Every finding on record at Port Rehabilitation and Healthcare Center

Based on observations, record reviews and interviews, the facility failed to ensure food was stored and distributed in accordance with professional standards of food safety to prevent the possible spread of foodborne illness in at risk residents. Specifically, 1. a. The facility failed to ensure food stored in the walk-in refrigerator was not stored and available after the use by date, b. The facility failed to ensure a loaf of bread was not stored after the use by date on one of three nourishments kitchens, and 2. Dietary Staff #1 a. failed to contain facial hair with a beard cover while in the food distribution area. Dietary Staff #1 failed to change his gloves and perform hand hygiene after resting his gloved hands on his facial hair and his nose and proceeded to pick up plate pallets and place them on multiple meal trays in preparation for the meal service line, potentially contaminating the meal trays. b. Dietary Staff #2 failed to properly dispose of used gloves during the lunch meal distribution. Dietary Staff #1 removed his gloves from both hands and placed the gloves onto the tray line. Findings include: Review of the facility's policy, titled Food Receiving and Storage, dated November 2022, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. 'Refrigerated/Frozen Storage' included but was not limited to the following:1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) 7. Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded. 1 a] During an observation of the main kitchen's walk-in refrigerator on 8/26/2025 at 7:20 A.M. the surveyor observed the following:-A tray with multiple covered individual servings bowls of fruit dated 8/21/25, 8/22/25, and 8/23/25. -A loosely wrapped pan of cooked burgers with congealed white substance dated 8/23/25-A pan of cooked pasta noodles, wrapped and dated 8/21/25-A plastic wrapped opened package of turkey deli meat dated 8/10/25.-A shallow pan of peas covered in loose plastic dated 8/19/25.-Nine covered cups of individually poured milk with no visible date. During an observation and interview on 8/26/25 at 7:31 A.M., The Food Service Director said food stored in the walk-in refrigerator was available for use. The FSD said all prepared food should be labeled with a use by date. The FSD said stored food should be used within three days. The FSD said the food stored in the walk-in refrigerator with dates of 8/19/25, through 8/22/25 should have been thrown out. The FSD said the turkey deli meat dated 8/10/25 should have been labeled with a use by date and should not have been in the refrigerator. 1b.) During observation of the [NAME] Unit Nourishment kitchen on 8/27/2025 8:33 A.M., the tag on one loaf of white bread indicated use by 8/26/25. During an interview on 8/27/25 at 2:07 P.M., the FSD said food should not be stored in the nourishment kitchens beyond the use by date. 2a.) During an observation of the meal service preparation on 8/27/25 at 11:39 A.M., the following observations were made: Dietary Staff #1 was observed to have facial hair that was not contained. Dietary Staff #1 was standing in the food distribution line area. Dietary Staff #1 rested his elbows on the shelf of the tray line and rested his head on his gloved hands resulting in his facial hair and nose having direct contact with his gloved hands. Dietary Staff #1 then proceeded to touch the plate warmer pallets and placed them on multiple meal trays. 2b.) During the tray distribution Dietary Staff #2 removed his gloves from his hands and placed the gloves directly onto the tray line shelf. The FSD was present and was made aware and directed Dietary Staff #2 to wash his hands. The FSD said the used gloves should not have been placed on a clean area. During an interview on 8/27/25 at 2:07 P.M., the FSD said Dietary Staff #1 should not have rested his gloved hands on his facial hair and nose while waiting for the tray line to begin. The FSD said he expected Dietary Staff with facial hair to cover with a beard cover when in food preparation areas and during food distribution. The FSD said Dietary Staff #1 should not have touched the plate pallets after touching his facial hair and nose with his gloved hands.

Based on observation, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#26) out of sample of 25 residents. Specifically, the facility failed to obtain a physician's order for oxygen administration. Findings include:Review of facility policy titled Oxygen Administration, dated as Revised October 2010, indicated the following:-Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #26 was admitted in May 2025 with diagnoses that include gastrointestinal hemorrhage, acute respiratory failure, muscle weakness and pressure ulcer stage 3. Review of the most recent Minimum Data Set (MDS) Assessment, dated 8/12/25, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS further indicated the use of continuous oxygen therapy. On 8/26/25 at 8:02 A.M., the surveyor observed Resident #26 awake in bed. The Resident was receiving oxygen via nasal cannula at 2 liters per minute (lpm). On 8/27/25 at 12:30 P.M. and 1:36 P.M., the surveyor observed Resident #26 awake in bed. The Resident was receiving oxygen via nasal cannula at 2 lpm. Review of Resident #26's active physician's orders failed to indicate orders for oxygen administration. Review of the weights and vital signs portal in the electronic medical record indicated that beginning 8/12/25 Resident #26 was documented as using oxygen via nasal cannula. During an interview on 8/27/25 at 1:38 P.M., the Charge Nurse said that if a resident is receiving oxygen there should be an order for administration. She said Resident #26 is receiving oxygen, but when she reviewed the medical record, she said there was no order for it. She said that the Resident was started on oxygen around 8/12/25 when he/she was diagnosed with pneumonia. During an interview on 8/28/25 at 7:57 A.M., Unit Manager #2 said that there needs to be a physician's order for oxygen administration, but that Resident #26 did not have one until it was brought to the facility's attention. During an interview on 8/28/25 at 9:26 A.M., the Director of Nurses said that the administration of oxygen requires a physician's order and would expect that if a resident is receiving oxygen there would be a physician's order.

Based on observation, record review and interview, the facility failed to ensure treatment and care was provided in accordance with standards in quality of care for one Resident (#12), out of a total sample of 25 residents. Specifically, for Resident #12, who has a known risk and care planned for the risk of bruising, bleeding and skin tears, the facility failed to identify areas of injury on his/her lower right leg. Findings include:Resident #12 was admitted to the facility in May 2024 with diagnoses that include, but are not limited to unspecified dementia, bipolar disorder, delusional disorders and heart disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/16/25, indicated Resident #12 had a staff assessment for mental status that indicated Resident #12 as having severe cognitive impairment. Further, the MDS indicated Resident #12 required substantial/maximal assistance for shower/bathing and was dependent on lower body dressing. During an observation on 8/26/25 at 10:35 A.M., Resident #12 was in his/her bed. Resident #12's lower legs were exposed, and yellow fading areas were observed going down his/her right shin. There was also a scrape-like red area on his/her shin. Resident #12 did not respond to the surveyor's greeting. During an observation on 8/26/25 at 3:34 P.M., Resident #12 was observed up and dressed and sitting in his/her wheelchair in his/her room. Resident #12 was wearing jogger pants, and his/her lower extremities were covered and could not be observed. Resident #12 did not respond to the surveyor's greeting. During an observation on 8/27/25 at 12:28 P.M., Resident #12 was sitting up in his/her wheelchair. Resident #12 had yellow fading areas on his/her right lower extremity, and a pea sized red area, consistent with a scab on his/her right shin. Review of Resident #12's active care plans indicated the following:-Focus I am at risk for bruising/bleeding/skin tear r/t (related to) ASA (aspirin) therapy, dated 8/20/25, with interventions including but not limited to Inspect skin for bruising/unusual bleeding/petechiae (small spots from bleeding blood vessels) daily during care, dated 8/20/25. Review of progress notes dated 8/18/25 through 8/26/25 failed to indicate any entries regarding any discoloration or alteration to Resident #12's lower right leg. Review of Resident #12's physician's orders indicated the following:-Weekly skin check, complete weekly skin check under assessments tab every day shift every Mon (Monday) for monitoring, dated 5/23/25. Review of the weekly skin checks under the assessment tab indicated Resident #12's skin intact on a weekly skin check V-2 dated 8/18/25. There were no further weekly skin checks assessments under the assessment tab. Review of the Treatment Administration Record (TAR) indicated the weekly skin check dated 8/25/25 as checked off as administered. Review of the progress notes failed to indicate a note that Resident #12 refused the weekly skin check dated 8/25/25. During an observation and interview on 8/28/25 at 7:55 A.M., the surveyor and Certified Nursing Assistant (CNA) #4 observed Resident #12's lower right leg. CNA #4 said Resident #12 had lower leg bruises on his/her right leg and that they had been there and that the nurses knew about the bruises. CNA #4 said she cared for Resident #12 on Tuesday (8/26/25) and they were there. CNA #4 said Resident #12 moved around in his/her wheelchair and bumped into things and that is how they happened. During an observation and interview on 8/28/2025 at 7:58 A.M., Nurse #1 observed Resident #12 with the surveyor present. Resident #12 was on his/her right side, and this limited Nurse #1's observation of his/her right lower leg. Nurse #1 said she could see some discoloration of the right leg and said a green bruise which could be a newer area was on the back of Resident #12's left calf. Further, Nurse #1 said when a nurse does a skin check it is head to toe and that it is documented on an assessment and not just checked off as administered. During an interview on 8/28/25 at 8:13 A.M., Charge Nurse #2 said when staff tell her that a resident has a skin injury, they start a risk report and will obtain statements, call the provider and family, get a treatment or order to monitor the area. Charge Nurse #2 said in the past Resident #12 has had injuries to his/her hands from wheeling around in his/her wheelchair. Charge Nurse #2 said she was not aware of any skin issues or injuries for Resident #12's lower right leg. At this time Unit Manger #1 entered the interview and said she was not aware of any skin issues for Resident #12. Unit Manager #1 said if a resident refuses a skin check the nurse doing the skin check would not check it off as administered. During an interview on 8/28/25 at 10:35 A.M., Nurse #6 said she signed off on the weekly skin check on 8/25/25, but did not document under the assessment, and that she did not see and was not informed of any skin issues. Nurse #6 said she worked yesterday (8/27/25) and no one brought it to her attention that Resident #12 had discoloration on his/her lower right leg. Nurse #6 said if staff see any bruises they are to report it immediately. Nurse #6 said yellow bruises are a sign of older bruises and that black and purple are likely newer bruises. During an interview on 8/28/25 at 9:33 A.M., the Director of Nursing (DON) said weekly skin checks are to be documented on the weekly skin assessment. The DON said she would expect that staff to report skin injuries seen during care to the nurse.

Based on observation, record review and interview, the facility failed to ensure for one Resident (#12), out of 7 residents reviewed for nutrition, out of a total sample of 25 residents, that a severe weight loss experienced by Resident #12 was addressed timely. Specifically, Resident #12's documented weight on 6/3/25 was 126.2 pounds and on 7/2/25 Resident #12's documented weight was 112.4 pounds, which is a body weight loss of 11.22 percent, which meets the criteria for severe weight loss. The clinical record failed to indicate a weight was retaken to confirm the weight loss, and the Registered Dietitian (RD) failed to conduct a nutritional assessment timely. A nutritional assessment by the RD was conducted 7/16/25, which was 14 days after Resident #12 experienced severe weight loss. Findings include: Review of the facility's policy entitled Weight Assessment and Interventions with a revision dated March 2022 included but not limited to the following:Residents weights are monitored for undesirable or unintended weight loss or gain.1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. 4. Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow the individual weight trends over time. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss+(usual weight-actual weight)/ (usual weight) x 100}: a.1 month-5% weight loss is significant; greater than 5% is severe, b.3 months- 7.5% weight loss is significant; greater than 7.5 percent is severe. c. 6 months-10% weight loss is significant; greater than 10% is severe. Resident #12 was admitted to the facility in May 2024 and has diagnoses that include, but are not limited to unspecified dementia, bipolar disorder, delusional disorders and heart disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/16/25, indicated Resident #12 had a staff assessment for mental status indicating Resident #12 as having severe cognitive impairment. Further, the MDS indicated Resident #12 required set up/cleanup assistance for eating, is 63 inches in height, weighs 112 pounds, and experienced a loss of 5% or more in the last month or loss of 10% in the last 6 months and is not on a physician-prescribed weight-loss regimen. During an observation on 8/26/25 at 10:35 A.M., Resident #12 was observed in his/her bed. Resident #12 did not respond to the surveyors greeting. During an observation on 8/27/25 at 7:59 A.M., Staff was observed in Resident #12's room and said the Resident's name 'you got to eat'. At 8:00 A.M., the tray was on the bedside table, and the Resident was in bed. On 8/27/25 at 8:41 A.M., Nurse #6 said I tried to feed Resident #12, he/she did not want to eat, so I got him/her some yogurt which he/she likes. Review of Resident #12's physician's orders indicated the following:-Regular Diet regular texture, regular thin liquids consistency dated 8/11/25.-Fortified foods dated 8/11/25-Offer yogurt twice a day at 2 PM (SIC) and HS (hour of sleep) document % consumed. Dated 8/11/25. Review of the physician's orders failed to indicate an order to obtain Resident #12s' weight. Review of the weight summary in Resident #12's electronic medical record indicated the following:-6/3/25 at 13:18 (1:18 P.M.) 126.6 (pounds) chair scale-7/2/25 at 14:18 (218 P.M.) 112.4 (pounds) chair scale (a 11.22 % of total body weight loss, which is severe)There was no documented weight to confirm the severe weight loss.-7/17/25 at 14:05 (2:05 P.M.) 117.8 (pounds) chair scale. This weight was 15 days after the 11.22 % severe weight loss was recorded in Resident #12's medical record and is a 6.95 % weight loss from 6/3/25.-7/24/25 14:13 (2:13 P.M.) 114.5 (pounds) chair scale-7/31/25 13:40 (1:40 P.M.) 112.8 (pounds)chair scale-8/1/25 10:38 A.M., 112.6 (pounds) chair scale-8/7/25 14:38 (2:38 P.M.) 111.6 (pounds) chair scale.No further weights were documented. Review of Resident #12's clinical record indicated a care plan with the following focus, Resident is at risk for malnutrition related to polypharmacy, limited mobility, need for therapeutic diet, weight changes, variable intakes, BMI (body mass index) 23, medical conditions: dementia, bipolar disorder, HTN (hypertension) emphysema, CAD (coronary artery disease) HLD (hyperlipidemia), dysphagia, anemia, dated as initiated 4/18/25, indicated: Goal: Gradually gain weight to healthy BMI parameters for population, Free from significant weight change, maintain meal intake of greater than 75 percent at 2-3 meals daily, no signs or symptoms of dehydration, skin will remain free of pressure injury comply with ordered diet, Labs WNL (within normal limits) revision on 8/7/25. The Care Plan goals for Resident #12 were revised 25 days after Resident #12 experienced a severe weight loss. Review of the interventions included but were not limited to: Provide fortified foods, dated 7/16/25 (14 days after the severe weight loss was documented in Resident #12's medical record), Alert RD to any decline in intake dated 4/22/25 monitor weights 4/22/25 Review of Resident #12's medical record indicated a Nutrition assessment dated [DATE], which was 14 days after Resident 12's documented severe weight loss. Comments: 1 month 6/3/25 126.2 # (pounds) (-10.9 % loss)3 months 4/2/25 128.8 # (-12.7 % loss)6 months 1/6/25 134# (-16.1 % loss)Assessment Comments/Summary (Resident) presents with significant weight loss x 1/3/6 months. Reweight requested to confirm accuracy. If weight loss confirmed, would be unplanned undesirable; etiology not clear. BMI 19.9 low for population. No fortified food or nutritional supplements on order. Recommending fortified foods with all meals. Review of the Nurse Practitioner encounter note, dated 7/15/25, (13 days after the documented weight of 112.4 pounds) indicated the weight of 126.2 and did not indicate or note that Resident #12 experienced a significant weight loss. Review of IDT (interdisciplinary team) note, dated 7/8/25, 6 days after Resident #12's documented severe weight loss indicated the following: Discussed patient with IDT team at risk meeting. Weight loss of 13 pounds noted. Discussed a re-weigh. The note was entered by an occupational therapist. The next recorded weight was documented on 7/17/25, 9 days after the IDT note dated 7/8/25. During an interview on 8/28/25 at 10:30 A.M., Nurse #6 said she was not aware Resident #12 was having any weight loss, but she only works two days a week. Nurse #6 said Resident #12 loves yogurt and blueberries and that Resident #12 did not eat too much yesterday and she ordered him/her a sandwich at lunch and fed him/her some pudding. Nurse #6 said fortified foods come up on a resident's meal tray from the kitchen. Nurse #6 said the nurses are responsible for making sure residents are weighed. Nurse #6 said if there is a loss then the resident is to be reweighed within a day or two to determine if the weight is accurate. During an interview on 8/28/25 at 1:19 P.M., Unit Manager #1 said the weight book they keep on the unit did not have any further weights or reweight for Resident #12 after the 7/2/25 entry and just had the weights listed in the electronic medical record. Unit Manager #1 said Resident #12 used to tool around in his/her wheelchair and help him/herself to yogurts in a manic way, which resulted in weight gain in the past. Unit Manager #1 said the behavior of eating yogurt changed about one month ago, and he/she was not eating as much as before. Unit Manager #1 said if a resident had a 3-pound weight change they will reweigh the resident within a few days to confirm the weight loss. Unit Manager said it is possible the next weight was obtained on 7/16/25. Unit Manager said they liberalized Resident #12's diet and added fortified foods around 7/16/25, which was 14 days after the documented severe weight loss. During an interview on 8/28/25 at 1:01 P.M., the Assistant Director of Nursing said Resident #12 had weight loss and that that a reweigh should have been obtained within a day or 2 of the documented weight loss. The ADON said when a resident has weight loss they are followed in a risk meeting with the team, and they take directions from the RD. During an interview on 8/28/25 at 12:23 P.M. the Registered Dietitian said the RD who covers the building was not available for interview and that she could speak to the process for monitoring resident's weights and nutritional status. The RD said obtaining resident's weights is entered as an order and specific to a resident's needs. The RD said residents will have nutritional assessments on admission, quarterly and with any identified changes or concerns. The RD said a weight report is pulled from the medical record which identifies any weight concerns. The RD said there is a strong focus on any weight changes over one month and a 6-month lookback. The RD said if a resident has a weight change including a gain or loss of 5% the team is responsible for the reweigh within 24 to 48 hours to confirm if it is a true weight change. The RD said the dietitian then would be notified by nursing and would complete an assessment to determine if it is unplanned and undesirable. For Resident #12 the RD reviewed the entries in the electronic medical record and said Resident #12 did have a weight loss and that there was no documented reweight taken after the 7/2/25 documented weight until 7/17/25. The RD said Resident #12's weight loss would be triggered as being significant. The RD said a nutritional assessment would be important to identify new interventions and monitor improvements to combat weight loss. The RD said she believes the delay of obtaining a reweight to confirm Resident #12's weight loss impacted having a nutritional assessment and implementing interventions timely.

Based on observations, interview and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV]), consistent with professional standards of practice for one Resident (#110) out of a total sample of 25 Residents. Specifically, the facility failed to change the PICC line dressing and measure the external length of the catheter as indicated in the physician's orders. Findings include:Review of facility policy titled Central Venous Catheter Care and Dressing Changes, dated as revised October 2024, indicated the following:-The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter- related infections that are associated with contaminated, loosened, soiled or wet dressings.-1. Assess central venous access devices with each infusion and at least daily:-2. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion.-3. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled).-5. Change the dressing if it becomes damp, loosened or visibly soiled and:-a. at least every 7 days-c. immediately if the dressing or site appears compromised. Resident #110 was readmitted to the facility in August 2025 with diagnoses that included presence of left artificial knee joint, encephalopathy and muscle weakness. Review of Resident #110's most recent Minimum Data Set (MDS) Assessment, dated 8/7/25 indicated a brief interview for mental status score of 15 out of 15, indicating intact cognition. On 8/26/25 at 7:53 A.M., the surveyor observed Resident #110 up and dressed in his/her wheelchair. The Resident had a PICC line to his/her right upper arm. The dressing was dated 8/20/25 and was peeling and lifting at the corners of the dressing. On 8/27/25 at 1:00 P.M., the surveyor observed the Resident in his/her room. A PICC line was observed to the right arm, and the dressing was dated 8/20/25, with the corners of the PICC line dressing lifting. On 8/28/25 at 7:26 A.M., the surveyor observed Resident #110 in his/her room up in his/her wheelchair. The Resident had a PICC line to his/her right arm. The dressing was dated 8/20/25 with the corners peeling and lifting. There was a piece of tape along one edge, taping down the dressing. Review of Resident #110's active PICC line care plan, dated 6/20/25, indicated the following:-Focus: I have a Single Lumen Central Line Catheter.-Interventions: Change dressing, injection caps and extension tubing weekly. Monitor every Shift and report any abnormalities to PCP, and treatments as ordered. Review of physician's orders indicated the following:- PICC Line Dressing/Connector(s): change and date PICC line dressing and change needless connector(s). Measure external PICC catheter. every night shift every Wed (Wednesday) for treatment, dated 8/13/25. Review of the August 2025 Treatment Administration Record (TAR) indicated that the PICC line dressing had been changed on 8/13, 8/20 and 8/27, despite an observation on 8/28/25 which indicated a PICC line dressing in place dated 8/20/25. Further Review of the TAR failed to indicate external catheter length was measured on 8/20 or 8/27. Review of Resident #110's progress notes failed to indicate external catheter length was measured and documented on 8/20 or 8/27. During an interview on 8/28/25 at 7:40 A.M., Charge Nurse #1 said that for every resident who admits with a PICC line she will ensure that the facility receives the insertion report as well as placement confirmation. She said that an order set is entered into the medical record for dressing changes on admission and weekly, as well as on an as needed basis. She said that part of the dressing change includes monitoring the external length of the catheter, which will assist in assessing whether or not the PICC line has migrated, or placement is compromised. She further said that if a nurse signs off that a dressing change is completed, she expects that it was completed, and if it was not, then it should not be signed off as such. During an interview on 8/28/25 at 7:47 A.M., Unit Manager #2 said that PICC line dressing changes should be completed as indicated in physician's orders; not completing dressing changes could increase the risk of infection. She further said that the as needed order should have been implemented for a peeling and lifting dressing. Unit Manager #2 also said an external catheter length should also be documented to confirm placement and that the PICC line has not migrated. During a phone interview on 8/28/25 at 10:20 A.M., Nurse #3 said that she was assigned to care for Resident #110 on 8/27/25. She said that she did not perform a PICC line dressing change. She said that she did administer IV medication for the Resident but does not recall noticing the date of the dressing or that it was peeling or lifting in the corners. During an interview on 8/28/25 at 9:27 A.M., the Director of Nurses (DON) said that a PICC line should be assessed at least every shift, and she would expect that dressing changes are being completed at least every 7 days and as needed. The DON said that part of the dressing change includes measuring the external catheter length to confirm that the PICC line has not migrated or dislodged from its placement. She said that if a PICC line dressing begins to lift or peel it increased the risk for infection and should be changed.

Based on observations, interviews and record review, the facility failed to maintain professional standards in managing and caring for urinary catheter devices for one Resident (#54) out of a total sample of 25 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not directly touching the floor.Findings include:Review of the facility policy titled Catheter Care, Urinary, revised August 2022, indicated:-The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.-Infection Control: Be sure the catheter tubing and drainage bag are kept off the floor.Resident #54 was admitted to the facility in July 2025 with diagnoses including obstructive uropathy (a condition in which the flow of urine is blocked) and dementia.Review of the most recent Minimum Data Set (MDS) assessment, dated 7/18/25, indicated Resident #54 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS also indicated Resident #54 had an indwelling urinary catheter. Review of Resident #54's physician's order, initiated 8/13/25, indicated:-Foley catheter (indwelling urinary catheter) care, every shift, initiated 8/13/25.Review of Resident #54's plan of care related to his/her indwelling urinary catheter, revised 7/15/25, indicated:-Provide catheter privacy bag and ensure that bag is not touching the floor.On 8/26/25 at 8:47 A.M., the surveyor observed Resident #54 in bed being assisted to eat by a staff member. He/she had a urinary catheter drainage bag which was attached to the bed frame by a privacy bag, and approximately half of it was directly touching the floor.On 8/26/25 at 10:45 A.M. and at 12:15 P.M., the surveyor observed Resident #54 in bed. He/she had a urinary catheter drainage bag which was attached to the bed frame by a privacy bag, and approximately half of it was directly touching the floor.On 8/26/25 at 12:24 P.M., the surveyor observed Resident #54 in bed. His/her health care proxy (HCP) was present and said she was concerned about how staff cares for his/her indwelling urinary catheter because he/she has had frequent urinary tract infections. Resident #54 had a urinary catheter drainage bag which was attached to the bedframe by a privacy bag, and approximately half of it was directly touching the floor.On 8/26/25 at 4:47 P.M., the surveyor observed Resident #54 in bed. He/she had a urinary catheter drainage bag attached to the bedframe by a privacy bag, and approximately a third of it was directly touching the floor.During an interview on 8/27/25 at 7:42 A.M., Certified Nurse Assistant (CNA) #1 said when Resident #54 is in bed the urinary catheter drainage bag should be attached to the bedframe by the privacy bag. CNA #1 said the privacy bag straps should be shortened to prevent the urinary catheter drainage bag from touching the floor. CNA #1 said the urinary catheter drainage bag and privacy bag should never directly touch the floor.During an interview on 8/27/25 at 7:47 A.M., Unit Manager #1 said Resident #54's urinary catheter drainage bag and privacy bag should never directly touch the floor because of the risk for infection. Unit Manager #1 said Resident #54 cannot adjust the height of his/her bed without assistance. Unit Manager #1 said Resident #54 was currently being treated for a urinary tract infection.Review of Resident #54's nurse progress note, dated 8/25/25, indicated:-Urine culture greater than 100,000 pseudomonas aeruginosa (a type of bacteria) n.o (new order) for ceftriaxone (an antibiotic medication) 1 gram daily x 7 days per NP (nurse practitioner).Review of Resident #54's provider progress note, dated 8/26/25, indicated a diagnosis of a urinary tract infection and that the urine culture collected prior to procedure positive.During an interview on 8/27/25 at 8:07 A.M., the Director of Nursing (DON) said Resident #54's urinary catheter drainage bag and dignity bag should never directly touch the floor and should be always elevated off the floor.

Based on observations, interviews, and record review the facility failed to provide care and services consistent with professional standards of practice for one Resident (#41) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 25 residents. Specifically, The facility failed to ensure ongoing assessment of the Resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.The facility failed to ensure an emergency kit including clamps were kept with the Resident in case of emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).Findings include: Review of the facility policy titled 'End-Stage Renal Disease, Care of a Resident with', dated September 2010, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.-If there is major bleeding from site (post dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on lumens. This is a medical emergency. Do not leave resident alone until emergency services arrive. Review of the facility policy titled 'Hemodialysis Catheters-Access and Care of' dated June 2025, indicated: Documentation-The nurse should document in the resident's medical record every shift as follows:1. Location of catheter.2. Condition of catheter (interventions if needed).3. If dialysis was done during shift.4. Any part of report from dialysis nurse post-dialysis being given.5. Observations post-dialysis. Resident #41 was admitted to the facility in August 2025 with diagnoses including chronic kidney disease, stage 5 and dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/9/25, indicated that Resident #41 was cognitively intact as evidenced by a Brief Mental Status (BIMS) score of 13 out of 15. This MDS indicated Resident #41 received hemodialysis. On 8/27/25 at 7:30 A.M., the surveyor observed dialysis access site to the right upper chest covered with undated bordered gauze. Resident #41 said that the nurse did not provide any care to assess the site upon his/her return from dialysis. Review of Resident #41's physician's order, dated 8/26/25, failed to indicate orders to monitor/assess the resident for any complications and to document in medical record. Review of Resident #41's plan of care related to hemodialysis, dated 8/3/25, indicated interventions including:-avoid blood pressure, blood work, and IV insertion on the affected arm.-check and change dressing daily at access site. Document.-monitor/document/report to physician (MD) as needed (PRN) and signs and symptoms of infection to access site: redness, swelling, warmth, or drainage.-monitor/document/report to MD PRN for signs and symptoms of the following: bleeding, hemorrhage, bacteremia, or septic shock.-obtain vital signs and weight per protocol. Report significant changes in pulse, respirations, and blood pressure immediately. Review of Resident #41's nursing progress notes, dated 8/2/25 through 8/26/25, failed to indicate observation and care of Resident #41's hemodialysis catheter or of Resident #41's condition pre- and post-dialysis. Review of Resident #41's Treatment Administration Record (TAR) and Medication Administration Record (MAR), dated 8/26/25, failed to indicate orders to monitor/assess site right chest port for any complications. Review of Resident #41's nursing admission assessment, dated 8/2/25, indicated he/she had right chest port for dialysis. On 8/26/25 at 8:57 A.M., Resident #41 was observed lying in his/her bed. The surveyor did not observe emergency clamps or pressure dressings in the Resident's room. On 8/27/25 at 7:30 A.M., Resident #41 was observed lying in his/her bed. The surveyor did not observe emergency clamps or pressure dressings in the Resident's room. During an interview on 8/27/25 at 7:36 A.M., Nurse #5 said that she had cared for Resident #41 last week and that he/she has a fistula in his/her right arm and care for him/her included checking for bruit and thrill in right arm access site and upon return from dialysis, a pressure wrap must be kept on site for 24 hours. She said that complications to the right arm access site could include bleeding and there should be clamp and dressing supplies in the Resident's room so that pressure can be applied but was not sure if they were there now. She said she documents an assessment on her residents every shift. During an interview on 8/27/25 at 9:35 A.M., Unit Manager #2 said that Resident #41's access for dialysis is a right chest port. She said the port must be kept covered. She said that the care of Resident #41 includes making sure his/her dialysis book is kept up to date and that they monitor any recommendations from dialysis, document any findings at dialysis including pre- and post-weights, update care plan, assess site every shift. She said there should be orders to assess the site. She said that there should be an order for no blood pressure on the arm on side where dialysis catheter is and that complications could include dislodgement, inflammation, or redness of the access site and there should be gauze, pressure dressing, and tape available for an emergency. She said there should be a clamp available in case of bleeding, but I don't have a clamp. During an interview on 8/27/25 at 11:36 A.M., the Director of Nursing (DON) said that a resident receiving dialysis should have a dialysis binder to communicate with the dialysis center. If the resident has a port there should be orders to check the site, maybe a dressing change and to visually assess site and document. She said that complications could include infection, or port could be compromised or dislodged. She said she would need to check on the protocol for emergency kit for external port and was not sure about the education provided to staff for a resident receiving dialysis. She said she would expect nursing staff to monitor access site before and after dialysis and to document in medical record, including signing on MAR or TAR. During an interview on 8/27/25 at 12:01 P.M., the DON said that another complication of a renal dialysis catheter could be bleeding. She was unable to provide a policy for emergency care of hemodialysis catheter. She said that Resident #41 has an emergency kit in his/her top drawer of his/her room and that she checked it herself. The surveyor went to room with DON and observed the emergency kit in Resident's top drawer with gauze in bag. The DON said the gauze would be used to apply pressure if there was bleeding at the catheter site. The DON was unaware that a clamp should be included in the emergency kit for a resident with a hemodialysis catheter.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to implement Enhanced Barrier Precautions for a central dialysis catheter for one Resident (#41), with a central dialysis catheter port, out of a total sample of 25 residents.Findings include:Review of the facility policy, titled 'Enhanced Barrier Precautions', dated December 2024, indicated: Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.-EBPs refer to infection prevention and control interventions designed to reduce the transmission of MDROs during high contact resident care activities.-EBPs apply when a resident has a wound or indwelling medical device.-indwelling medical devices include central lines, catheters, feeding tubes, and tracheostomies.-EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.-Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include:a. dressing.b. bathing.c. providing hygiene or grooming.d. transferringe. providing bed mobility.f. changing linens.g. changing briefs or assisting with toileting.h. device care or use.-Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. Resident #41 was admitted to the facility in August 2025 with diagnoses including chronic kidney disease, stage 5 and dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/9/25, indicated that Resident #41 was cognitively intact as evidenced by a Brief Mental Status (BIMS) score of 13 out of 15. This MDS indicated Resident #41 receives hemodialysis. This MDS also indicated that he/she required assistance with all personal care and mobility and that he/she had incontinence. On 8/26/25 at 8:57 A.M., the surveyor observed that the facility failed to post any signs on the door or wall outside Resident #41's room indicating he/she required EBPs. Review of Resident #41's entire medical record, dated 8/26/25, failed to indicate an order or documentation of the use of EBPs. On 8/27/25 at 12:03 P.M., Certified Nursing Aide (CNA) #2 said she had cared for Resident #41 before, and she had not used EBPs to care for that Resident. On 8/27/25 at 7:36 A.M., Nurse #5 said that Resident #41 should have sign for EBPs posted outside of his/her room. She said that she had not used EBPs to care for Resident. On 8/27/25 at 9:35 A.M., Unit Manager #2 said that Resident #41 should have EBPs for care related to open access (central line). She said that she had not used EBPs to care for Resident. On 8/27/2025 at 11:56 A.M., the Assistant Director of Nursing (ADON) said a resident with a port should have EBPs as it is an open line. On 8/27/25 at 11:36 A.M., the Director of Nursing (DON) said that Resident #41 should have EBP if he/she has a port as it is an open line. The DON said that the need for EBPs is communicated by a sign and a precaution cart outside of the Resident's room.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), and for one of three sampled employees (Certified Nurse Aide #1), and the Facility failed to ensure staff implemented and followed their abuse policy related to reporting of abuse allegations and employment requirements. 1) On 11/22/24, although Nurse #1 and the Charge Nurse were aware that Resident #1 had made an allegation that CNA #1 had slapped him/her on the arm during care, neither of them reported the allegation of abuse immediately to the Administrator or Director of Nurses, who were not made aware until three days later, and 2) prior to working at the facility, a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Certified Nurse Aide (CNA) #1, as required. Findings include: 1) The Facility Policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, revised 10/2022, also indicated that mandated reporters have a legal obligation to report all actual, suspected or alleged cases of abuse. The Policy indicated an immediate report should be made (following the facility's chain of command) listed as the Immediate Supervisor, the Administrator, the Director of Nursing Services, House Manager and Director of Social Services. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 11/25/24, indicated that at approximately 9:00 P.M. on 11/22/24, Nurse #1 immediately met with Resident #1 after CNA #1 stated he/she (Resident#1) had kicked her (CNA #1) during care and refused to take a shower. The report indicated Resident #1 told Nurse #1 that when he/she (Resident #1) asked CNA #1 for help to put on his/her shoes, CNA #1 slapped him/her on the left forearm. Review of Resident #1's clinical record indicated his/her diagnoses included a fracture of the right pubis and anxiety. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated 11/13/24, indicated he/she had intact cognitive functioning, scoring a 15 out of 15, on a Brief Interview for Mental Status. The MDS assessment indicated Resident #1 was able to understand others and make himself/herself understood. During a telephone interview on 12/17/24 at 3:30 P.M., Resident #1 said during the evening on a 3:00 P.M. to 11:00 P.M. shift (exact date unknown) CNA #1 was irritated with him/her and slapped him/her on the forearm with an open hand, while they were in the bathroom. Resident #1 said it was an open hand slap and it smarted for a minute. Resident #1 said he/she immediately reported the incident a nurse (exact staff member name unknown) and that other CNAs assisted him/her further that night. During a telephone interview on 12/17/24 at 10:20 A.M., Nurse #1 said at 8:40 P.M. on Friday 11/22/24 Resident #1 told her that CNA #1 slapped his/her left forearm intentionally, while providing assistance in the bathroom. Nurse #1 said Resident #1 told her he/she did not understand why CNA #1 wore protective gloves for collecting the laundry, was upset and said he/she (Resident #1) told CNA #1 not to wear them. Nurse #1 said Resident #1 told her then CNA #1 slapped him/her on the left forearm after his/her shoes were put on. Nurse #1 said she assessed Resident #1 for injury, and did not see any redness or evidence of physical harm. Nurse #1 said on 11/22/24, she immediately reported the alleged incident to the Charge Nurse on the unit. Nurse #1 said she did not report the allegation of abuse to the Administrator of Director of Nurses. Nurse #1 said witness statements were written and collected regarding the allegation of abuse and were placed in the Unit Manager's mailbox so that the Unit Manager would receive and review them on Monday 11/25/24 (which was when the Unit Manager work next, after the weekend). During a telephone interview on 12/17/24 at 3:25 P.M., the Charge Nurse said at approximately 9:15 P.M. on 11/22/24 (Friday) Nurse #1 told her that Resident #1 reported that CNA #1 had slapped his/her left forearm. The Charge Nurse said she gave Nurse #1 her written statement. The Charge Nurse said Nurse #1 told her that the written statements she collected, were put in the Unit Manager's mailbox. The Charge Nurse said she did not contact the Administrator of Director of Nursing to report the allegation of abuse. The Charge Nurse said she did not direct Nurse #1 to report the allegation immediately either. During an interview on 12/12/24 at 12:15 P.M., the Unit Manager said she found three written witness statements in her mailbox in the morning on 11/25/25 (Monday) from the Charge Nurse, Nurse #1 and Resident #1. The Unit Manager said she discovered, based on a review of the statements, that Resident #1 had alleged CNA #1 slapped his/her left forearm on 11/22/24. The Unit Manager said she immediately reported the allegation of abuse to the Director of Nurses. During an interview on 12/12/24 at 2:45 P.M., the Administrator and Director of Nurses (DON) said in the morning on 11/25/24 the Unit Manager reported to the DON that based on a review of written statements retrieved from her mailbox that morning, Resident #1 alleged CNA #1 had slapped his/her left forearm at approximately 8:40 P.M. on 11/22/24. The Administrator and DON said, prior to 11/25/24, they had not been made aware of the allegation. The Administrator and DON said Nurse #1 and the Charge Nurse should have immediately reported the allegation of abuse to them, per Facility Policy. 2) Review of Facility Policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, revised 10/2022, indicated the Facility will strictly adhere to screening protocol. The Policy indicated prior to employment, all potential new employees are subject to a Nurse Aide Registry (NAR) check. Review of CNA #1's Employee File indicated her first date of employment at the Facility was on 06/30/23. Further review of CNA #1's Employee File indicated there was no documentation to support that an NAR check had been conducted prior to her employment at the Facility. During on interview on 12/12/24 at 2:05 P.M., the Director of Nurses (DON) said CNA #1 was an agency contracted employee. The DON said CNA #1's NAR should have been completed prior to employment at the Facility by the agency. The DON said after speaking with the agency President, it was discovered that CNA #1 had not had a NAR check conducted prior to hire at the Facility.

Based on observation and interviews the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Specifically, the facility failed to ensure that insulin pens were labeled with resident name, open and expiration dates in one out of three medication carts observed. Findings Include: Review of facility policy titled Medication Storage in the Facility, dated as revised December 2019, indicated the following: -Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solution and strips, once opened require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. -Drugs dispensed in the manufacturer's original container will carry manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: -1. In a multi-dose injectable vial -3. An item for which the manufacturer has specified a usable life after opening. -The nurse will check the expiration date of each medication before administering it. During an observation on 9/11/24 at 9:15 A.M., the high end medication cart on the [NAME] unit had two Lantus insulin pens in it. Both pens were stored freely in the medication cart and failed to indicate an open or expiration date. Both insulin pens also had illegible resident names written on them with a black marker. During an interview on 9/11/24 at 9:15 A.M., Nurse #1 said that insulin pens should be labeled with an open date and expiration date since they are only good for 28 days once opened. She said that the writing on the insulin pens with black marker was illegible and unable to tell what resident each pen is intended for. During an interview on 9/11/24 at 9:18 A.M., Charge Nurse #2 said insulin pens should be labeled with resident names, open dates as well as expiration dates. She said Lantus insulin is good for 28 days only after opening. Charge Nurse #2 observed the unlabeled insulin pens and said she was unable to identify who each pen was for and that they are not labeled with an open or expiration date and they should have been. During an interview on 9/12/24 at 8:10 A.M., the Director of Nurses (DON) said that insulin pens, once opened require an open and expiration date label. She said the resident's name should also be on the medication.

Based on observations, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#104) out of a total sample of 26 residents. Specifically: 1a. For Resident #104, the facility failed to develop a plan of care for a stage 3 pressure ulcer that was present on admission to the facility and, 1b. For Resident #104, the facility failed to implement bed and chair alarms as indicated in the falls plan of care. Findings Include: Review of facility policy titled Interdisciplinary Care Planning, dated as revised 4/2024, indicated the following: -Care planning schedules are developed and coordinated by the Case Manager and/ or Social Services, in collaboration with the MDS (Minimum Data Set) Coordinator and nursing department. -The care plan process is not limited to developing a written plan but also addresses the ongoing execution of care, treatment, and services with a person- centered approach. The plan is continually reevaluated and modified to ensure the resident's needs are met. The plan includes: -Integrating the assessment findings into the care-planning process. -Regularly reviewing the care plan and modifying the plan as deemed necessary. -Comprehensive person-centered care plans are developed and/or reviewed and revised by the interdisciplinary team representing all appropriate health care workers: -As soon as possible after admission to address key clinical areas -No later than 7 calendar days after completion of the Comprehensive MDS for additional triggered areas. -With change in resident status. -Per regulatory mandates. Resident #104 was admitted to the facility in August 2024 with diagnoses including sepsis and osteomyelitis. Review of Resident #104's most recent Minimum Data Set (MDS) Assessment, dated 8/19/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that Resident #104 is cognitively intact. The MDS further indicated that the Resident has had no falls since admission and has one stage 3 pressure ulcer. 1a. On 9/10/23 at 9:14 A.M., Resident #104 was observed sitting up in his/her wheelchair. An air mattress was observed on his/her bed. Resident #104 said that he/she has a wound on their bottom. Review of Resident #104's most recent weekly skin check, dated 9/6/24, indicated a wound to coccyx. Review of Resident #104's Initial Wound Consult Form, dated 8/14/24 indicated the following: -Pt (patient) arrived with a large sacral wound he/she developed in the hospital. -Location: Sacrum, pressure wound Stage 3 measuring 4 x 4 x 0.2 centimeters (cm). Review of Resident #104's most recent wound consultant note, dated 9/11/24, indicated the following: -Location: Sacrum -Context: Pressure -Wound #1 Sacrum is a Stage 3 Pressure Injury Pressure Ulcer acquired on 8/14/24 and has received a status of not healed. Review of the facility matrix for providers provided to the survey team on 9/10/24 at 1:00 P.M., indicates that Resident #104 has a stage 3 pressure ulcer. Review of Resident #104's physician orders indicated the following: -An order dated 8/30/24, wound treatment: Sacrum. Cleanse with wound cleanser, pat dry, apply medihoney impregnated alginate and cover with silicone border MWF (Monday, Wednesday Friday) and as needed. (sic) -An order dated 9/5/24, Air Mattress settings according to manufacturer's guidelines. Check settings and function every shift. (sic) Review of Resident #104's active care plan indicated the following: -A care plan dated as reviewed/revised on 7/26/24 indicating potential for skin breakdown r/t (related to): impaired mobility with a goal indicating skin will not exhibit breakdown x 90 days. (sic) Review of Resident #104's active care plan failed to indicate a plan of care for actual skin breakdown related to a stage 3 pressure injury to the sacrum. During an interview on 9/12/24 at 7:09 A.M., Charge Nurse #1 said when residents are admitted or readmitted from the hospital, care plans are initiated or updated as appropriate with any new acute concerns. She said that Resident #104's returned from the hospital with a stage 3 pressure injury but his/her active care plan did not include a plan of care for actual skin breakdown that was present upon readmission from the hospital, but it should have. During an interview on 9/13/24 at 8:10 A.M., the Director of Nurses said care plans should be reviewed and updated upon readmission from the hospital. 1b. On 9/10/24 at 9:14 A.M., Resident #104 was observed sitting up in his/her wheelchair, no chair alarm was in place. On 9/10/24 at 1:06 P.M., Resident #104 was observed sitting up in his/her wheelchair, no chair alarm was in place. No bed alarm was observed during this time. Resident #104 said that he has not had alarms to bed or chair since admission. On 9/11/24 at 7:33 A.M., Resident #104 was observed lying in bed, no bed alarm was in place. On 9/11/24 at 7:57 A.M. and 11:14 A.M., Resident #104 was observed sitting up in his/her wheelchair, no chair alarm was in place. Review of Resident #104's physician orders indicated the following: -Bed/chair alarm at all times, every shift, dated 7/27/24. Review of Resident #104's active falls care plan, dated as last reviewed/revised 8/14/24, indicated that the Resident has the potential for injury related to increased risk for falls r/t: (related to) weakness, impaired mobility, with approaches that include alarms a/o (as ordered) (7/27 Bed/Chair Alarms). (sic) Review of Resident #104's September 2024 Treatment Administration Record (TAR) indicated that Bed/ Chair alarms were documented as applied every shift in September. During an interview on 9/11/24 at 11:36 A.M., Certified Nursing Assistant (CNA) #1 said that she is assigned to care for Resident #104. She said that he/she does not use bed or chair alarms because he/she uses the call light to ask for assistance with getting up and getting out of bed. During an interview on 9/12/24 at 7:09 A.M., Charge Nurse #1 said that nurses and CNAs should be following the plan of care and implementing physician's orders as indicated. She said that Resident #104 has not utilized bed or chair alarms since mid-August, and the plan of care and physician's orders should have been implemented or updated, but they were not. During an interview on 9/12/24 at 8:10 A.M., the Director of Nurses (DON) said the plan of care should be implemented as indicated or updated for current appropriate approaches for each resident.

Based on observations, record review and interviews, the facility delayed the implementation of a wound treatment for two days after discovering a new wound for one Resident (#1) out of a total sample of 26 residents. Findings include: Review of the facility policy titled, Pressure Injury Prevention & Treatment Program, dated February 2022, indicated the following: Policy: The facility is committed to providing a comprehensive, interdisciplinary, and evidence-based approach to: -implement individualized person-centered interventions to attempt to stabilize, reduce or remove underlying risk factors. Documentation A. Modify the care plan to meet the changing needs of the resident and utilizing a person-centered care approach. Resident #1 was admitted to the facility in June 2022 with diagnoses including diabetes, osteoarthritis, and muscle weakness. Review of Resident #1's most recent Minimum Data Set, dated dated dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she is cognitively intact. Review of the nursing note dated 9/7/24 indicated the following: Alert. OOB (out of bed), in room this morning. Per resident, hemorrhoids bleeding. Nurse also noted blood in toilet. Cream applied. Nurse noted open area to L (left) buttock. no s/s (signs/symptoms) of infected noted. Nurse cleaned area, applied opti-foam (wound dressing). Declined pain .Provider and HCP notified. During an interview on 9/12/24 at 8:20 A.M., Resident #1 said he/she got a wound on his/her buttock due to the plastic incontinence pad sticking to his/her skin and pulling off the skin. Resident #1 said nursing puts a pad on it now, but did not put anything on it for the first couple of days. Review of the Treatment Administration Record (TAR) for September 2024, indicated the following orders: -Change Opti-foam dressing to bottom daily or as needed until healed, initiated on 9/9/24. -Wound treatment: L buttock. Cleanse area with NS, pat dry and apply Opti-foam every other day and PRN (as needed) if soiled, initiated on 9/12/24. Review of Resident #1's medical record failed to indicate any further notes describing the new open area. The skin assessment completed on 9/10/24 indicated ongoing treatment to buttocks and did not describe the wound size or condition. Review of Resident #1's care plans failed to indicate an actual skin breakdown care plan has been initiated. During an interview on 9/12/24 at 7:56 A.M., the Director of Nursing (DON) said any new skin areas need to be investigated, reported to the physician and new interventions need to be implemented immediately. The DON said weekly skin checks are completed on everyone and residents who have wounds should have measurements documented on the assessments. The DON was unable to answer specific questions regarding Resident #1's wounds.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they implemented and followed their abuse policy, when after being made aware that Resident #1's family member physically restrained him/her in his/her wheelchair to prevent him/her from getting up, the Facility did not conduct an investigation into the incident and did not report the use of the restraint to their State Agency, as required. Findings include: The Facility Policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated 10/2022, indicated residents had the right to be free from abuse, which included corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's symptoms. The Policy indicated that when alleged violations were observed by or reported to or suspected by an employee, they would immediately notify the Administrator or designee, and the person who received notification would initiate an investigation, identify and interview all involved persons, document all interviews on Occurrence Witness Statement forms, immediately initiate an internal investigation, and maintain evidence that all alleged violations have been thoroughly investigated The Policy indicated the Facility would submit an initial report immediately but not later than two hours after the allegation was made to the Department of Public Health via the Health Care Facilities Reporting System (HCFRS). The Facility Policy titled, Guidelines for the Use of a Restraint, dated 11/2016, indicated the following: -Physical Restraint was defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident could not remove easily which restricts freedom of movement or normal access to their body, including trays, tables, bars, or belts that the resident could not remove easily or prevent the resident from rising. -Use of restraints for discipline or convenience was prohibited. -Every resident had the right to be free from any physical or chemical restraint imposed for purposes of discipline or convenience, and not required to treat the resident's symptoms. Resident #1 was admitted to the Facility in July 2023, diagnoses included left femur fracture, history of falls, atrial fibrillation, end stage renal disease, and cognitive communication deficit. During an interview on 01/11/24 at 4:00 P.M., Certified Nurse Aide (CNA) #1 said, some time in August 2023 (exact date unknown), he had observed that Resident #1 was restrained in his/her wheelchair by a gait belt (safety device used to help someone move, such as from a bed to a chair, also used to help hold someone up while he/she walks). CNA #1 said he did not remove the gait belt but said he told Nurse #4 right away. During a telephone interview on 01/11/23 at 02:41 P.M., Nurse #4 said that on 08/21/23 at 4:00 P.M., she observed Resident #1 in his/her room, restrained in his/her wheelchair with a gait belt secured around his/her waist and around the back of the wheelchair, with the clip in the back that was out of Resident #1's reach. Nurse #1 said Resident #1's family member was in the room with him/her and admitted to securing the gait belt to Resident #1 and the wheelchair so he/she would not fall. Nurse #1 said she removed the gait belt, educated Resident #1's family member, and reported the incident of resident restraint to the Director of Nurses right away, that same day. Review of Resident #1's Nurse Progress Note, dated 08/21/23, indicated Nurse #4 educated Resident #1's family member regarding the use of a gait belt and the Facility's policies. Review of the Reports submitted by the Facility via the Health Care Facility Reporting System (HCFRS) from 08/21/23 (the date of the incident) through 01/11/24 (the date of the survey) indicated there were no reports submitted by the Facility to the Department of Public Health regarding an incident of resident restraint, involving Resident #1 and his/her family member. During an interview on 01/11/23 at 08:48 A.M., and throughout the survey, the Director of Nurses (DON) said she was made aware on 08/21/23 by Nurse #4 that Resident #1's family member had secured a gait belt around his/her waist and wheelchair as a restraint and said the Facility had not investigated or reported the incident of resident restraint to the Department of Public Health.

Based on record reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of Warfarin (an anticoagulant) which required blood laboratory work to be completed and reported to the physician so new orders could be obtained for the Warfarin, the Facility failed to ensure that he/she was free from significant medication errors, when due to a transcription error by nursing, the blood laboratory work was not ordered and obtained, therefore new physician orders for the Warfarin were not obtained, and Resident #1 went two weeks without receiving his/her Warfarin, placing him/her at increased risk for the development of blood clots. Findings include: The Facility Policy, titled General Guidelines for Medication Administration, dated 12/2019, indicated medications would be administered safely and without unnecessary interruptions, and the right resident, drug, dose, route and time would apply for each medication. The Facility Policy, titled Anticoagulant Monitoring, dated 01/2016, indicated residents on anticoagulation therapy would be assessed and monitored to ensure that safe laboratory parameters established by the attending physician were maintained. Resident #1 was admitted to the Facility in July 2023, diagnoses included left femur fracture, history of falls, atrial fibrillation, end stage renal disease, and cognitive communication deficit. Review of Resident #1's Admission History and Physical, dated 07/18/23, indicated Resident #1 had a physician's order for Warfarin and the therapeutic goal for his/her International Normalized Ratio (INR), (blood laboratory value which is used to monitor the effectiveness of anticoagulants such as Warfarin) was between 2.0 and 3.0. Review of Resident #1's Blood Laboratory Report, dated 07/24/23, indicated his/her INR was 1.7. Review of Resident #1's Physician Order Report for July 2023, indicated he/she had a physician's order, dated 07/24/23 for Warfarin 3.5 milligrams (mg) by mouth, once daily in the evening, and to recheck his/her INR on 07/27/23. Further review of Resident #1's Medical Record indicated there was no documentation to support his/her INR was obtained on 07/27/23. As a result of not obtaining and reporting Resident #1's INR to the physician, new orders related to the administration of Warfarin were not obtained by nursing, and Resident #1 was not administered Warfarin for two weeks. Review of Resident #1's Physician's Note, dated 08/09/23, indicated his/her Warfarin medication was missed, and a STAT INR was ordered for 08/10/23. Review of Resident #1's Medication Administration Record (MAR), for July 2023 and August 2023, indicated he/she did not receive any Warfarin from 07/26/23 through 08/10/23. Review of the Facility's Clinical Occurrence Report, dated 08/09/23, indicated there was a delay in treatment related to the omission of Resident #1's Warfarin. The Report indicated that when Nurse #1 transcribed Resident #1's Warfarin order dated 07/24/23, she did not enter the INR into the Facility's laboratory order system. The Report indicated that as a result, nursing staff did not obtain Warfarin orders for the dates of 07/27/23 through 08/10/23 (14 days). Review of Resident #1's Blood Laboratory Report, dated 08/10/23, indicated his/her INR was 1.0, which was below his/her therapeutic goal. During a telephone interview on 01/18/23 at 4:51 P.M., Physician Assistant (PA) #1 said that on 08/09/23 she reviewed Resident #1's Medical Record and noticed that his/her Warfarin had not been ordered since 07/27/23, and that blood laboratory work for an INR had not been completed since 07/24/23. PA #1 said Resident #1 was prescribed Warfarin because he/she had Atrial Fibrillation (abnormal heart rate), and was on Warfarin to prevent blood clots. PA #1 said Resident #1's below therapeutic INR level put him/her at risk for blood clots, deep vein thrombosis, and Pulmonary Embolisms (blood clot in the lungs), which could become life threatening. During an interview on 01/11/23 at 04:26 P.M., Nurse #1 said that on 07/24/23, she transcribed Resident #1's Physician's order for Warfarin, however she failed to enter the INR in the Facility's laboratory draw system, and as a result Resident #1's INR was not obtained, and his/her physician's order for Warfarin dosage were not in place for a period of 14 days. During an interview on 01/11/23 at 8:48 A.M., the Director of Nurses said that on 07/24/23, Nurse #1 did not enter Resident #1's INR order for 07/27/23 into the Facility's laboratory order system, therefore his/her INR was missed and he/she was not administered Warfarin orders for a period of 14 days. The DON said the lab order should have been entered.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls and required the use of pressure sensitive alarms in an effort to prevent falls, the Facility failed to ensure he/she was provided with the necessary functional safety devices to maintain his/her safety, when on 8/20/23 after he/she was found on the floor after a fall, it was determined that his/her pressure sensitive alarm was not in place, and on 8/21/23 the pressure sensitive alarm was knowingly disabled by a staff who left Resident #1 alone in the bathroom and he/she was found a short time later on the floor by staff. Resident #1 sustained multiple skins tears as result of both falls. Findings include: The Facility Policy titled Accident and Incidents, dated 01/2020, indicated: -an incident was defined as any event that occurred by chance or arising from unknown cause which was not consistent with the desired operation of the Facility or the care of the residents. -All accidents or incidents must be reported and investigated and an occurrence report would be filled out, including the date, time, place, circumstances, any witnesses, date and time next of kin was notified, corrective action taken, person filling out the report, and any other pertinent data. The Facility Policy titled, Interdisciplinary Care Planning, dated 11/2017, indicated the Facility would assess each resident's individual needs and provide effective person-centered care that met professional standards of quality of care. The Facility Policy titled Falls Management Program, dated 01/2018, indicated an avoidable accident was defined as an accident that occurred because the Facility failed to implement interventions consistent with a resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. The Facility Policy titled, Guidelines for the Use of Position Change Alarms, dated 09/2018, indicated position change alarms were defined as an alerting device intended to monitor a resident's movement. The Device emits an audible signal when the resident moves in a certain way and may be implemented as one approach to alert staff when a resident requiring contact guard or physical assistance is attempting to stand or transfer independently. Resident #1 was admitted to the Facility in July 2023, diagnoses included left femur fracture, history of falls, atrial fibrillation, end stage renal disease, and cognitive communication deficit. Review of Resident #1's Fall Assessment Tool, dated 07/14/23, indicated he/she was assessed as being at high risk for falls. Review of Resident #1's Physician Order Report, indicated he/she had a physician's orders for the following: -Bed alarm at all times, check function and placement every shift, dated 07/18/23 -Chair alarm on at all times, check function and placement every shift, dated 07/18/23. Review of Resident #1's Activities of Daily Living Care Plan, dated 07/18/23, indicated he/she was at high risk for falls, and interventions included pressure sensitive alarms, as ordered, to Resident #1's bed and chair. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 07/20/23, indicated he/she was dependent on staff to safely come to a standing position and for toilet transfers. Review of the Facility's list of falls for August 2023 indicated Resident #1 fell four times while at the Facility, that falls occurred on the following dates: 08/10/23, 08/20/23, 08/21/23, and 08/24/23, with two of the falls resulting in injuries. Review of Resident #1's Nurse Progress Note, dated 08/20/23, indicated Nurse #2 heard Resident #1 fall, and found him/her lying on his/her back on the floor in his/her room. The Note indicated Resident #1 said he/she was trying to get into bed. The Note indicated Resident #1's chair alarm was not in place at the time. The Surveyor was unable to interview the Certified Nurse Aide who was assigned to care for Resident #1 on 08/20/23, as he was unavailable for interview, and did not respond to the Departments multiple requests for an interview. During an interview on 01/18/23 at 1:28 P.M., Nurse #2 said that Resident #1 was known to be impulsive, was unsteady on his/her feet, and was known to attempt to self transfer. Nurse #2 said that on 08/20/23 at 10:30 A.M., she was near Resident #1's room and heard a loud thud. Nurse #2 said she found Resident #1 in his/her room lying on his/her back on the floor. Nurse #2 said Resident #1 told her that he/she was trying to get in bed from the chair and fell . Nurse #2 said Resident #1's chair alarm was not sounding at the time, and he/she had skin tears on his/her both knees as a result of the fall. Review of Resident #1's Nurse Progress Note, dated 08/21/23, indicated that at 6:45 P.M., Resident #1 was found on the floor of the bathroom in his/her room. The Note indicated that Certified Nurse Aide (CNA) #1 had left Resident #1 alone in the bathroom before he/she fell . During an interview on 01/11/23 at 4:00 P.M., CNA #1 said that on 08/21/23 at 6:45 P.M., he assisted Resident #1 to the bathroom, onto the toilet and left him/her there while he answered another call bell. CNA #1 said he had disabled Resident #1's chair alarm before transferring him/her. CNA #1 said he knew leaving Resident #1 on the toilet meant there was no alarm in place, and that staff would not be alerted if Resident #1 attempted to self transfer. CNA #1 said when he returned to Resident #1's bathroom a few minutes later, he/she was already on the floor. During an interview on 01/19/23 at 08:12 A.M., Nurse #3 said Resident #1 was known to be impulsive, was unsteady on his/her feet, and would often attempt to self transfer. Nurse #3 said that on 08/21/23 at 6:45 P.M., she was alerted by another staff member that Resident #1 had a fall, that he/she was on the floor in the bathroom and had multiple skin tears on his/her arms as a result. During an interview on 01/11/23 at 8:48 A.M., and throughout the survey, the Director of Nurses (DON) said that on 08/20/23 Resident #1's bed and chair alarms should have been in place and checked for functioning as per his/her care plan but was not, and said that on 08/21/23, CNA #1 should not have left Resident #1 without his/her chair alarm in place and should not have left him/her alone on the toilet.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose care plan interventions included that he/she required the use of pressure sensitive alarms at all times when in bed and/or chair, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her Plan of Care, that his/her pressure sensitive alarms were in place and functioning, and as a result, Resident #1 experienced falls two day in a row and sustained skin tears with each fall. Findings include: The Facility Policy titled, Interdisciplinary Care Planning, dated 11/2017, indicated the Facility would assess each resident's individual needs and provide effective person-centered care that met professional standards of quality of care. The Facility Policy titled, Falls Management Program, dated 01/2018, indicated an avoidable accident was defined as an accident that occurred because the Facility failed to implement interventions consistent with a resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. The Facility Policy titled, Guidelines for the Use of Position Change Alarms, dated 09/2018, indicated position change alarms were defined as an alerting device intended to monitor a resident's movement. The Device emits an audible signal when the resident moves in a certain way and may be implemented as one approach to alert staff when a resident requiring contact guard or physical assistance is attempting to stand or transfer independently. Resident #1 was admitted to the Facility in July 2023, diagnoses included left femur fracture, history of falls, atrial fibrillation, end stage renal disease, and cognitive communication deficits. Review of Resident #1's Fall Risk Assessment Tool, dated 07/14/23, indicated he/she was assessed as being at high risk for falls. Review of Resident #1's Physician Order Report indicated he/she had a physician's orders for the following: -Bed alarm on at all times, check function and placement every shift, dated 07/18/23. -Chair alarm on at all times, check function and placement every shift, dated 07/18/23. Review of Resident #1's Activities of Daily Living Care Plan, dated 07/18/23, indicated he/she was at high risk for falls, and interventions included pressure sensitive alarms, as ordered, to Resident #1's bed and chair. Review of Resident #1's Admission Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she was dependent on staff for safely to come to a standing position and for toilet transfers. Review of Resident #1's Nurse Progress Note, dated 08/20/23, indicated Nurse #2 heard Resident #1 fall, and found him/her lying on his/her back on the floor in his/her room, and he/she said he/she was trying to get into bed. The Note indicated Resident #1's chair alarm was not in place at the time. The Surveyor was unable to interview the Certified Nurse Aide who was assigned care for Resident #1 on 08/20/23, as he was unavailable and did not respond to the Department of Public Health's request for an interview. During an interview on 01/18/23 at 1:28 P.M., Nurse #2 said that Resident #1 was known to be impulsive, was unsteady on his/her feet, and was known to attempt to self transfer. Nurse #2 said that on 08/20/23 at 10:30 A.M., she was near Resident #1's room and heard a loud thud. Nurse #2 said she found Resident #1 in his/her room lying on his/her back on the floor. Nurse #2 said Resident #1 told her that he/she was trying to get in bed from his/her chair and fell . Nurse #2 said Resident #1's chair alarm was not sounding at the time of the fall. Nurse #2 said Resident #1 had sustained skin tears to both of his/her knees, as a result of the fall. Review of Resident #1's Nurse Progress Note, dated 08/21/23, indicated that at 6:45 P.M., Resident #1 was found on the floor of the bathroom in his/her room. The Note indicated that Certified Nurse Aide (CNA) #1 had left Resident #1 alone in the bathroom before he/she fell . During an interview on 01/11/23 at 4:00 P.M., CNA #1 said that on 08/21/23 at 06:45 P.M., he assisted Resident #1 to the bathroom onto the toilet, and left him/her there while he answered another call bell. CNA #1 said he had disabled Resident #1's chair alarm before transferring him/her, CNA #1 said he knew leaving Resident #1 on the toilet meant there was no alarm in place, and that staff would not be alerted if Resident #1 attempted to self transfer. CNA #1 said when he returned to Resident #1's bathroom a few minutes later, he/she was already on the floor. During an interview on 01/19/23 at 08:12 A.M., Nurse #3 said Resident #1 was known to be impulsive, was unsteady on his/her feet, and would often attempt to self transfer. Nurse #3 said that on 08/21/23 at 6:45 P.M., she was alerted by another staff member that Resident #1 had a fall, that he/she was on the floor in the bathroom and had multiple skin tears on his/her arms as a result. During an interview on 01/11/23 at 8:48 A.M., and throughout the survey, the Director of Nurses (DON) said that on 08/20/23 Resident #1's bed and chair alarm should have been in place and checked for functioning as per his/her care plan but was not, and said that on 08/21/23, CNA #1 should not have left Resident #1 without his/her chair alarm in place and should not have left him/her alone on the toilet.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure it maintained a complete and accurate medical record related to Activities of Daily Living care provided by Certified Nurse Aides. Findings include: The Facility Policy titled Documentation Expectations, dated 03/01/21, indicated documentation would be complete and conducted in a timely manner. Resident #1 was admitted to the Facility in July 2023, diagnoses included left femur fracture, history of falls, atrial fibrillation, end stage renal disease, and cognitive communication deficit. Review of the Shower Schedule for the Clipper Unit, undated, indicated Resident #1 was scheduled to receive showers three times weekly on Monday, Wednesday, and Friday, (so from 07/14/23 through 08/23/23, Resident #1 should have received a total of 20 showers), Review of Resident #1's Point of Care ADL Category Report, dated 07/14/23 through 08/23/23 indicated Resident #1 only received four showers during this time frame (which were on 07/30/23, 08/06/23, 08/14/23, and 08/22/23). During an interview on 01/11/24 at 08:48 A.M., the Director of Nurses (DON) said that during Resident #1's admission to the Facility she was made aware that his/her family was concerned that he/she was not receiving showers. The DON said she had interviewed CNAs who had provided care for Resident #1 and was told he/she had received showers as scheduled. The DON said she reviewed the CNA documentation and said it indicated that CNAs had not documented Resident #1's showers as given but should have.

Based on observation and interview the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings include: Review of the undated facility policy titled Refrigerator Guidelines, indicated the following: -Label and date all leftovers and refrigerate immediately -Label and date food items when removing from the freezer to thaw On 9/5/23 at 6:59 A.M., the following observations were made during the initial walk through of the kitchen: -Whipped cream in an open piping bag, unlabeled and undated in the walk-in refrigerator. -Shredded carrots, unlabeled and undated in the walk-in refrigerator. -Five boxes containing food items stored directly on the freezer floor -Two beverages from a local franchise stored in direct contact with resident drinks in the reach-in refrigerator. -A tin foil pan containing chili in the freezer, the wrap was ripped exposing the chili to open air; there was ice buildup present on the chili. During an interview on 9/5/23 at 7:11 A.M., a cook said that one of the beverages from the local franchise stored with resident food items belonged to her. On 9/6/23 at 11:46 A.M. through 12:09 P.M., the following observations were made on the tray line during breakfast service: -The cook contaminated her gloves by touching the handles of serving utensils, the bottom of plates, a knife handle, and then with the same contaminated gloves directly grabbed six ready to eat [NAME] sandwiches placing the sandwiches on six different residents' trays. -The other cook contaminated her gloves by touching the handles of serving spoons, tongs, the outside of a pan, scoops, and by leaning/holding on to the food preparation table in a way that her fingers touched underneath the table. The cook then, with the same contaminated gloves, directly grabbed ready to eat food including bread and a [NAME] sandwich placing the food items on four different residents' trays During an interview on 9/5/23 at 7:01 A.M., the Food Service Director (FSD) said food items should not be stored on the floor and should be put away/elevated as soon as possible, the FSD said that they have not received a food order today and that the food stored on the freezer floor was from the previous day. The FSD also said that all food items should be labeled and dated, and unlabeled and undated food items should be discarded. The FSD said staff drinks should not be stored in refrigerators containing resident food, drinks or ingredients.

Based on observation, record review the facility failed to revise the plan of care for one Resident (#105) out of a total of 25 sampled Residents. Findings include: Resident #105 was admitted to the facility in April 2023 with diagnoses including vascular dementia and dysphagia. Review of Resident #105 Minimum Data Set assessment dated [DATE] indicated Resident #105 scored 8 out of a possible 15 on the Brief Interview for Mental Status Exam indicating moderate cognitive impairment. The MDS also indicated Resident #105 requires assistance with eating. During an interview on 9/5/23 at 8:13 A.M., Resident #105 said I have a swallowing problem. The surveyor then observed a sign taped to the wall above Resident #105's bed indicating: Cue to perform second swallow after food/liquid intake. The surveyor observed Resident eating his/her breakfast alone in his/her room and occasionally coughing and clearing his/her throat. On 9/5/23 at 12:15 P.M., the surveyor observed staff deliver Resident #105's lunch meal to him/her in his room and leave. Resident #105 ate his/her lunch meal alone in his/her room. Review of Resident #105's Speech Therapy discharge summary dated 8/21/23 indicated: Patient Progress Progress & Response to Tx (Treatment): Pt shown to aspirate all consistencies trailed with greater instance of residue on thickened liquid and ground food trials. Least restrictive diet texture at this time is puree, thin liquids with strategy to reduce [sic] residue and instance of aspiration being repeated dry swallows s/p (after) PO intake. Supervision for Oral Intake: Close supervision Review of Resident #105's clinical record on 9/5/23 included an Activities of Daily Living care plan dated 4/26/23 indicated Resident #105 was independent with eating. On 9/6/23 at 8:18 A.M., the surveyor observed Resident #105 eating breakfast alone in his/her room. During an interview on 9/6/23 at 8:23 A.M., Certified Nurse Assistant #1 said that Resident #105 has swallowing issues and eats by himself/herself in his/her room. During an interview on 9/6/23 8:44 A.M., Speech Therapist #1 said that Resident #105 had a swallow study done which found Resident #105 aspirates all consistency foods and liquids. Speech Therapist said that the facility had a family meeting and Resident #105 was put on hospice services. Speech Therapist #1 said that Resident #105 was at risk for choking and should be supervised and cued for a second swallow during meals. During an interview on 9/6/23 at 12:11 P.M. Unit Manager #1 said that Resident #105's care plan was not updated.

Based on observation, record review and interview the facility failed to ensure the plan of care was implemented for 1 Resident (#76) out of a total sample of 25 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #76 is supervised with one person assist for meals. Further review of the MDS indicated that Resident #76 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Review of the care plan dated 8/12/23, indicated Resident #76 is supervised with meals. On 9/5/23, at 8:25 A.M., the surveyor observed Resident #76 in bed, eating a puree diet without staff present. On 9/6/23, at 8:14 A.M., the surveyor observed Resident #76 in bed sleeping with a meal tray, untouched, on the over the bed table. The surveyor also observed that no staff were present in the room. On 9/6/23, at 8:39 A.M., the surveyor observed Resident #76 in bed eating without staff present in the room. During an interview on 9/06/23, at 11:58 A.M., the Director of Nursing said that the expectation is that resident care plans are to be followed.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be at high risk for falls and required physical assistance from staff for transfers (with the use of a gait belt) and ambulation, the Facility failed to ensure staff provided the appropriate level of assistance, use of an assistive device, and provide properly functioning equipment in an effort to maintain his/her safety to prevent an accident when: -On 06/01/22, Certified Nurse Aide (CNA) #2 assisted Resident #1 with a transfer out of bed without the use of a gait belt, left him/her standing alone with his/her walker as she walked to the other side of the bed to disconnect a piece of medical equipment and Resident #1 fell to the floor. -On 06/06/22, Resident #1 was observed on the floor of his/her room, his/her pressure alarm (an alarm that alerts staff if he/she attempts to stand without assistance) was found to be plugged in but not working (not sounding), his/her wheelchair brakes were found to be improperly functioning and as a result did not secure the wheelchair from moving when the brakes were engaged. -On 06/07/22, CNA #3 attempted to assist Resident #1 with a transfer out of bed and into a wheelchair without the use of a gait belt, he/she lost his/her balance, fell to the floor, struck his/her head and sustained a laceration. Resident #1 was transferred to the Hospital Emergency Department where he/she required four surgical staples to close the laceration on his/her head. Findings Include: Review of the Facility Policy titled Ambulation, dated 2/2016, indicated that a gait belt should be used for transfer and/or ambulation if a resident required hands on assistance to transfer or ambulate. Review of the Facility Policy titled Falls Management Program, dated 01/2018, indicated it was the policy of the Facility to ensure that the resident environment remains as free from hazards as possible and to provide adequate supervision and assistive devices to reduce the risk of accidents. Review of Resident #1's Fall Risk Assessment Tool, dated 05/23/22 indicated he/she was assessed to be at high risk for falls. Review of Resident #1's Physical Therapy (PT) Evaluation and Plan of Care, dated 05/24/22, indicated that he/she required partial/moderate assistance with transfers from chair/bed-to-chair and that he/she required partial to moderate assistance with sitting to standing. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 05/29/22, indicated that he/she was admitted to the Facility in May 2022, diagnoses included: [CONDITION(S)], infection following a surgical procedure, [CONDITION(S)], irritable bowel syndrome, restless leg syndrome, and muscle weakness. The MDS indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and indicated that he/she required the physical assistance of staff for transfers and ambulation. 1. Review of Resident #1's Incident Report, dated 06/01/22, indicated that at 4:20 P.M., he/she fell to the floor while he/she transferred into his/her wheelchair with staff present. Review of Resident #1's Occurrence Witness Statement, dated 06/01/22, indicated that CNA #2 assisted him/her out of bed with his/her walker, and while CNA #2 bent down to pick up his/her wound vacuum equipment, Resident #1 began to turn towards the wheelchair, lost his/her balance, and landed on the floor. The Statement indicated that after the fall, a nurse came to assess Resident #1 and a gait belt was applied in order to transfer him/her into the wheelchair. During an interview on 06/28/22 at 2:59 P.M., CNA #2 said that, on 06/01/22, when she attempted to take Resident #1 to the bathroom, she assisted him/her out of bed on the left side of bed and said while Resident #1 stood there with his/her walker, she walked away from Resident #1 to go to the right side of the bed to move a piece of medical equipment (part of a wound vacuum). CNA #2 said when she walked to the other side of the bed, Resident #1 started to walk, he/she lifted the walker up, and he/she fell backwards. CNA #2 said Resident #1 required staff assistance with transfers and said she thought Resident #1 was also a high fall risk. CNA #2 said she did not use a gait belt with Resident #1 at the time of the fall on 06/01/22 because she said she had not seen any other staff use a gait belt with him/her. Review of Resident #1's PT Treatment Encounter Note, dated 06/02/22, indicated that during transfer training he/she was noted to be frequently unsafe with transfers due to fatigue. During an interview on 06/28/22 at 3:28 P.M., the Director of Nursing (DON) said CNA #2 should have unplugged his/her wound vacuum prior to assisting him/her with transferring rather than leaving him/her standing alone (on 06/01/22). 2. Review of Resident #1's Incident Report, dated 06/06/22, indicated that at 6:30 A.M., he/she was observed on the floor next to his/her bed. Review of Resident #1's Incident Investigation Occurrence Summary Statement, dated 06/06/22, indicated that he/she was observed on the floor next to his/her bed. The Statement indicated that Resident #1 told the nurse that the locks on his/her wheelchair did not work and that was why he/she kept falling. Review of Resident #1's Post Fall Report, dated 06/06/22, indicated that he/she fell when attempting to transfer from bed into the wheelchair. The Report indicated that one of the interventions established after Resident #1's falls was to obtain a new wheelchair with working brakes. Review of Resident #1's PT Treatment Encounter Note, dated 06/06/22, indicated that he/she fell that morning due to the wheelchair brakes not working properly. The Note indicated that Resident #1 was very off balance and while gait training with PT, he/she had two losses of balance backwards into his/her wheelchair and one sideways which he/she was caught by the Physical Therapist and restored to an upright position. Review of Resident #1's Nurse Progress Note, dated 06/06/22, indicated that he/she was heard yelling from his/her room and when staff responded, observed him/her on the floor. The Note indicated that Resident #1's alarm was plugged in but that it had not been sounding at the time of the fall. Review of Resident #1's Alarm Checklist, for the month of June 2022, indicated that there was no documentation to support that his/her alarm had been checked to see if it was functioning on the 11:00 P.M. to 7:00 A.M. shift on 06/06/22. The Alarm Checklist contained no initials in the sign off section for that date and shift. Review of Resident #1's Risk for Falls Care Plan, dated 06/03/22, indicated that Resident #1 was at risk for falls related to impaired balance and activity intolerance. The Care Plan indicated that Resident #1 had chair and bed alarms in place, that he/she required the assistance of one staff member with transfers, and that he/she used a wheelchair for mobility on and off the unit with assistance to his/her destination. During an interview on 06/29/22 at 8:46 A.M., Nurse #1 said after Resident #1 fell on [DATE], she observed that the breaks on his/her wheelchair did not fully secure the wheels and said the wheelchair moved when the brakes were engaged. Nurse #1 said Resident #1 was at risk for falls, was not steady at all, and said he/she required a gait belt for transfers and ambulation. The DON said that she was not aware that Resident #1's pressure alarm was not sounding at the time of his/her fall on 06/06/22 and said CNAs are supposed to check to make sure that alarms are functioning on each shift and sign a sheet that indicated the alarm was checked. The DON said she was not aware of any issue with the brakes on Resident #1's wheelchair on 06/06/22. 3. Review of Resident #1's PT Treatment Encounter Note, dated 06/07/22, indicated that during sit to stand with contact guard, he/she demonstrated slight retropulsion (force that contributes to loss of balance in a backwards or posterior direction) and indicated while ambulating he/she had one to two losses of balance corrected with contact guard. Review of Resident #1's Incident Report, dated 06/07/22, indicated that at 12:00 P.M., he/she had a witnessed fall in his/her room. Review of Resident #1's Post Fall Report, dated 06/07/22, indicated that during a transfer from his/her bed to a chair he/she lost his/her balance, fell backwards, and hit his/her head on the floor. Review of Resident #1's Incident Investigation Occurrence Summary Statement, dated 06/07/22, indicated that when CNA #3 assisted him/her from the bed to his/her chair, Resident #1 started to turn towards the chair, lost his/her balance, fell backwards onto the floor and hit his/her head. The Statement indicated that Resident #1's head was bleeding and 911 was called. The Statement indicated that Resident #1 had a history of gait retropulsion. Review of Resident #1's Nurse Progress Note, dated 06/07/22, indicated that he/she was transferred to the Hospital Emergency Department due to a head laceration after he/she fell backwards and hit his/her head while being transferred, from the bed to a chair, by a CNA. Review of Resident #1's Hospital Emergency Department Note, dated 06/07/22, indicated that he/she was evaluated and treated for a head laceration after he/she sustained a fall with a head strike at the Facility. The Note indicated that Resident #1 required four surgical staples to close the wound. The Note indicated that Resident #1's fall occurred when he/she was transferring from bed to chair, his/her foot got caught on the bed which caused him/her to fall backwards and hit the back of his/her head. The Note indicated that the fall had been Resident #1's third fall within the past week and that he/she reported that the falls had been similar in fashion, and mechanical in nature. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, dated 06/03/22, indicated he/she had impaired balance and activity intolerance related to prolonged illness. The Care Plan indicated that Resident #1 required the assistance of one staff member for transfers and use of a gait belt if indicated. During an interview on 06/29/22 at 3:03 P.M., CNA #3 said she had provided care for Resident #1 several times and said he/she had always required assistance from staff with transfers and ambulation. CNA #3 said when she assisted Resident #1 on 06/07/22, Resident #1 stood from his/her bed by putting his/her hands on his/her walker and pulling himself/herself up to stand. CNA #3 said due to the way she positioned Resident #1's wheelchair, the space where they stood was tight because of the bed, walker and wheelchair were there. CNA #3 said Resident #1's wheel on his/her walker got caught on the wheel of the bed and said she thought he/she became overwhelmed and pulled his/her walker up which caused him/her to fall backwards away from the bed and he/she hit his/her head. CNA #3 said she was aware that Resident #1 required the use of a gait belt with transfers at the time of the fall but said she did not use a gait belt because she was confident transferring him/her. During an interview on 06/28/22 at 11:11 A.M., the Charge Nurse said that on 06/07/22 while she was at the nurse's station she heard a CNA say Resident #1 was on the floor in his/her room and there was a CNA in the room with him/her. The Charge Nurse said when she went down to Resident #1's room, she observed him/her on the floor perpendicular to the end of his/her bed, laying on his/her back, and bleeding from the back of his/her head. The Charge Nurse said she put gauze and pressure on Resident #1's laceration and called for someone to call 911. The Charge Nurse said CNA #3 told her that Resident #1 lost his/her balance during a transfer and that she attempted to prevent him/her from falling but was unable. The Charge Nurse said Resident #1 required the assistance of one staff member for transfers and ambulation since he/she was admitted . The Charge Nurse said that nursing staff was supposed to use a gait belt for any resident who was not independent with transfers or ambulation. The Charge Nurse said that CNA #3 did not have a gait belt on Resident #1 at the time of the fall on 06/07/22. The Charge Nurse said that once a CNA places the gait belt around a resident's waist, they must hold the gait belt at all times during the transfer and if staff need to get something or move a piece of medical equipment, they should do so before attempting to transfer a resident so they can keep their hands on the gait belt. During an interview on 06/28/22 at 10:35 A.M., the Physical Therapist (PT) said she completed Resident #1's Physical Therapy Evaluation (on 05/24/22). The PT said that Resident #1's main issue was balance and he/she had the tendency to fall backwards and was retropulsive. The PT said Resident #1 required the assistance of one staff member and contact guard from staff while ambulating and transferring. The PT said, when documenting in their electronic medical record documentation system for therapy, the system does not allow a separate choice for contact guard, but when someone is contact guard, it shows up as supervision or touching in their documentation. The PT said if a resident has a functional status that indicated they required the assistance of one staff member for transfers, a gait belt should be used for transfers. The DON said that staff should use gait belts for any resident who required to be touched during transfer or ambulation and that Resident #1 had required the use of a gait belt with transfers.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being at high risk for falls, was unsteady on his/her feet, and required a chair alarm, the Facility failed to ensure adequate supervision and safety interventions were implemented by staff when he/she was left unattended standing at the sink in the bathroom, Resident #1 went to sit in his/her wheelchair which had been left unlocked, and as a result Resident #1 fell to the floor and sustained a laceration to the back of his/her head, requiring four staples to close. Findings Include: A Post Fall Report, dated 11/26/19, indicated that, at 7:30 [NAME]M. on 11/26/19, Resident #1 was standing at the bathroom sink brushing his/her teeth and fell backwards when he/she attempted to sit in his/her unlocked wheelchair. An Incident Report, dated 11/26/19, indicated that, at 7:30 [NAME]M. Resident #1 was observed on the bathroom floor with blood on the back of his/her head. An Emergency Department Disposition, dated 11/26/19, indicated that Resident #1 sustained a scalp laceration and his/her wound had been stapled. A Nurse Progress Note, dated 11/26/19, indicated that, at approximately 7:20 [NAME]M. Resident #1 was observed laying on his/her back on the floor of his/her bathroom with his/her feet near the sink and his/her head almost out of the bathroom door. The Nurse Progress Note indicated that there was blood visible in Resident #1's hair and he/she reported a headache. The Note indicated Resident #1 was transferred to the Hospital Emergency Department for evaluation, and later returned to the Facility with four staples to his/her scalp laceration. The Nurse Progress Note indicated that Certified Nurse Aide (CNA) #2 told the nurse she left Resident #1 in the bathroom standing in front of the sink brushing his/her teeth, stepped out of the bathroom for a second, heard a loud crash, and went back into the bathroom saw Resident #1 on the floor. Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 had [DIAGNOSES REDACTED]. A Falls Risk Assessment Tool, dated 11/7/19, indicated that Resident #1 was at high risk for falls. Resident #1's Activity of Daily Living Functional Rehabilitation Care Plan, dated as last reviewed on 11/19/19, indicated that Resident #1 had decreased mobility, unsteady shuffling gait, impaired balance, and required a staff member's assistance for toileting, grooming, and oral hygiene. Resident #1's Falls Care Plan, dated as last reviewed on 11/19/19, indicated that Resident #1 was at risk for injury and was an increased risk for falls related to [MEDICAL CONDITION], shuffling gait, and decreased strength. The Care Plan indicated that Resident #1 required bed and chair alarms. Resident #1's Physician Orders, dated (MONTH) 2019, indicated that Resident #1 required bed and chair alarms at all times. During an interview on 12/6/19 at 1:47 P.M., the Unit Manager said Resident #1 was at high risk for falls and had fallen a few days prior to his/her fall on 11/26/19. The Unit Manager said Resident #1 was impulsive, had poor balance, poor gait, and was not safe to be left alone in the bathroom. The Unit Manager said it was a general rule in the Facility for staff to stay in the bathroom with any residents who required bed or chair alarms. During an interview on 12/6/19 at 1:30 P.M., the Director of Nursing (DON) said Resident #1 had alarms and staff should not have been left alone in the bathroom because staff is supposed to be in the bathroom with any resident who required alarms. During an interview on 12/6/19 at 11:20 [NAME]M., CNA #2 said that on 11/26/19 she took Resident #1 into the bathroom in his/her wheelchair so he/she could brush his/her teeth. CNA #2 said that while Resident #1 was standing at the sink, another CNA came into the room and asked her a question, so she walked out of the bathroom, leaving Resident #1 alone, for a minute to help the other CNA and said Resident #1 fell . CNA #2 said that there was an alarm on Resident #1's wheelchair and said while Resident #1 stood in front of the sink to brush his/her teeth, she shut off the alarm, and positioned the wheelchair behind him/her but did not lock the brakes. CNA #1 said she should not have left Resident #1 alone in the bathroom because he/she had alarms and she was not supposed to leave any resident with alarms alone in the bathroom but she made a mistake.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure safety when, on 2/21/19, while a Certified Nurse Aide assisted Resident #1 with personal care, Resident #1 reached for the upper side rail on his/her bed as he/she attempted to roll onto his/her right side, and the side rail, which was not locked or secured in the upright position, moved when Resident #1 touched it and Resident #1 rolled off his/her bed and fell to the floor. Resident #1 was transferred to the Hospital where he/she was diagnosed and admitted with a fractured nose. Findings Include: Resident #1's Face Sheet indicated that his/her medical [DIAGNOSES REDACTED]. A Side Rail Assessment, dated 4/20/18, indicated that Resident #1 had upper extremity weakness, was unable to support himself/herself in an upright position, and had a history of [REDACTED].#1 when turning in bed from side to side and with holding a side position in bed. A Certified Nurse Aide (CNA) Care Information Sheet, undated, indicated that Resident #1 was to have half side rails constantly. The Facility Report, dated 3/1/19, submitted to the Department of Public Health via the Health Care Facility Reporting System (HCFRS) indicated that during personal care, Resident #1 attempted to grab hold of the ¼ side rail on his/her bed, the side rail was not locked into position, it went down, and Resident #1 rolled out of bed. An Incident Report, dated 2/21/19, indicated that at 5:45 A.M. Resident #1 rolled off the bed and landed on the floor face down when he/she was being assisted with morning care. The report indicated that Resident #1 sustained a contusion and hemorrhage. A written Statement, dated 2/21/19 and signed by Certified Nurse Aide (CNA) #3, indicated that when CNA #3 asked Resident #1 to roll to the side, Resident #1 rolled right off the bed. A written Statement, dated 2/21/19 and signed by Nurse #2, indicated that at approximately 5:45 A.M. Nurse #2 was called to Resident #1's room and Nurse #2 observed Resident #1 on the floor face down bleeding profusely and he/she was transferred to the Hospital. A Nurse Progress Note, dated 2/21/19, indicated that Resident #1 rolled out of bed during care, landed on his/her face, he/she bled profusely and was transferred to the Hospital. The Hospital Patient Health Summary Report, dated 2/25/19, indicated that Resident #1 was transferred to the Hospital Emergency Department on 2/21/19 with soft tissue swelling and a laceration on his/her nose. The Hospital Report indicated that a Computed [NAME]ography (CT) Scan of Resident #1's head revealed a right nasal bone fracture with slight displacement, it was repaired in the Emergency Department, and Resident #1 was admitted to the hospital with [REDACTED]. The Surveyor interviewed Resident #1 at 11:40 A.M. on 3/27/19. Resident #1 said that he/she fell off the bed after CNA #3 asked him/her to turn over and said when she went to reach for the side rail it did not feel like it was high enough, but then could not feel it and he/she fell to the floor. Resident #1 said when he/she was on the floor, he/she thought he/she landed in water because he/she felt something wet, but realized that he/she was bleeding badly. Resident #1 said that he/she was taken to the Hospital, his/her lips, cheek, and head were black and blue, and he/she had a broken nose which he/she said was still sore at the time of the interview. The Surveyor interviewed CNA #3 at 8:33 A.M. on 4/4/19. CNA #3 said that, between 4:30 A.M. and 5:00 A.M. on 2/21/19, while Resident #1 was in bed, she assisted him/her with personal care and asked Resident #1 to roll onto his/her right side. CNA #3 said when Resident #1 started to roll over he/she reached for the upper side rail, but it was not locked in place so it went right down, and Resident #1 rolled out of bed onto the floor. CNA #3 said that she did not check to see if Resident #1's side rail was locked in place prior to providing care for him/her and said she did not know who last raised Resident #1's side rail but that it was the responsibility of the staff member who raised the side rail to ensure that the side rail locked into place when the side rail was raised. The Surveyor interviewed the Director of Nursing (DON) at 8:38 A.M. on 3/27/19. The DON said that the Facility had no specific policy related to securing side rails, but it was the responsibility of staff members to ensure that the side rails are locked in place when they raise them.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure staff implemented interventions to prevent an accident or injury, when Resident #1 was left seated in a wheelchair, his/her safety alarm was not turned on, and staff were alerted to his/her fall after he/she was found on the floor. Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with [REDACTED]. Findings include: The Facility policy titled Falls Management Program, dated 1/2018, indicated: -Staff would implement interventions consistent with the resident's needs and care plan in order to reduce the risk of an accident. -Position change alarms were defined as alerting devices that emit an audible signal when a resident moves a certain way. -A falls risk assessment would be completed on the day of admission/readmission, with a significant change in condition, and quarterly. Resident #1's medical record face sheet indicated he/she was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Care Plan, dated 12/18/18, indicated Resident #1 was at risk of falls, and interventions included falls risk assessments per Facility policy, and bed and chair position change alarms. The Nurse's Note, dated 1/31/19, indicated Resident #1 was found on the floor in the hallway, and was transferred to the Hospital Emergency Department. The Hospital Imaging Report, dated 1/31/19, indicated Resident #1 had a nondisplaced right clavicle fracture. The Surveyor interviewed Nurse #1 at 11:58 A.M. on 3/6/19. Nurse #1 said that on 1/31/19 at approximately 2:30 P.M. Resident #1 was seated in his/her wheelchair across from the Nurses' station. Nurse #1 said she was sitting at the Nurses station when someone said someone fell or words to that effect. Nurse #1 said she saw Resident #1 on the floor, and said Resident #1's wheelchair alarm was not sounding. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:17 A.M. on 3/6/19. CNA #1 said she had toileted Resident #1 at approximately 2:20 P.M. on 1/31/19, and put Resident #1 seated in his/her wheelchair in the hallway in front of the Nurses Station. CNA #1 said Resident #1's wheelchair alarm was in place, but said she could not recall if she turned the alarm back on when she finished toileting Resident #1. The Surveyor interviewed the Director of Nurses at 2:20 P.M. on 3/6/19. The Director of Nurses said staff should check for functioning of position change alarms after each transfer.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to administer oxygen when, on 4/4/17, Resident #1, who complained of chest pain and difficulty breathing, became unresponsive and had an oxygen saturation level (measurement of oxygen carried by red blood cells) of 83% (normal 95-100%, below 90% considered low). Resident #1 was provided a nasal cannula (device used to deliver supplemental oxygen) with oxygen tubing connected to an oxygen tank that was not opened, therefore preventing oxygen flow, which resulted in Resident #1 not receiving supplemental oxygen until Emergency Medical Services arrived at the Facility. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated that Resident #1's medical [DIAGNOSES REDACTED]. The MDS indicated Resident #1 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 (0-7 indicates severe cognitive impairment) and Resident #1's primary means of mobility was by wheelchair. A Nurse's Note, dated 4/4/17, timed at 3:30 P.M., and written by Nurse #1, indicated that Resident #1 wheeled himself/herself out of his/her room, said he/she was having difficulty breathing and within moments became pasty colored and unresponsive. The Note indicated that Resident #1 had a blood pressure of 182/116, a heart rate of 66, respirations of 20, and his/her O2 Sat was 83% (low) on room air. The Note indicated Resident #1 was assisted into bed, became responsive, 911 was initiated, and Resident #1's Physician was notified. A Physician's Interim Telephone Order, dated 4/4/17 and timed at 3:15 P.M. indicated to transfer Resident #1 to the Emergency Department for a period of unresponsiveness. A Police Report, dated 4/5/17, indicated that on 4/4/17 at approximately 3:24 P.M. a Police Officer was dispatched to the Facility. The Report indicated that upon arrival, the Officer entered Resident #1's room and found Resident #1 alone in the room, conscious, responsive, and complaining of difficulty breathing. The report indicated that the Officer checked Resident #1's oxygen tank, which was on a stand next to his/her bed, and found that there was no oxygen being delivered to Resident #1. The Report indicated the Officer went to the Nurse's Station to inform staff, who then brought in an oxygen concentrator and administered oxygen to Resident #1. The Surveyor interviewed Nurse #1 at 8:40 A.M., on 6/9/17. Nurse #1 said, towards the end of her 7:00 A.M., to 3:00 P.M., shift, Resident #1 came out of his/her room, said he/she didn't feel good, was short of breath, appeared to be pale, and complained of chest pain. Nurse #1 said she took Resident #1's vital signs, his/her blood pressure was high and said Resident #1's oxygen saturation level was low, but not that low, or words to that effect. Nurse #1 said Resident #1 did not become unresponsive. (This was not consistent with Nurse #1's progress note dated 4/4/17.) -Nurse #1 said she and a Certified Nursing Assistant (CNA) brought Resident #1 into his/her room, put him/her to bed and she placed the nasal cannula on Resident #1 and set the oxygen tank to deliver 2 liters of oxygen. Nurse #1 said she did not open the flow valve on Resident #1's oxygen tank because the oxygen tanks are usually always open. -Nurse #1 said she was unaware that Resident #1 had not been receiving any oxygen, and she said did not reassess Resident #1's O2 Sat again because she thought his/her oxygen on. -Nurse #1 said that after the Advanced Life Support team arrived, they informed Nurse #1 that Resident #1's oxygen tank was not turned on. (This was not consistent with the Police Report.) An Emergency Medical Service (EMS) report, dated 4/4/17, indicated that 911 was called at 3:22 P.M. on 4/4/17. The EMS team responded to Resident #1 at 3:30 P.M. and, at 3:34 P.M., 2 liters of oxygen was continued by the Emergency Medical Technician (EMT). The EMS report indicated that at 3:39 P.M., Resident #1 was pale in color and his/her O2 Sat was 94%, at this time. The Surveyor Interviewed the Director of Staff Development at 7:56 A.M., on 6/9/17. The Director of Staff Development said although she could not recall if there were any issues or concerns with oxygen administration for Resident #1 on 4/4/17, she was aware that staff needed to obtain another oxygen tank for Resident #1 that day but did not know why. The Director of Staff Development said after Resident #1 was transferred to the hospital on [DATE], she educated staff about confirming that they open the oxygen tank, adjust settings, and apply nasal cannula or oxygen mask correctly. The Surveyor Interviewed the Director of Nursing (DON) at 11:25 A.M., on 6/9/16. The DON said she did not recall any concerns brought to her attention about Resident #1's oxygen on 4/4/17. The DON said she did recall having a discussion about oxygen tanks and that the Director of Staff Development provided education to staff that related to oxygen administration, but was unsure of the content.

Based on record review, interview and observation, for 1 of 3 sampled residents (Resident #1), the Facility failed to develop and implement alternative interventions when the Health Care Agent refused to allow Resident #1 (who was at risk for elopement) to wear a wanderguard bracelet to prevent Resident #1 from wandering off his/her secured unit. On 8/24/13 Resident #1 eloped from the building and had an unwitnessed fall which resulted in a 1 centimeter laceration above the left eyebrow. Resident #1 was transferred to the Hospital and required 2 sutures to close the wound. Findings include: Resident #1's elopement care plan, dated 6/25/13, indicated he/she was at risk for elopement as evidenced by: a history of attempts to leave the Facility unattended, wandering aimlessly, impaired safety awareness and disorientation to place. The elopement risk care plan interventions included: remain on unit with alarmed doors and all staff are to be aware of his/her elopement risk. Resident #1's quarterly elopement/wandering risk assessment, dated 7/13/13, indicated he/she was at risk for elopement and he/she asked to go home on a daily basis. The elopement assessment interventions included: exit and stairwell alarms, frequent monitoring and staff awareness of his/her wander/elopement risk. Resident #1's quarterly Minimum Data Set assessment, dated 7/13/13, indicated he/she had impaired memory and disorganized thinking and a [DIAGNOSES REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 9:00 A.M. on 9/26/13. The DON said said that Resident #1 lived on a secured unit (second floor) because of his/her risk for elopement and the unit's exit doors were alarmed. The DON said the unit elevator had a wanderguard sensor and when it was activated the siren sounded and the elevator did not move. The DON said that Resident #1's Health Care Agent (activated) declined a wanderguard transponder attached to him/her and staff were required to monitor his/her whereabouts. The DON said that staff was required to prevent Resident #1 from entering the elevator without staff supervision. The Surveyor interviewed Nurse #1 at 11:20 A.M. on 9/26/13. Nurse #1 said she was assigned to Resident #1 at the time of his/her elopement. Nurse #1 said she saw Resident #1 at approximately 6:15 P.M. sitting in a chair near the nursing station. Nurse #1 said she first became aware that Resident #1 eloped from the unit when a first floor nurse escorted Resident #1 back to the unit via the elevator. Nurse #1 said that Resident #1 had bark mulch on his/her clothing and a cut above his/her left eye and blood on his/her face. Nurse #1 said that, prior to the incident, she did not think Resident #1 was at risk for elopement because he/she did not wear a wanderguard transponder. The Surveyor observed, at 8:45 A.M. on 9/26/13, that the second floor elevator (accessible from Resident #1's unit) could be taken to the ground floor. The Surveyor observed that the ground floor exit doors had wanderguard sensors and alarms, but were not otherwise locked or alarmed. Without a wanderguard transponder, Resident #1 could take the elevator from his/her unit to the ground floor and exit through an exit door without activating an alarm or triggering the door to lock. Resident #1's nurse's note, dated 8/24/13, indicated that at approximately 6:40 P.M. Resident #1 had an unwitnessed fall, which resulted in a laceration above the left eye and a bruise and swelling to the area. The nurse's note indicated he/she was transferred to the Hospital and treated with sutures. The DON said that it was not known how Resident #1 eloped from the unit and the Facility. The DON said Resident #1 sustained a 1 centimeter laceration above the left eye and was transferred to the Hospital and he/she required 2 sutures to close the wound.

2. Resident #2 had [DIAGNOSES REDACTED]. Record review and interview with the second floor Charge Nurse #3 on 8/8/12 at 2:35 P.M., indicated that this Resident consistently took in less fluids than the Dietician determined were required for this Resident, and the facility failed to identify and address this problem. The Nutrition Risk Assessment, dated 3/5/12, documented that the total fluid needs for Resident #2 were 2500 cubic centimeters (cc), intake 20 - 50 % and no signs and symptoms of fluid imbalance. The Admission Minimum Data Set (MDS), dated [DATE] documented that the Resident had a severe cognitive impairment, was total care and non ambulatory. The Care Area Assessment summary, dated 3/15/12, for dehydration/fluid maintenance stated, "Resident triggers for dehydration/fluid maintenance risk due to recent hospitalization [MEDICAL CONDITION] and UTI. Fluids are encouraged which Resident readily accepts. The nutrition risk assessment indicated that Resident consumes 1000-1500 cc daily. Resident is at risk for recurrent UTI [MEDICAL CONDITION] related to coccyx wound." The Resident's current care plan, dated 3/15/12 and last reviewed on 6/12 addressed the potential for fluid volume deficit related to recent UTI, wound infection, stage IV wound, impaired cognition and impaired physical mobility. Interventions included the following: - Monitor fluid intake and output every shift. - Staff to assist/cue resident to drink all fluids. - Monitor lab reports. - Encourage 2500 cubic centimeters (cc) / 24 hours per dietician recommendation. A laboratory report on 4/11/12 documented that the Resident's blood urea nitrogen (BUN) was 40 which was high (potential indicator of dehydration) as reference range was 10 - 24. The Resident's creatinine was normal. Review of the Monthly Intake & Output Record for May 2012 indicated that the Resident's fluid intake for a 24 hour period was below 2500 cc. It ranged from 400 cc to 900 cc on 18 days in May. The remainder of the days had no totals recorded. Review of the Monthly Intake & Output Record for June 2012 indicated that the Resident's fluid intake for a 24 hour period was below 2500 cc. It ranged from 600 cc to 1820 cc on 17 days in June. The remainder of the days had no totals recorded. Review of the Monthly Intake & Output Record for July 2012 indicated that the Resident's fluid intake for a 24 hour period was below 2500 cc. It ranged from 610 cc to 1430 cc on 19 days in June. The remainder of the days had no totals recorded. A laboratory report on 7/16/12 indicated that the Resident's blood urea nitrogen (BUN) was 37 which was high (potential indicator of dehydration) as reference range was 10 - 24. The Resident's creatinine was normal. Review of the Monthly Intake & Output Record for August 2012 indicated that the Resident's fluid intake for a 24 hour period was below 2500 cc as it ranged from 460 cc to 600 cc on the 5 days it was recorded. Although the Monthly Intake and Output records indicated that the Resident's total fluid needs were not being met, there was no evidence in the record to indicate that the facility was aware that the amount taken in was less than what was required for fluid intake. When interviewed on 8/8/12 at 2:35 P.M., Charge Nurse #3 reportedly was not aware that Resident #2's fluid requirement was 2500 cc per 24 hour period and was not aware that the Resident was falling below this as evidenced by the monthly intake and output records. Charge Nurse #2 reported that she did not monitor the intake and output data and was not aware of who monitored the data. Based on record review, staff and resident interviews and observations, the facility failed to monitor and ensure that two residents (Resident #2 and #6), out of an total sample of 17 residents, were monitored to ensure that their calculated fluid needs were met to prevent dehydration. The lack of monitoring for Resident #6 resulted in rehospitalization due to dehydration. Findings include: 1. For Resident #6, the facility failed to monitor hydration status and failed to utilize the assessed fluid needs to ensure that the resident was receiving a sufficient amount of fluid to prevent dehydration. When the resident developed a urinary tract infection [MEDICAL CONDITION], the facility failed to reassess the resident's fluid needs and institute interventions. The resident became dehydrated. Resident #6 was admitted on [DATE], from the hospital with [DIAGNOSES REDACTED]. The hospital discharge summary stated that the resident was "somewhat dry and BUN (blood urea nitrogen) and (Cr) creatinine revealed evidence of prerenal azotemia" (nitrogen retention resulting in from something other than primary [MEDICAL CONDITION]. " IV (intravenous fluids) were given to correct fluid volume loss." The Admission Nursing Assessment conducted on 6/4/12 did not assess the oral cavity. In addition, under "patient history /reason for hospitalization " only the left shoulder dislocation was addressed and not the [DIAGNOSES REDACTED]. According to the Initial Nutrition Assessment conducted on 6/5/12, the resident was assessed to need 1600 cc (cubic centimeter) of fluids daily. In addition, the assessment documents the elevated BUN and Cr consistent with recent [DIAGNOSES REDACTED]. The nutrition care plan dated 6/12 (Alteration in nutrition related labs labs (increased BUN and Cr) related to dehydration included: monitor intake, weight weekly x 4 weeks, then monthly, honor preferences within diet and offer menu selections. No specific care plan related to dehydration was written. The Admission History and Physical, conducted by the physician on 6/5/12 noted that the resident was admitted to the facility status [REDACTED]. The 6/11/12 Initial Minimum Data Assessment (MDS) indicated that the resident was coded as being mildly cognitively impaired and required assistance with most ADLs (activities of daily living). The resident required set up for meals. He/she was occasionally incontinent of bladder and bowel. The resident weighted 103 pounds and was 61 inches tall. The Dietitian reviewed the chart again on 6/12/12, and documented that the resident's po (by mouth) intake was between 40-60%. Laboratory findings were elevated sodium 147 mmol/L (133-145), BUN 40 high (10-24 mg/dL), and white blood cells high 14.4 K/uL (4.8-10.8 K/ul). Adaptive equipment was recommended as was House Supplement twice a day to provide increased calories, protein and fluids. On 6/12/12, the physician ordered a urinalysis and culture and sensitivity. On 6/14/12, the resident was started on Keflex (an anti-infective) for a UTI. After the resident developed a UTI, the facility did not reassess the resident's fluid needs. A UTI can increase the resident's fluid needs. The facility initiated a care plan for the UTI on 6/14/12. This care plan included the following approaches related to hydration: increase/encourage PO fluids and educate the resident on the importance of producing adequate fluids (minimum of 6-8 glasses every day) to prevent UTI. No monitoring of intake and output (I &O) was conducted. The lack of adequate monitoring of fluid intake resulted in the resident being rehospitalized on [REDACTED]. On 6/21/12, a review of the Resident/Family Education Record indicated that the resident was provided education for the need to remain adequately hydrated. This was due to being at risk for dehydration. The resident reported that he/she does not like to drink as it increases urinary incontinence. This information did not trigger the facility to provide interventions. No monitoring of intake and output (I & O) was conducted. Nurses' notes indicated the following: 6/21/12 at 3:45 P.M., alert and oriented X 1-2. 6/23/12 at 8:00 A.M., resident states no appetite anymore. 6/24/12 at 9:00 A.M., states is not hungry . 6/25/12 at 3:00 P.M., resident oriented X 1-2, observed sitting on floor, range of motion within normal limits, called physician due to confusion. 6/25/12 at 5:00 P.M., increased confusion, hallucinating, frequently restless, appetite poor, accepted 2 glasses of HI-Pro nutritional supplement. 6/25/12 at 7:00 P.M., agitated called physician to get medication to help decrease agitation. 6/26/12 at 11:30 A.M., transferred to hospital. On 6/26/12, at the hospital, the History and Physical note indicated the resident was assessed to be somewhat obtunded (having diminished arousal and awareness) and only slowly able to respond to stimulus. The resident was markedly dehydrated with an elevated BUN and Cr of 104 and 4.4 respectively, other abnormal labs were sodium 134 (133-145) and potassium 5.8 (3.5-5). This workup revealed evidence of dehydration and prerenal azotemia. Exam was significant for extremely dry oral mucous membrane. The treatment plan included rehydration with significant intravenous crystalloid and IV [MEDICATION NAME] for possible pneumonia. The resident was readmitted to the facility on [DATE]. The hospital discharge (D/C) summary indicated: Final [DIAGNOSES REDACTED]. The physician D/C summary reiterates that the resident presented from the facility markedly dehydrated. The physician emphasizes that the resident needs to be monitored carefully, weighed daily, and evaluations done to determine that the resident is consuming adequate fluids. Upon return from the hospital on [DATE], the facility did not write a specific care plan to address the dehydration. On 7/3/12, the Dietitian reassessed the resident after the resident was readmitted from the hospital due to dehydration. Weight decreased from 103 lbs to 99 lbs. Intake was noted to be 0-50 % at meals. The nutrition care plan indicated: to monitor labs, weight, appetite and percentage meal intake. The Initial Nutritional assessment (dated 6/5/12) indicated that the resident's fluid requirement was 1600 cc. However, I & O documentation did not start until 7/6/12. (This was 8 days after the resident's return from the hospitalization for dehydration). Review of I & O summary sheets from 7/6/12 through 8/5/12 indicated the average daily intake documented was 759 cc. Examples follow: 7/16/12 Intake 900 cc 7/17/12 Intake 1090 cc 7/18/12 Intake 870 cc 7/19/12 Intake 780 cc 7/20/12 Intake 480 cc 7/21/12 Intake 840 cc 7/22/12 Intake 580 cc The 759 cc average fluid intake indicated that the resident's intake was less than half the resident's recommended daily fluid intake of 1600 cc. This amount of fluid is needed in order to maintain proper hydration and health. This less than adequate fluid intake was not addressed by staff. The resident was observed on 8/6/12 at 5:00 P.M.. in his/her room. Observation of the supper tray revealed that he/she ate approximately one quarter of his/her meal. A water pitcher and a cup of ginger ale were on his/her tray table. The resident stated that coffee was only consumed at breakfast, not at other meals. The resident was observed on 8/7/12 at 12:15 P.M., the lunch was not eaten, only 2 ounces (oz) of chocolate cake, and 4 oz of milk were eaten. The coffee was untouched. An interview was conducted at this time. The resident said that he/she will finish the juice and milk and that he/she is aware of the need to drink. At 1:20 P.M., the resident was observed. and he/she did not drink anymore of the juice or milk. During interview with Unit Manager (UM) #2 and charge nurse #2 (covering the second floor) on 8/7/12 at 11:35 A.M., they said upon admission the major concern was with left shoulder dislocation. The dehydration was not seen as a major problem at that time. When asked why the decreased intake was not addressed, the UM stated that there was a breakdown in communications, and that they had not been informed on the decreased intake by staff. When asked what intervention should have been implemented he/she stated that I & O should have been monitored for a resident admitted with recent dehydration. During interview with the Director of Nurses (DON),UM #2, and the Regional Nurse Consultant on 8/7/12 at 1:45 P.M., the DON and Regional Nurse Consultant were informed of the lack of monitoring which led to the resident getting dehydrated again. UM #2 said that the resident (on 6/21/12) was provided education for the need to remain adequately hydrated, due to being at risk for dehydration. During the education, the resident had reported that he/she did not like to drink as it increases urinary incontinence. When the UM #2 was asked why further interventions were not put into place to prevent further dehydration, UM #2 stated that UM #2 thought that the resident was alert and oriented and could monitor his/her intake. The lack of monitoring resulted in dehydration and rehospitalization . The initial MDS conducted on 6/11/12 indicated that the resident was mildly cognitively impaired. UM #2 stated that the ST (speech therapist ) was working with the resident to teach the skill of self recording all liquids consumed during the day. This training had started 8/1/12. The ST report indicated that the resident had altered mental status (6/1/12 and 6/26/12). Review of the ST's report dated 8/7/12 indicated the reason for continued skilled services included: cognition/communication to minimize the risk of dehydration, minimize risk of weight loss with swallow analysis, and enhance short term memory. During interview on 8/7/12 at 2:45 P.M., the Regional Nurse Consultant said that the staff should have put inventions into place. The Regional Nurse Consultant said that a new system needs to be put in place.

2. The facility failed to provide adequate supervision to Resident #3, who was confused, had an unsteady gait, and exhibited wandering and exit seeking behavior. Record review revealed that between 4/18/12 and 7/19/12, Resident #3 had 7 falls (4/18/12 (fractured rib), 4/20/12, 4/26/12, 6/1/12, 7/3/12 (8 sutures to the left ear), 7/14/12, and 7/19/12) and one aborted attempt to climb off a deck (6/23/12), located off the second floor unit. Resident #3 was admitted at the end of March 2012 with [DIAGNOSES REDACTED]. The Resident's Admission Minimum Data Set (MDS) Assessment, dated 4/6/12, revealed that this Resident had a severe cognitive impairment (score of 7 on the Brief Interview for Mental Status (BIMS) ), and wandered daily. This assessment identified Resident #3 as independent in transfers, supervision walking in the Resident's room, independent walking in the corridor, supervision with a one assist for toilet use, and unsteady gait. This assessment further revealed that this Resident had a fall at prior facility with injury. The Care Area Assessment (CAA) Summaries, dated 4/6/12, documented: - Behaviors - "(Resident #3) wanders around the unit continuously and has made attempts to leave the unit." - Falls -"(Resident #3) is cognitively impaired with poor insight and safety awareness as well. (Resident #3) also uses psychotropic medications which increase risk for falls and injury. The Resident's care plan, initiated on 3/26/12, included the following plans: A. Problem of "potential for falls" - "Check resident at least every two hours to determine need for toileting, position change and other needs." - "Diversional activities to assist in safety management: structured activities." B. Problem of "elopement risk as evidenced by history of attempts to leave facility unattended. Resident wanders aimlessly." - "To remain on unit with alarmed doors." C. Problem of impaired physical mobility - "1:1 ambulation, requires cues, reminders and limited assistance of one staff." - "1 to 1 ambulation." - "Monitor resident's gait, and assist as necessary." The 3/28/12 physical therapy evaluation, indicated: (Resident #3 exhibits forward lean of trunk, knees never fully extended during stance, lack of arm swing and trunk rotation. When Resident is fatigued gait deviations and near loss of balance increase as does fall risk. Resident with poor safety awareness placing Resident at high risk for falls.) Although the Resident's assessments indicated that this Resident was at high risk for falls, and the care plan called for one to one ambulation, record review indicated that from admission in March 2012 until July 2012, the Resident was allowed to wander the unit with distant supervision. During interview, on 8/8/12 at 8:50 A.M., the second floor Unit Manager (UM #2) said that from admission until the Resident's last fall on 7/19/12, Resident #3 was allowed to wander the unit with distant supervision, unless agitated or tired. Review of the Nurse's Notes indicated that from 3/26/12 to 4/18/12, this Resident wandered around the unit aimlessly in the halls and into other residents rooms, as well as exhibited exit seeking behavior. The Nurse's Note on 4/18/12 at 9:15 P.M. documented that the resident had a witnessed fall while ambulating ad lib (as much or as often as wanted) in the hall resulting in a non-displaced fracture of the left fifth rib. Despite the fall on 4/18/12, the Nurse's Notes on 4/19/12 at 2:00 P.M. indicated that the Resident continued to wander on the unit ad lib and, on 4/20/12, the Resident fell again. The Nurse's Note on 4/20/12 at 10:30 A.M. indicated: (CNA observed the Resident, who was standing at the closet door, fell backward landing on the hall floor, outside the door to the Resident's room. The back of the Resident's head hit the floor. There were no injuries noted.) The Nurse's Note on 4/26/12 at 9:00 P.M. indicated: (Resident #3's gait was unsteady and the Resident was falling and needed to be guided physically into the chair. Was wandering in and out of residents' rooms). Although the Resident had three falls (4/18/12, 4/20/12 and 4/26/12), the facility failed to revise this Resident's plan of care, and the Resident continued to wander, as documented in Nurse's Notes (on 4/28/12, 4/29/12, 4/30/12, 5/10/12, and 5/31/12), and exhibited exit seeking behavior on 4/28/12 and 5/1/12. The Nurse's Note on 4/28/12 documented that the facility blocked the entrance to the outside, second floor deck with carts to prevent the Resident from going out to the deck. On 6/1/12 at 6:00 P.M., the Nurse's Note indicated that Resident #3 had an unwitnessed fall and was found lying next to the bed. The Resident stated that the right knee gave out causing the fall. The resident sustained [REDACTED]. After this fourth fall, Resident #3's care plan remained unchanged, despite the continued wandering and falls. On 6/23/12, the Nurse's Note indicated that the Resident continued wandering independently on the unit, was in and out of other residents' rooms and at 6:00 P.M. started to exhibit exit seeking behavior. On 6/23/12 at 6:15 P.M., a facility incident report indicated: ( Resident was observed on the second floor deck with one leg over the deck railing. Staff intervened and easily redirected the Resident away from the railing. One to one was provided until the Resident was sent out for a psychiatric admission.) During interview with the second floor Unit Manager (UM) #2 on 8/8/12 at 9:30 A.M., the Director of Nurses on 8/9/12 at 3:00 P.M. and the Resident's family member (Family Member #1) on 8/3/12 at 11:30 A.M., each of these individuals reported that Resident #3 was on the second floor deck unsupervised on 6/23/12 when this incident occurred. In addition, they stated that it was a housekeeping staff person on the grounds of the building who first observed the Resident with one leg over the deck rail, attempting to put the other leg over. This housekeeping staff immediately alerted the unit staff, who intervened. Although the Resident's care plan called for alarmed doors, UM #2, the Director of Nurses and Family Member #1 each reported, during the above interviews, that the door to the second floor deck in the facility (off the second floor unit) was kept unlocked. Resident #3 was transferred to a psychiatric hospital on [DATE], and returned to the facility on [DATE]. Record review indicated that Resident #3 fell again on 7/3/12 at 11:15 P.M. and was found on the floor next to the Resident's bed, bleeding from left ear and had a contusion on back of head. The Resident was sent to the hospital for evaluation and returned to the facility on [DATE] with approximately 8 sutures around the cartilage of the top of the left ear. The record indicated that after the 7/3/12 fall, the Resident required one assist for ambulation and a bed and chair alarm. Interview with the second floor UM #2 revealed that the bed and chair alarm were ordered on [DATE] after the fall. However, these interventions were ineffective as the Resident fell again on 7/14/12. The Nurse's Note on 7/14/12 at 3:00 P.M. indicated that at approximately 9:00 Amalgam sounded and upon entering room (Resident #3) was observed prone on floor outside bathroom door with left arm behind (Resident). Resident incontinent of loose stool and stated "I needed to get to the bathroom." resident sustained [REDACTED]. The Nurse's Note on 7/19/12 at 8:00 A.M. indicated that the Resident was lethargic and gait was unsteady and at 7:00 P.M. the Resident was medicated with an antianxiety medication for agitation (demanding, confrontational and physically abusive to staff). Although this Note indicated that the Resident was agitated, the following Nurse's Note indicated that the Resident was left unsupervised in the Resident's room, at which time the Resident got up and fell while walking in the room at 7:30 P.M. Further documentation in the Nurse's Note on 7/19/12 at 7:30 P.M. indicated, "When answering Resident's alarm call, I witnessed Resident had walked to the wall unassisted without walker and turned so Resident's back was against wall. As I went to assist the Resident, the Resident slowly slid down the wall and I tried to hold Resident up, ending with Resident sitting on the floor." The note indicated that the Resident was not injured. During interview on 8/8/12 at 8:50 A.M., UM #2 said that Resident #3 was to be seated in front of the nurses' station at change of shift and when out of bed in the morning. However, the following surveyor observations revealed that this Resident was left unsupervised in the Resident's room on 8/3/12 and 8/7/12. On 8/3/12 at 3:13 P.M., Resident #3 was observed attempting to walk out of the Resident's room, where the Resident had been sitting unsupervised. The Resident stopped in the doorway and teetered back and forth a couple of times before steadying by leaning against the door frame. The Resident's chair alarm in the room was sounding, but it was so low it was barely audible in the hall. There were 3 licensed nurses at the nurses' station which was up the hall from the Resident's room, and there were no certified nurse's aides (CNAs) visible on the floor. The surveyor observed this Resident standing in the doorway for approximately 3 minutes before Medication Nurse #1 responded and directed the Resident back to the chair in the Resident's room. Medication Nurse #1 then left this Resident in the room unsupervised. On 8/3/12 at 3:20 P.M., the surveyor went into Resident #3's room and discovered that the Resident was not in the room. The chair alarm on the Resident's chair in the room was going off, but the sound was barely audible. The surveyor immediately reported this finding to Medication Nurse #1, who upon further investigation, found Resident #3 seated on the toilet in the bathroom which adjoined Resident #3's room. Medication Nurse #1, then directed CNA #1 to assist the Resident back to the chair in the Resident's room. At 3:25 P.M., the surveyor observed the Resident, once again, sitting in the chair in the Resident's room alone and unsupervised. The Resident was observed bending forward in the chair trying to tie the Resident's sneakers. CNA #1, who was passing by the room, noticed and intervened by assisting the Resident to sit back in the chair. Additional observations, during the survey on 8/7/12, revealed that Resident #3's care plan to prevent falls was not followed as the Resident was left in the Resident's room unsupervised and was not provided with activities as called for in the Resident's care plan. Observation on 8/7/12 from 9:18 A.M. to 9:52 A.M. revealed that Resident #3 was left sitting in a chair in the Resident's room unsupervised. Observations revealed that the Resident was not invited to participate in appropriate morning activities that occurred on 8/7/12. On 8/7/12 at 11:08 A.M. observations and interview with CNA #2 revealed that the chair alarm was not effective as the Resident, who was alone in the Resident's room, was repeatedly getting up from the chair and walking, although the alarm kept sounding. At this time, CNA #2, who was providing care to another Resident in the adjoining room, said it was impossible to provide the care to the other Resident, as CNA #2 had to keep running into Resident #3's room to direct Resident #3 back to the chair. 3. The facility failed to provide Resident NS #4, with adequate supervision, as the facility allowed this Resident unsupervised access to a second floor open deck, which presented a safety hazard to this Resident, who had a [DIAGNOSES REDACTED]. The Annual MDS for Resident NS #4, dated 12/17/11, indicated that this Resident had a [DIAGNOSES REDACTED]. The CAA, dated 12/29/11, for falls documented, "Resident is at risk for falls because Resident exhibits an impaired balance with transfers and ambulation. Resident is dependent on staff to steady oneself. Resident has forgetfulness because of dementia and this could pose a safety risk. Resident is at risk for significant injury should Resident fall due to advanced age and frailty." This Quarterly MDS dated [DATE] indicated that the Resident declined to extensive assist of one staff for transfer and walking. The current plan of care, initiated on 1/14/08, addressed the problem of "Potential for falls secondary to poor safety awareness and history of falls." The care plan included the intervention (initiated on 6/3/12) "keep in a common area." On 8/9/12 at 10:12 A.M., Resident NS #4 was observed sitting outside in a wheelchair at the far end of the second floor, exterior deck. The deck was covered by a roof and had a railing around it that was approximately 43 inches high. There were no facility staff present on the deck to supervise the Resident. There were two painters working on the deck. The surveyor immediately asked second floor Medication Nurse #2, who was inside the facility, if this Resident was all right out on the deck and how the Resident got out to the deck. Medication Nurse #2 was not aware of how the Resident got out onto the deck and said that a staff person must have brought the Resident out to the deck. Medication Nurse #2 reported that the Resident had dementia, liked to sit outside on the deck, was not able to walk and was allowed to sit out on the deck alone. This nurse said that they usually sat the Resident closer to the deck door. Medication Nurse #2 then moved the resident closer to the center of the deck, near the door, and left the Resident on the deck unsupervised. Observation revealed that this Resident remained out on the deck for at least another 15 minutes. On 8/10/12 at 1:45 P.M., Resident NS #4 was observed sitting in a wheelchair, alone, on the outside second floor deck. Ongoing observation on this date revealed that the Resident sat alone on the deck until 2:25 P.M. At this time, the surveyor went out to the deck, and the Resident said to the surveyor, "I think I will go in now. I've been out here quite awhile." In addition to being left alone on the deck, there was no means for this Resident to call for help and the outside temperature at this time was in the high 80's with high humidity. The surveyor immediately informed the facility staff and the Resident was brought back inside the facility. 4. The facility failed to provide Resident NS #3, with adequate supervision, as the facility allowed this Resident unsupervised access to a second floor open deck, which presented a safety hazard to this Resident, who had a [DIAGNOSES REDACTED]. Resident NS # 3 had [DIAGNOSES REDACTED]. The CAA Summary for falls for this Resident, dated 7/10/12, documented, "Resident had a fall down some stairs in May of 2012 resulting in multiple facial fractures and intractability hemorrhage with [DIAGNOSES REDACTED] which resulted in profound disability in self care, transfers, and functional mobility. Due to [DIAGNOSES REDACTED], Resident continues to have some problem solving (difficulty) and balance and safety awareness are impaired. Resident also has poor insight into limitations. Resident is at risk for falls and further injury." The Resident's current care plan addressed potential for falls and included the following interventions: - Place call light within reach at all times. - Implement the following safety procedure. However, the plan failed to document what these safety procedures were. The Resident's current care plan, dated 7/18/12, documented that this Resident had an alteration in mood state related to current health status , spouse's terminal illness and Resident's inability to care for spouse. On 8/8/12 from 11:30 A.M. to 11:40 A.M., this Resident was observed sitting in a wheelchair, out on an open deck off the first floor unit. Although off the first floor unit, the height of the deck was one story from the ground. The deck was surrounded on three sides by a deck rail that was approximately 43 inches high. There was no means for this Resident to call for assistance. There were three other cognitively impaired residents (Resident #11, NS #2 and NS #5) on the deck at this time. There were no staff on the deck to supervise these Residents. 5. The facility failed to provide Resident NS #2, with adequate supervision, as the facility allowed this Resident, unsupervised access to a second floor open deck, which presented a safety hazard to this Resident, who had a [DIAGNOSES REDACTED]. Record review revealed that Resident NS #2 had [DIAGNOSES REDACTED]. The Annual MDS Assessment for Resident NS #2, dated 5/8/12, indicated that this Resident had severe cognitive impairment with a BIMS score of 5, was extensive assist of one staff for transfer, was non ambulatory, had upper and lower extremity impairments in range of motion and had episodes of agitation and combative behavior. The CAA Summary, dated 5/3/12, for falls documented "Resident NS #2 had a fall from wheelchair, that was observed by another resident, who was able to give details of the fall. Resident was using the foot board of bed to (pull self along in room and slid out of the chair). Resident concurred with the circumstances of the fall. This seems to be an isolated incident as resident was dependent with the wheelchair mobility at the facility the Resident came from, did not attempt independent transfer, and had had no falls there. Resident was assessed by Occupational Therapy and given a smaller wheelchair with no-slip chair pad to facilitate wheelchair mobility." The current care plan, included the following interventions: - Staff will ensure that Resident is closely supervised.. - Place call light within reach at all times. On 8/9/12 at 9:55 A.M., the Resident was observed out on an open first floor deck, that was one story off the ground and surrounded on three sides by a deck rail (approximately 43 inches high). There was no means for the Resident to call for assistance. There were 6 other residents on the deck at this time. There were no staff on the deck to supervise these Residents. On 8/9/12 from approximately 11:30 A.M. to 11:40 A.M., Resident NS #2 was once again observed sitting in a wheelchair, on the first floor deck. There was no means for this Resident to call for assistance. There were three other cognitively impaired residents on the deck at this time. There were no staff on the deck to supervise these Residents. 6. The facility failed to provide Resident #11, with adequate supervision, as the facility allowed this Resident, unsupervised access to a first floor open deck, which presented a safety hazard to this Resident, who had a [DIAGNOSES REDACTED]. Record review indicated that Resident #11 had [DIAGNOSES REDACTED]. The Admission MDS, dated [DATE], indicated that this Resident had severe cognitive impairment with a BIMS score of 3, and required supervision in Activities of Daily Living and walking. This Resident's current care plan, included the following interventions: - To remain on unit with alarmed doors. - Staff to accompany Resident to off unit activities. - Make sure all staff is aware of elopement risk. On 8/9/12 at 9:55 A.M., Resident #11 was observed out on an open first floor deck, that was one story off the ground and surrounded on three sides by a deck rail (approximately 43 inches high). There was no means for this Resident to call for assistance. There were 6 other residents on the deck at this time. There were no staff on the deck to supervise these Residents. On 8/9/12, from approximately 11:30 A.M. to 11:40 A.M., Resident #11 was once again observed on this first floor deck. There was no means for this Resident to call for assistance. There were three other cognitively impaired residents (Resident #2, NS #3 and NS #5) on the deck at this time. There were no staff on the deck to supervise these Residents. 7. Both the second floor Unit Manager (UM #2), when interviewed on 8/8/12 at 9:30 A.M., and the Director of Nurses, when interviewed on 8/9/12 at 3:00 P.M., said that it was a practice of the facility to allow any Resident, without a chair alarm or a wanderguard, to sit out on the second floor deck, alone without staff supervision. They reported that the exit doors to the deck were kept unlocked. In addition, both Unit Manager #2 and the Director of Nurses said that there was no facility policy and procedure in place for assessment of Residents to determine whether they were safe to use these decks without supervision. Based on observation, record review, family and staff interview, the facility failed to ensure that three sampled residents ( #3, #5, #11) and 3 non-sampled (NS) residents (NS #2, NS #3, NS #4) received adequate supervision to prevent accidents, out of an total sample of 17 residents and 3 of 6 non-sampled residents. Findings include: 1. For Resident #5, the facility failed to ensure that the resident's environment remained free of accident hazards and that the resident received adequate supervision to prevent accidents. Findings include: Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) conducted on 6/7/12 identified the resident as being alert and oriented, requiring only supervision for activities of daily living and mobility. The Significant Change MDS of 7/20/12, identified the resident as being alert and oriented, needing extensive assist for bed mobility, transfer and ambulation secondary to a recently fractured hip. The Brief Interview for Mental Status (BIMS) review on both MDSs were coded as 14/15 and 15/15 respectively, indicating that the resident was alert and oriented. Record review and review of the incident report dated 7/3/12 indicated that the resident sustained [REDACTED].M. in the resident's bathroom. Per the incident report, the resident was found on the floor, lying of the right side. At that time the resident complained of pain to the right hip area. The resident was sent to the emergency room for evaluation and was diagnosed with [REDACTED]. Review of the incident report and the facility's investigation into the incident, as well as the information sent to the Department of Public Health (DPH) indicated, that the resident "was thrown off the toilet seat." Upon checking the toilet seat, the facility noted that the seat was "cockeyed, but secure." During interview on 8/2/12 at 11:30 A.M., Resident #5, who is alert and oriented, said: "I went to the bathroom and when I was finished, as I applied pressure on the handles of the overseat commode in order to stand, the legs on the commode skated in water or urine and sent me flying." When asked if the resident had reported the incident as it had just been reported to this surveyor, the resident said "I sure did." During observation of the resident's bathroom, on 8/2/12 at 11:40 A.M., a toilet with a secure seat was noted. However, the "over toilet commode" which raises the toilet seat for the resident's comfort and safety, was wobbly and not secured. During interview on 8/2/12 at 11:30 A.M., Charge Nurse #4 said that the fall was due to a toilet seat which had become "cockeyed" during use. Staff Nurse #4 stated that the resident had not reported anything about the over toilet commode slipping in water or urine at the time of the fall. On 8/10/12 at 12:00 noon, two surveyors interviewed the resident again about his/her fall. The resident related the same details, in the same order, without any change in the story. The resident demonstrated to the surveyors how the incident occurred and said, " this wobbly thing is the cause of the accident. It still is not fixed. I am afraid that when I start to use the bathroom independently again, the same thing might happen." The facility failed to ensure that the assistive equipment, provided to this resident for safe toilet use, remained appropriate and safe for this resident.

Based on observation, record review and staff interview, the facility failed to ensure that adequate supervision was provided to 1 resident (#7) in a sample of 19. Findings include: For Resident #7, the facility failed to ensure that two nursing staff were present and providing care to the resident when the resident was in the whirlpool room. Resident #7 requires transfer with a Hoyer Lift and two nursing staff during transfers. On 2/7/2011, at 7:00 P.M., the resident was being cared for by one nursing assistant and suffered a head injury which required 6 sutures. Resident #7 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as having severely impaired cognitive skills, being non-ambulatory and requiring two person assist during transfers. In addition, the resident utilized a Hoyer lift for transfers. Record review revealed the resident suffered a head injury on 2/07/11 at 7:00 P.M., following a whirlpool bath which was given to the resident by only one nursing assistant. Further record review revealed a 2/10/11 Incident Investigation Report which stated the resident had just finished a whirlpool bath, given to the resident by one nursing assistant. The resident was sitting on the whirlpool chair with a belt in place. The resident leaned forward, and the resident's head hit the wall and grab bar. Further information revealed the resident was transferred to the hospital and returned with six sutures to the forehead. During interview, on 7/11/11at 2:30 P.M., the Director of Nursing (DON) stated that any resident who requires a Hoyer lift for transfers requires two 2 nursing staff to be present at the time the whirlpool bath is being given. The DON also stated that all nursing staff had been inserviced and were aware of this requirement prior to the incident. The DON stated that the resident suffered the injury while only one nursing assistant and not two nursing assistants, as required, was present and providing the resident with a whirlpool bath.