and an infected pressure sore at the scope and severity of harm (G level), which included the coccyx and heel pressure ulcers. Resident #3 sustained a [MEDICAL CONDITION] at the facility, upon readmission, Resident #3 developed facility acquired heel pressure sores (a stage 4 pressure sore, the right heel bone was visible) and an unstagable pressure sore, a full thickness tissue loss covered with dead tissue on the left heel). In addition, Resident #3 developed facility acquired [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) infections of both pressure sores of the heels. Consultations with both the Vascular and Wound Care Physicians have recommended a right [MEDICAL CONDITION]. Interview on 12/13/11 at 2:50 P.M. with the Director of Nursing indicated that some of these areas were also identified during the Quality Assurance meetings, but the current plans were ineffective in resolving the quality of care issues for falls and pressure sores and infections in the pressure sores for Resident #3, during this survey. Please Refer to F314.

Based on record review, interview, and observation, the facility failed to provide effective interventions and adequate supervision to prevent falls and/or accidents for 1 resident (#3) out of 7 applicable residents with falls, in a total sample of 17 residents. Resident #3 sustained 6 falls between 1/20/11 and 11/19/11. One fall resulted in a hip fracture and another fall resulted in a hematoma on the right shoulder and a bruise under the right axilla. Findings included: Resident #3 was admitted to the facility in 11/08. This Resident's [DIAGNOSES REDACTED]. This Resident's postoperative course was complicated by bilateral facility acquired heel pressure sores, which became infected. Because of the inability of the heel sores to heal, the Vascular and Wound Physicians have recommended an above the knee amputation. Review of an quarterly Minimum Data Set (MDS) assessment, dated (11/10/10), indicated that the Resident's Brief Interview for Mental Status indicated a severe cognitive impairment, was an extensive assist of one for bed mobility, transfers, ambulation and toilet use. Under J1800 for falls, there were no falls since admission or prior assessment. Review of the falls care plan of 11/17/10 indicated that this Resident was at risk for falls and injury due to impaired cognition and poor safety awareness related to dementia. This care plan had the following pertinent interventions: - Anticipate needs, redirect to promote safety and decrease restlessness -Transfer and ambulate with a gait belt, walker and one assist - Pressure alarm in bed and chair - Seat near door in family room for meals Review of the nurse's note and facility investigation of 1/20/11 indicated that the resident had an unwitnessed fall at 5:15 A.M. in this Resident's bedroom. A Certified Nursing Assistant (CNA) entered the Resident's room, heard alarms sounding and found this Resident with his/her buttocks on the floor next to his/her bed. This Resident indicated he/she was trying to get out of bed. No injuries were sustained. The falls care plan was updated on 1/20/11, for 1/2 siderails on the window side of the bed. It was again updated on 3/28/11 for non-skid strips on both sides of bed and in front of the chair and for 2 1/2 siderails on both sides of the bed. Review of the nurse's note and facility investigation of 5/30/11 indicated that the resident had an unwitnessed fall at 5:30 A.M. A Nurse was called to this Resident's room by a CNA and this Resident was noted to be lying on the floor. The CNA indicated that this CNA was responding to the Resident's alarm. The Resident indicated he/she had to get socks out of the dresser. No injuries were sustained. Review of the Rehabilitation Screening Request of 5/30/11, under recommendations, indicated that the fall of 5:30 A.M., was in the early morning, and if this Resident is an early riser, to assist this Resident out to the activities early morning program. Encourage out of room activities, possibly watch television in the multi-purpose room (Day Room). The falls care plan was updated on 6/1/11 to get this Resident out of bed on the 11 P.M. to 7 A.M. shift, if awake early morning or if restless, get up earlier. Review of this intervention (by the Surveyor on 11/30/11), it was yellowed out (which indicated it was discontinued), with no date as to when it was discontinued. Review of the nurse's note and facility investigation of 9/14/11 indicated that the Resident had an unwitnessed fall at 4:45 P.M. in the Family Room, while waiting for supper. At 4:45 P.M., the alarm sounded, 2 Nurses and the Physician responded. The Resident had right hip pain and the Physician assessed this Resident and sent this Resident to the Community Hospital. This Resident was admitted to the hospital with [REDACTED]. Review of the Discharge Summary from the Community Hospital indicated in the emergency room , this Resident had significant right hip pain and some outward deviation rotation of the right leg. The hip X-Ray showed acute femoral head fractures and hip fracture. The Resident was taken to the Operating Room on 9/15/11 and a right open reduction internal fixation was done. Review of the nurse's note of 9/23/11 indicated that this Resident was readmitted back to this Nursing Home with an abductor pillow in place (this Resident was 8 days post operatively). The falls care plan was updated on 9/23/11 for 2 assist with transfers, weight bearing as tolerated and wheelchair for transport. Review of the Admission physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. The falls care plan was updated on 11/12/11 to include a motion sensor on the wall. Review of the nurse's note and facility investigation of 11/18/11 indicated that the Resident had an unwitnessed fall at 5:40 A.M. A Nurse entered this Resident's Room and found the Resident lying on the floor next to the bed. The alarms were in place but not functioning. A statement from a CNA indicated that at 5:15 A.M., this Resident was in bed watching TV. This resident sustained [REDACTED]. The previously care planned intervention on (6/1/11) was to get him/her out of bed on the 11:00 P.M. to 7:00 A.M. shift, when this Resident was awake, since this was when he/she had sustained other falls. The falls care plan was updated on 11/18/11 to include a low bed and floor mats on each side of the bed. Review of the facility investigation of 11/18/11 (there was no nurses note written at the time of this fall) indicated that the Resident had an unwitnessed fall at 11:50 P.M.. This Resident was found on his/her left side on the floor in this Resident's Room and the alarm was not sounding. Review of the facility investigation of 11/19/11 at 2:00 A.M. (there was no nurses note written at the time of this fall) indicated that the Resident had an unwitnessed fall at 2:00 A.M. This Resident's alarm was sounding and he/she was found on his/her knees on the left side of his/her bed. Review of the nurse's note of 11/19/11 at 9:00 A.M. indicated that this Nurse received report that this Resident fell out of bed twice last night. The first incident was at 11:50 P.M. and the second was at 2:00 A.M. The investigation stated that, the alarm was sounding at 11:50 P.M. and not sounding at 2:00 A.M. (this was not consistent with the fall investigation which indicated the alarm was sounding at the 2:00 A.M. fall). Observation on 12/1/11 from 7:05 A.M. to 10:00 A.M., indicated this Resident was in bed, the bed blanket was resting on his/her feet, and the bed cradle was not on the bed. This Resident had a motion detector alarm over the head of his/her bed. During an interview with CN #1 on 12/6/11 at 8:55 A.M., regarding the fall of 9/14/11 she said, "Two Nurse's were sitting in the Nurse's Station charting from the day shift and a Physician was in the nurses station as well in the Nurses Station and heard alarm." When the Surveyor asked what prevented the nurses from seeing this Resident across from the Nurse's Station in the Family Room, she said that the walls around the Nurse's station do not allow for seeing the Resident unless you stand up. When CN #1 was questioned that there were no nurses' notes on the 11:00 P.M., to 7:00 A.M. shift for the 2 falls sustained on 11/18/11 at 11:50 P.M. and at 2:00 A.M., she indicated nurses notes should have been written on the night shift for both those falls. Observation of the Family Room (the location of Resident #3's fall on 9/14/11) with Maintenance staff on 12/6/11 at 7:15 A.M. indicated it is across the hall from the Nurses Station. If the staff are sitting in this nurses station, then the Family Room and this Resident can not be seen, since there is a 58 inch wooden enclosure around the 8 foot by 5 foot nurses station. During an interview with CN (Charge Nurse) #1 on 12/6/11 at 8:55 A.M., she indicated that this Resident had 6 unwitnessed falls over a 10 month period of time. CN # 1 also indicated that for 2 of 6 falls there were injuries: a right hip fracture and a hematoma and bruise. In addition, for 2 of the 6 falls the alarms were not working.

Based on record review, interview, and observation, for one of four sampled residents (Resident #1), the Facility failed to provide the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing when Resident #1 returned to the Facility after a hospitalization with a red "boggy" (spongy) left heel and a red coccyx, but there was no indication the areas were monitored or treated until nine days later when Resident #1's left heel had a 5 centimeter (cm) x 7 cm necrotic (dead tissue) area and then two days later when Resident #1 had a 0.5 cm x 0.5 cm stage two pressure ulcer (partial thickness skin loss presenting as a shallow open ulcer with red or pink wound bed) on the coccyx. In addition, approximately seven weeks later, the daily wound flow sheet indicated Resident #1's coccyx pressure ulcer had a slight odor with moderate exudate; however, the physician was not notified until 5 days later when the odor was foul and the pressure ulcer was 6 cm x 6 cm x 0.2 cm with heavy purulent drainage, and at that time the physician ordered antibiotic therapy and a treatment change. The findings included: Resident #1 was admitted to the Facility in July 2008 with [DIAGNOSES REDACTED]. Resident #1's medical record indicated Resident #1 had completed a Health Care Proxy which listed Family Member #1 as Health Care Agent and Resident #1's Health Care Proxy was invoked on 7/14/08. An annual Minimum Data Set (MDS) assessment, dated 8/13/10, indicated Resident #1 had impaired short term memory, impaired long term memory, and severely impaired decision making ability. The MDS indicated Resident #1 was easily distracted, had an altered perception of surroundings, had periods of disorganized speech, and had periods of restlessness. The MDS indicated Resident #1 had unclear speech, only sometimes understood others, and was only sometimes understood by others. The MDS indicated Resident #1 had highly impaired vision, was physically abusive to staff, and was resistive to care. The MDS indicated Resident #1 was dependent on staff for bed mobility, dressing, toilet use, personal hygiene, and bathing; and required extensive staff assistance with transfers, locomotion, and eating. The MDS indicated Resident #1 was incontinent of bowel and bladder function. The MDS indicated Resident #1 had a pressure relieving device on the bed and was on a turning and repositioning schedule. According to the MDS, Resident #1 had no pressure ulcers. A review of a potential for skin breakdown care plan, updated on 8/18/10, indicated Resident #1 was at risk for skin breakdown related to incontinence, diabetes with [MEDICAL CONDITION], anticoagulant therapy, decreased mobility, and fluctuating oral intake. Care plan interventions included: assessing Resident #1 for redness or irritation during care; completing a weekly skin check; providing a pressure reducing mattress on the bed; providing a cushion for Resident #1's wheelchair; repositioning Resident #1 every 2 hours as tolerated; providing incontinent care every two hours and as needed; applying barrier cream to the hips, coccyx, and buttocks every shift and as needed; observing for weight loss and decreased intake; documenting daily intake; providing adequate fluids; providing diabetic foot care; and notifying the physician of any skin breakdown. A weekly skin assessment, dated 8/24/10, indicated Resident #1 had no red or open areas. A review of a Hospital Discharge Summary, dated 9/16/10, indicated Resident #1 was admitted to the hospital on [DATE] with pneumonia and a left [MEDICAL CONDITION], and was started on intravenous antibiotics. The Discharge Summary indicated Resident #1 was placed on bedrest and on 9/11/10 Resident #1 underwent surgical correction of the left femoral neck fracture. The Discharge Summary indicated Resident #1 was anemic and received two units of packed red blood cells. The Discharge Summary indicated Resident #1 had an infectious diseases consultation (9/15/10) due to a resistant urinary tract [MEDICAL CONDITION] and was started on [MEDICATION NAME]. The Discharge Summary indicated Resident #1 was discharged back to the nursing Facility. The Hospital Discharge Summary contained no documentation regarding Resident #1's skin or the presence of any pressure ulcers. An admission nurse's note, dated 9/16/10, indicated Resident #1 returned to the Facility at 4:30 P.M. by ambulance stretcher. The nurse's note indicated Resident #1 had a suture line of 18 staples on the left hip with no signs of infection, but Resident #1's left heel was red and "boggy", and Resident #1's coccyx was red with no open areas. A weekly skin check record, dated 9/16/10, indicated Resident #1 had the following: multiple bruises on the bilateral arms and hands; a red, blanchable area on the coccyx; and a red, blanchable, "boggy", area on the left heel. A pressure ulcer risk assessment, dated 9/16/10, indicated Resident #1 scored 5 points and according to the assessment tool used by the Facility, a score of 10 or less was representative of high risk for pressure ulcer development. A weekly skin check record, dated 9/21/10, indicated no documentation regarding Resident #1's red coccyx or red, boggy left heel. A Review of the POS [REDACTED]'s back from 12 midnight to 11:00 A.M. on 9/18/10 and there was no documentation that Resident #1 was repositioned from 4:00 P.M. to 11:00 P.M. on 9/25/10. A review of Resident #1's clinical record indicated no documentation regarding Resident #1's coccyx or heels from 9/17/10 to 9/24/10. The Certified Nursing Assistant (CNA) flow sheet indicated Resident #1 received a barrier cream to the coccyx every shift. A review of the treatment sheet indicated no documentation that Resident #1 received daily diabetic foot care in September 2010. A nurse's note, dated 9/25/10 at 4:00 P.M., indicated Resident #1 had a very large unstageable pressure area on the left heel that measured 5 centimeters x 7 centimeters and the area was completely necrotic (dead devitalized tissue) with some redness around the edges. The nurse's note indicated the physician and family were notified and the physician ordered a dry dressing to the heel daily and a protective boot to the left heel and elevate the left foot. The nurse's note indicated a wound flow sheet was started. The nurse's note contained no documentation regarding Resident #1's coccyx. Nurse #1 was interviewed at 3:05 P.M. on 12/10/10. Nurse #1 said Resident #1 returned from the hospital and Nurse #1 recalled being made aware of the pressure area, but was not sure when the area started. Nurse #1 said Resident #1 was pretty much bedfast, but was repositioned every 2 hours. Nurse #1 said Resident #1 did not take fluids well and presented with a closed mouth and turned head to refuse liquids, food, and medications. Nurse #1 said Resident #1 ate and drank poorly and was on a protein supplement. A significant change MDS, dated [DATE], indicated Resident #1 was now dependent on staff for all activities of daily living. The MDS indicated Resident #1 had two stage 1 pressure ulcers. The MDS indicated Resident #1 had pressure relieving devices on the bed and chair, Resident #1 was on a turning and repositioning program, and Resident #1 received dressing changes. A review of a pressure ulcer record, dated 9/27/10, indicated Resident #1 had a 5 centimeter (cm) x 6 centimeter unstageable pressure ulcer on the left heel that was present when Resident #1 returned from a recent hospitalization (9/16/10). The pressure ulcer record indicated the left heel ulcer was treated with skin prep every shift. The pressure ulcer record, dated 9/27/10, also indicated Resident #1 had a 0.5 cm x 0.5 cm x less than 0.1 cm stage two pressure ulcer on the coccyx that was also acquired during the recent hospitalization and the area was treated with a [MEDICATION NAME] dressing. The pressure ulcer record indicated on 10/4/10 Resident #1's coccyx pressure ulcer was 3 cm x 3.7 cm x 0.1 cm with light bloody drainage and the area was clean with maceration (softening, thinning of skin due to exposure to wetness). The pressure ulcer record indicated Resident #1's left heel pressure ulcer was unchanged. The pressure ulcer record indicated on 10/11/10 Resident #1's coccyx pressure ulcer was 3 cm x 3.5 cm x 0.1 cm and was otherwise unchanged. The pressure ulcer record indicated Resident #1's left heel pressure ulcer remained unchanged. The pressure ulcer record indicated on 10/18/10 Resident #1's coccyx pressure ulcer was 1.9 cm x 1.5 cm with light bloody drainage and the area had improved. The pressure ulcer record indicated the treatment to Resident #1's coccyx was changed from [MEDICATION NAME] to [MEDICATION NAME]. The pressure ulcer record indicated Resident #1's left heel pressure ulcer was unchanged on 10/18/10. The daily wound flow sheet indicated Resident #1's coccyx pressure ulcer was monitored daily from 10/1/10 to 10/18/10 and the [MEDICATION NAME] dressing was changed on 10/1/10, 10/6/10, 10/9/10, and 10/14/10. On 10/18/10 the treatment to Resident #1's coccyx was changed to [MEDICATION NAME] (multipurpose moisture barrier cream) with every care. The daily wound flow sheet indicated Resident #1's left heel was monitored daily and skin prep (topical product to toughen the skin) was applied every shift. The pressure ulcer record indicated on 10/25/10 Resident #1's coccyx pressure ulcer remained unchanged at 1.9 cm x 1.5 cm with light bloody drainage and the area was clean with maceration. The pressure ulcer record indicated Resident #1's left heel pressure ulcer was unchanged on 10/25/10. The positioning record for October 2010 indicated no documentation that Resident #1 was repositioned during 5 shifts out of the month. A review of dietary records for October 2010, indicated Resident #1 was reviewed by the Dietician on 10/5/10, 10/7/10, 10/19/10, 10/21/10, and 10/23/10, and recommendations were made related to the pressure ulcer healing. On 11/1/10, the pressure ulcer record indicated Resident #1's coccyx pressure ulcer had exacerbated and was 5.5 cm x 5.6 cm x 0.1 cm with light bloody drainage and the area was clean with maceration. The pressure ulcer record indicated there was another open area and the two pressure ulcers were measured together. The pressure ulcer record indicated Resident #1's left heel pressure ulcer was unchanged on 11/1/10, but the edges were lifting up. On 11/1/10, the physician ordered the [MEDICATION NAME] discontinued and Resident #1's coccyx to be cleaned with normal saline, patted dry, and [MEDICATION NAME] (dressing with antimicrobial properties) applied with a dressing and changed daily and as needed. The pressure ulcer record indicated on 11/8/10 Resident #1's coccyx pressure ulcer remained unchanged and Resident #1's left heel pressure ulcer was unchanged. A review of the daily wound flow sheet indicated on 11/10/10 Resident #1's coccyx pressure ulcer now had a slight odor. The daily wound flow sheet indicated Resident #1's coccyx pressure ulcer also had slight odor with moderate exudate on 11/11/10, there was no documentation for 11/12/10, there was slight odor with moderate exudate documented on 11/13/10 and 11/14/10. The daily wound flow sheet indicated on 11/15/10 Resident #1's coccyx pressure ulcer had heavy exudate and a foul odor. Nurses' notes from 11/10/10 to 11/14/10 contained no documentation that Resident #1's coccyx pressure ulcer had increased exudate or slight odor and there was no indication the physician was notified of the changes. The pressure ulcer record indicated on 11/15/10 Resident #1's coccyx pressure ulcer was 6 cm x 6 cm x 0.2 cm with purulent drainage and an odor. The pressure ulcer record indicated Resident #1's left heel pressure ulcer was unchanged on 11/15/10. Nurse #2 was interviewed at 11:51 A.M. on 1/26/11. Nurse #2 said Nurse #2 completed weekly pressure ulcer rounds on Resident #1 and recalled that one week Resident #1's pressure ulcer had a foul odor when Nurse #2 assessed the area. Nurse #2 said Nurse #2 notified the physician of the odor and the physician ordered antibiotic therapy, because the pressure ulcer was infected. Nurse #2 said the previous week the pressure ulcer had no odor and Nurse #2 was not made aware of any odor prior to the weekly pressure ulcer check (which was on 11/15/10). Nurse #2 said the physician should have been notified as soon as the odor was present, because the area was infected. A nurse's note, dated 11/15/10, indicated during the 7:00 A.M. to 3:00 P.M. shift facial grimacing was noted and Resident #1 was medicated with [MEDICATION NAME] (narcotic [MEDICATION NAME]). The nurse's note indicated Resident #1's coccyx pressure ulcer had a medium amount of foul smelling greenish drainage. The nurse's note indicated the physician was notified and ordered Bactrim (antibiotic) twice daily by mouth for 10 days and the wound dressing changed to [MEDICATION NAME] twice daily. A nurse's note, dated 11/16/10, indicated Resident #1's coccyx area had several open areas and the area was cleansed and a new dressing applied. On 11/16/10, the physician ordered a dietary consultation, which was not completed until 11/23/10. The dietary consultation indicated a recommendation to send chocolate shakes to Resident #1 instead of strawberry. The pressure ulcer record indicated on 11/22/10 Resident #1's coccyx pressure ulcer measured 9 cm x 6 cm x 0.2 cm with a slight odor and moderate bloody drainage. The pressure ulcer record indicated the physician was notified. The pressure ulcer record indicated Resident #1's left heel pressure ulcer was 6 cm x 6 cm with necrotic edges lifting and a small amount of bloody drainage. A physician's orders [REDACTED]. On 11/23/10, the physician ordered an air mattress overlay and the treatment sheet indicated the air mattress overlay was applied to Resident #1's bed on 11/23/10. The pressure ulcer record indicated on 11/29/10 Resident #1's coccyx pressure ulcer was unchanged and Resident #1's left heel pressure ulcer was unchanged. A nurse's note, dated 11/29/10 at 3:30 P.M., indicated Resident #1 left by ambulance for a wound consultation. A nurse's note, dated 11/29/10 at 8:00 P.M., indicated Resident #1 returned from the wound consultation with a recommendation for surgery for [REDACTED]. The November 2010, positioning record indicated no documentation that Resident #1 was repositioned during four shifts. A physician's progress note, dated 12/2/10, indicated Resident #1 had a significant decline in the past few months and was having increased difficulty with swallowing. The progress note indicated surgery was planned for Resident #1's coccyx pressure ulcer, but Resident #1 had advanced dementia, was frail, cachectic (exhibiting [MEDICAL CONDITION] and wasting), and anemic. The progress note indicated the planned debridement (removal of dead, damaged tissue) surgery was on hold secondary to Resident #1's decline. A progress note, dated 12/4/10, indicated Resident #1's Health Care Proxy had clarified Resident #1's advanced directives. The progress note indicated Resident #1 was a DNR (do not resuscitate), DNI (do not intubate), DNH (do not hospitalize), no feeding tube, no diagnostic testing, no [MEDICAL TREATMENT], no intake and output monitoring, no intravenous access, and comfort measures only. On 12/4/10, the physician ordered a comfort measures only and a Hospice consultation. The pressure ulcer record indicated on 12/6/10 Resident #1's coccyx pressure ulcer was 9 cm x 6.5 cm x 0.2 cm with moderate bloody drainage and slight odor. The pressure ulcer record indicated Resident #1's coccyx treatment was changed to [MEDICATION NAME] AG, covered with border gauze, and changed every three days and as needed. The pressure ulcer record indicated Resident #1's left heel pressure ulcer remained unchanged on 12/6/10. The Surveyor observed a dressing change by the Hospice Nurse at 10:00 A.M. on 12/10/10. The Hospice Nurse said Resident #1's coccyx pressure ulcer was less wet and looked better with the new treatment.

Based on record review and interview, for one of four sampled residents (Resident #1), the Facility failed to notify the physician for five days when Resident #1's coccyx pressure ulcer developed an odor on 11/10/10 and the physician was notified of the change on 11/15/10. The findings included: Resident #1 was admitted to the Facility in July 2008, with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 8/13/10, indicated Resident #1 had impaired short term memory, impaired long term memory, and severely impaired decision making ability. . The MDS indicated Resident #1 had unclear speech, only sometimes understood others, and was only sometimes understood by others. The MDS indicated Resident #1 was dependent on staff for bed mobility, dressing, toilet use, personal hygiene, and bathing; and required extensive staff assistance with transfers, locomotion, and eating. The MDS indicated Resident #1 was incontinent of bowel and bladder function. A review of a potential for skin breakdown care plan, updated on 8/18/10, indicated Resident #1 was at risk for skin breakdown related to incontinence, diabetes with [MEDICAL CONDITION], anticoagulant therapy, decreased mobility, and fluctuating oral intake. Care plan interventions included: assessing Resident #1 for redness or irritation during care; completing a weekly skin check; providing a pressure reducing mattress on the bed; providing a cushion for Resident #1's wheelchair; repositioning Resident #1 every 2 hours as tolerated; providing incontinent care every two hours and as needed; applying barrier cream to the hips, coccyx, and buttocks every shift and as needed; observing for weight loss and decreased intake; documenting daily intake; providing adequate fluids; providing diabetic foot care; and notifying the physician of any skin breakdown. On 11/1/10, the pressure ulcer record indicated Resident #1's coccyx pressure ulcer had exacerbated and was 5.5 centimeter (cm) x 5.6 cm x 0.1 cm with light bloody drainage and the area was clean with maceration (softening, thinning of the skin due to exposure to wetness). The pressure ulcer record indicated there was another open area and the two pressure ulcers were measured together. On 11/1/10, the physician ordered the [MEDICATION NAME] discontinued and Resident #1's coccyx to be cleaned with normal saline, patted dry, and [MEDICATION NAME] (dressing with antimicrobial properties) applied with a dressing and changed daily and as needed. The pressure ulcer record indicated on 11/8/10 Resident #1's coccyx pressure ulcer remained unchanged. A review of the daily wound flow sheet indicated on 11/10/10 Resident #1's coccyx pressure ulcer now had a slight odor. The daily wound flow sheet indicated Resident #1's coccyx pressure ulcer also had slight odor with moderate exudate on 11/11/10, there was no documentation for 11/12/10, there was slight odor with moderate exudate documented on 11/13/10 and 11/14/10. The daily wound flow sheet indicated on 11/15/10 Resident #1's coccyx pressure ulcer had heavy exudate and a foul odor. Nurses' notes from 11/10/10 to 11/14/10 contained no documentation that Resident #1's coccyx pressure ulcer had increased exudate or slight odor and there was no indication the physician was notified of the changes. The pressure ulcer record indicated on 11/15/10 Resident #1's coccyx pressure ulcer was 6 cm x 6 cm x 0.2 cm with purulent drainage and an odor. Nurse #2 was interviewed at 11:51 A.M. on 1/26/11. Nurse #2 said Nurse #2 completed weekly pressure ulcer rounds on Resident #1 and recalled that one week Resident #1's pressure ulcer had a foul odor when Nurse #2 assessed the area. Nurse #2 said Nurse #2 notified the physician of the odor on 11/15/10 and the physician ordered antibiotic therapy, because the pressure ulcer was infected. Nurse #2 said the previous week the pressure ulcer had no odor and Nurse #2 was not made aware of any odor prior to the weekly pressure ulcer check (which was on 11/15/10). Nurse #2 said the physician should have been notified as soon as the odor was present, because the area was infected. A nurse's note, dated 11/15/10, indicated during the 7:00 A.M. to 3:00 P.M. shift facial grimacing was noted and Resident #1 was medicated with [MEDICATION NAME] (narcotic [MEDICATION NAME]). The nurse's note indicated Resident #1's coccyx pressure ulcer had a medium amount of foul smelling greenish drainage. The nurse's note indicated the physician was notified and ordered Bactrim (antibiotic) twice daily by mouth for 10 days and the wound dressing changed to [MEDICATION NAME] (topical antibacterial cream) twice daily. The pressure ulcer record indicated on 11/22/10 Resident #1's coccyx pressure ulcer measured 9 cm x 6 cm x 0.2 cm with a slight odor and moderate bloody drainage.