Every finding on record at Quabbin Valley Healthcare

Based on observation, interviews and records reviewed for one of three sampled residents (Resident #2) who required dressing changes to a wound on his/her coccyx and per facility policy was to be placed on Infection Control precautions, the facility failed to ensure the required level of precautions were put in place and that nursing implemented and followed all necessary precautions during wound care dressing changes. Findings include:Review of the Facility Policy titled Enhanced Barrier Precautions, effective 01/2023, indicated the following:-Enhanced Barrier Precautions are a level of protection for staff, and visitors who may be in a direct contact with a resident who possibly or has MDRO (multi-drug-resistant organisms) on their body or medical device.-These residents include residents with a wound regardless of their MDRO status (this includes chronic and surgical wounds, does not apply to skin tears or small wounds that can be easily covered with a dressing)-Enhanced Barrier Precautions (EBP) must be in place when delivering high-contact resident care activities such as performing wound care (for example, any chronic or surgical wound requiring a dressing of any type).-The staff member must wear gowns and gloves that are donned before contact with the resident and removed upon completion of the intervention and disposed of in the identified waste and laundry containers.-Signage indicating the need for Enhanced Barrier Precautions are posted outside the identified resident's room door along with a precaution cart stocked with gowns and gloves.-Enhanced Barrier Precautions must remain in place for the resident's entire say or unless the wound is fully healed.Resident #2 was admitted to the Facility February 2026, with diagnoses including schizoaffective disorder (a chronic mental health disorder), and diabetes mellitus type 2.Review of Resident #2's medical record indicated he/she was admitted to the facility with a Stage II pressure injury (partial thickness skin loss involving the epidermis and/or dermis, appears as shallow pink/red, moist open injury or intact/ruptured blister) on the coccyx (tail bone) measuring 2 centimeters in length by 0.7 centimeters width, with 0 centimeters in depth. Review of Resident #2's Physicians order, dated 02/22/26 indicated he/she had the following order for wound care:-Coccyx wound- cleanse with normal saline, pat dry, apply Santyl (a topical debriding agent used to remove dead tissue) followed by 2-inch by 2-inch gauze and cover with foam border dressing, change daily and prn (as needed).On 02/25/26 at 2:35 P.M., the surveyor observed the following during Resident #2's wound care and dressing change:-Although facility policy indicated that residents receiving wound care needed to be on EBP, there was No Enhanced Barrier Precautions (EBP) signage or precaution cart stocked with gowns and gloves observed at Resident #2's door.-Nurse #4 donned a mask and gloves (no gown) and removed Resident #2's old dressing, the wound was observed to be an open, shallow wound with scant drainage, the wound bed had yellow tissue and the skin surrounding the wound was reddened. -Nurse #4 cleansed the wound, applied Santyl and a new dressing.During an interview on 02/25/26 at 3:00 P.M., Nurse #4 said she did not think she needed to wear a gown during Resident #2's wound care because he/she did not have MRSA (an antibiotic-resistant bacteria) and because there was not at Enhanced Barrier Precautions sign at his/her door.During an interview on 02/25/26 at 3:05 P.M., the Infection Preventionist (IP) said Resident #2 should have been placed on Enhanced Barrier Precautions upon admission because he/she had a wound. The IP said Nurse #4 should have worn a gown during Resident #2's wound care to help prevent transmission of infection, and per facility policy.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose comprehensive care plan indicated he/she required assistance of two staff members for bed mobility/positioning, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 12/05/25, CNA #1 repositioned Resident #1 in bed without another staff member present to assist her, and he/she fell out of bed. Findings include: Review of the Facility's policy titled, Plans of Care, dated as revised on 04/04/25, indicated all staff involved in the resident's care must be familiar with and follow the care plan. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/08/25, indicated that during morning care on 12/05/25, Resident #1 was sliding off an air mattress and could not be retrieved to midline of the bed, was lowered to the floor, and did not have any injuries.Review of the Facility's Internal Investigation Narrative indicated the following:-Resident #1 sustained a witnessed fall on 12/05/25.-Certified Nurse Aide (CNA) #1 was providing care to Resident #1 (who was on an air mattress), his/her legs slid towards the edge of the bed, CNA #1 repositioned him/her back to the center of the bed, turned to obtain linens and when she turned her head back to Resident #1, he/she was sliding off the bed.-CNA #1 grabbed Resident #1's midsection to reposition him/her, but he/she continued to slide with his/her weight being more than CNA #1 could manage, and he/she subsequently fell to the floor.Review of the Administrator's interview with CNA #1, dated 12/08/25, indicated CNA #1 said she had cared for Resident #1 in the past (on a different unit), that she did not know that Resident #1 required two persons to assist with his/her care, and while there was another CNA (CNA #2) present in the room, that CNA was caring for another resident and that she (CNA #1) was caring for Resident #1 by herself when he/she fell out of bed.Resident #1 was admitted to the Facility in February 2022, diagnoses included unspecified dementia with agitation and adjustment disorder with mixed disturbance of emotions and conduct.Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 10/07/25, indicated he/she was severely cognitively impaired with a score of zero out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact).Further review of his/her MDS Assessment indicated he/she had impairment to both his/her lower extremities, and was dependent on staff for hygiene, dressing, bed mobility, transfers, and positioning. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her Annual MDS Assessment, dated 10/07/25, indicated he/she was dependent on two staff members for transfers (via mechanical lift), and two staff members for positioning in and out of bed.Review of Resident #1's current CNA Care Card (reference tool for CNAs to obtain critical patient information that includes their care needs and level of staff assistance required to meet those needs), last updated 02/23/25, indicated he/she was dependent on two staff members for positioning in bed.During a telephone interview on 12/23/25 at 11:16 A.M., CNA #1 said she was working on 12/05/25 and was caring for Resident #1 without the assistance of another caregiver when he/she fell out of bed.CNA #1 said she had cared for Resident #1 one or two times previously when he/she was on a different unit, but that she was not familiar with his/her care needs. CNA #1 said every resident in the facility has a CNA Care Card, located in the CNA assignment books kept at the Nursing Station. CNA #1 said the Care Card includes information about the type of care a resident would need, including how many staff members are required to complete care.CNA #1 said she did not check Resident #1's Care Card prior to caring for him/her, that she did not know Resident #1 required two caregivers for bed mobility and said if she had checked his/her Care Card she would have seen he/she required two caregivers and would have gotten assistance from another staff member prior to providing care.During a telephone interview on 12/23/25 at 12:05 P.M., CNA #2 said she was working the morning of 12/05/25 when Resident #1 fell out of bed. CNA #2 said she was caring for Resident #1's roommate, that CNA #1 was caring for Resident #1 by herself, and that she did not see him/her fall.During an interview on 12/23/25 at 2:00 P.M., Unit Manager #1 said Resident #1 was completely dependent on staff for all his/her care needs, and that his/her Care Card indicated he/she required assistance from two staff members for care, including bed mobility and positioning.Unit Manager #1 said all CNAs should check the Care Card prior to providing care to a resident, and that the Care Cards are easily accessible in the CNA Book located at the Nursing Station.During an interview on 12/23/25 at 4:20 P.M., the Director of Nurses (DON) said she was aware Resident #1 had fallen on 12/05/25 and that the Administrator interviewed the two CNAs that were present in Resident #1's room during the fall (CNA #1 and CNA #2). The DON said the Administrator's investigation revealed that while CNA #2 was in the room when Resident #1 fell, she was providing care to Resident #1's roommate and that CNA #1 was providing care to Resident #1 alone.The DON said Resident #1's Care Card indicated he/she required two caregivers to assist with bed mobility and positioning and that CNA #1 should not have provided care to him/her alone.During a telephone interview on 12/26/25 at 11:52 A.M., the Administrator said she learned in morning report on 12/05/25 that Resident #1 had experienced a fall and it was reported that he/she was lowered to the floor with no injuries.The Administrator said she interviewed all staff that were present during his/her fall on 12/05/25. The Administrator said CNA #1 told her she was providing care to Resident #1 without assistance from another staff member when he/she fell, that she was unaware Resident #1 required two caregivers for positioning and bed mobility and had not checked his/her Care Card prior to providing care. The Administrator said Resident #1's Care Card clearly identified he/she was a two person assist with positioning.On the day of the survey, the facility provided the surveyor with a plan of correction, with an effective date of 12/16/25, that addressed the area of concern as follows:A) Resident #1 was assessed after his/her fall on 12/05/25, and he/she showed no signs of an injury or change in behavior as a result of the fall.B) On 12/08/25, when Resident #1 exhibited signs of discomfort, he/she was reassessed by nursing and the Nurse Practitioner, imaging studies were ordered, results were inconclusive, and he/she continued to be monitored by staff. C) On 12/08/25, the Administrator initiated an investigation into the circumstances surrounding Resident #1's fall and determined his/her fall was the result of Certified Nurse Aide (CNA) #1 providing care to him/her without the assistance of another caregiver present. CNA #1 was immediately re-educated on the importance of reviewing the Care Card and ensuring she provides care consistent with the Care Card. D) On 12/08/25, the Staff Development Coordinator (SDC) and/or her designee, initiated education for all clinical staff titled, Dependent Assist, one or two Caregivers, with the goal for nursing staff / CNAs to recognize and understand how to read and implement individual residents' needs in accordance with their Care Card. E) On 12/08/25, the Director of Nurses (DON) initiated a whole house audit of resident falls to determine accuracy of resident care plans, to determine whether the resident Care Cards were consistent with their care plans, and whether any falls were as a result of staff failing to implement residents' care plans. F) On 12/12/25, the Unit Managers initiated weekly audits to ensure residents who require two persons for bed mobility, positioning and transfers were provided the appropriate level of staff assistance to prevent falls. G) The incident was presented and discussed at the December 2025 Quality Assurance Performance Improvement (QAPI) committee meeting. Audit results were reported to the QAPI committee and will be continued to be reported to the committee and remain ongoing until 100% compliance is met.H) The Administrator and/or her designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for bed mobility and positioning, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent an incident/accident, when on 12/05/25, during the provision of care, CNA #1 provided care to Resident #1 without having another staff member present to assist her, and Resident #1 fell out of bed.Findings include:Review of the Facility policy titled Fall Prevention, dated as revised 09/04/25, indicated the following:-Preventative care planning for the resident at risk for falls should involve all relevant disciplines.-All team members should be aware of the risks and benefits of interventions chosen, and preventative interventions will be entered into the resident care plan and will be updated as indicated.-Ensure caregivers, resident and family are aware of care plan interventions to promote continuity of care.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/08/25, indicated that during morning care on 12/05/25, Resident #1 was sliding off an air mattress, could not be retrieved to midline of the bed, was lowered to the floor, and did not have any injuries.Review of the Facility's Internal Investigation indicated the following:-Resident #1 sustained a witnessed fall on 12/05/25.-Certified Nurse Aide (CNA) #1 was providing care to Resident #1 (who was on an air mattress), his/her legs slid towards the edge of the bed, CNA #1 repositioned him/her back to the center of the bed, turned to obtain linens and when she turned her head back to Resident #1, he/she was sliding off the bed.-CNA #1 grabbed Resident #1's midsection to reposition him/her, but he/she continued to slide with his/her weight being more than CNA #1 could manage, and he/she subsequently fell to the floor.-On 12/08/25 after Resident #1 experienced pain and discomfort with care, the Administrator began an internal investigation and interviewed CNA #1 about the fall. Review of the Administrator's interview with CNA #1, dated 12/08/25, indicated CNA #1 said she had cared for Resident #1 in the past (on a different unit), that she did not know that Resident #1 required two persons to assist with his/her care, and while there was another CNA (CNA #2) present in the room, that CNA was caring for another resident and that she (CNA #1) was caring for Resident #1 by herself when he/she fell out of bed.Resident #1 was admitted to the Facility in February 2022, diagnoses included unspecified dementia with agitation and adjustment disorder with mixed disturbance of emotions and conduct.Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 10/07/25, indicated he/she was severely cognitively impaired with a score of zero out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact).Further review of his/her MDS Assessment indicated he/she had impairment to both his/her lower extremities, and was dependent on staff for hygiene, dressing, bed mobility, transfers, and positioning. Review of Resident #1's Fall Risk Care Plan, reviewed and renewed with his/her Annual MDS Assessment, dated 10/07/25, indicated that he/she was at increased risk for falls.Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her Annual MDS Assessment, dated 10/07/25, indicated he/she was dependent on two staff members for transfers (via mechanical lift), and two staff members for positioning in and out of bed.Review of Resident #1's current CNA Care Card (reference tool for CNAs to obtain critical patient information that includes their care needs and level of staff assistance required to meet those needs), last updated 02/23/25, indicated he/she was dependent on two staff members for positioning in bed.Review of a Nursing Post Fall Evaluation Note, dated 12/05/25 at 6:57 A.M. (written by Nurse #1), indicated Resident #1 experienced a witnessed fall on 12/05/25 at 6:15 A.M. during morning care and upon assessment, had no injuries. Review of Nurse #1's Written Witness Statement, undated, indicated that a CNA (later identified as CNA #2) approached her at 6:15 A.M. on 12/05/25 saying, we need you, he/she fell (referring to Resident #1), that she went to Resident #1's room and found him/her to be lying on his/her back with CNA #1 holding his/her head in her lap.Nurse #1's Statement further indicated CNA #1 told her Resident #1 started to slide out of bed and that she could not stop him/her from falling.The surveyor was unable to interview Nurse #1 as she did not respond to the Department of Public Health's request for an interview.Review of CNA #1's Written Witness Statement, dated 12/05/25, indicated that on 12/05/25, she was changing Resident #1, that she was standing on the left side of the bed, that Resident #1 rolled off the right side of the bed and landed on his/her fall mat on the floor.During a telephone interview on 12/23/25 at 11:16 A.M., CNA #1 said she was working on 12/05/25 and caring for Resident #1 when he/she fell out of bed. CNA #1 said she was getting ready to provide incontinent care to Resident #1, that she rolled him/her to his/her side when he/she started to move his/her legs off the side of the bed. CNA #1 said at that time, she pulled Resident #1's legs back onto the bed and that she turned her head to obtain clean linen and a brief.CNA #1 said when she turned her head back towards Resident #1, he/she had moved his/her legs over the side of the bed again, that the rest of his/her body started to slide off the bed, and she was unable to stop him/her from falling to the floor. CNA #1 said she cared for Resident #1 only one or two times previously and that she was not familiar with his/her care needs. CNA #1 said every resident in the facility has a CNA Care Card, located in the CNA assignment books kept at the Nursing Station. CNA #1 said the Care Card includes information about the type of care a resident would need, including how many staff members are required for bed mobility.CNA #1 said she did not check Resident #1's Care Card prior to caring for him/her, that she did not know Resident #1 required two caregivers for bed mobility. CNA #1 said if she had checked the Care Card, she would have seen that Resident #1 required two caregivers and would have gotten assistance from another staff member prior to providing care.During a telephone interview on 12/23/25 at 12:05 P.M., CNA #2 said she was working the morning of 12/05/25 when Resident #1 fell out of bed. CNA #2 said she was caring for Resident #1's roommate, and that CNA #1 was caring for Resident #1 by herself.CNA #2 said she did not see, but heard Resident #1 fall, heard CNA #1 yell out for help, saw that Resident #1 was lying on the floor with his/her head near the wall in between the bed and the nightstand and he/she was lying on his/her side. CNA #2 said she went to get the nurse on duty, who came to assist.CNA #2 said after the nurse determined Resident #1 had no injuries, she and the nurse used the mechanical lift to transfer Resident #1 back to bed. CNA #2 said she and CNA #1 then provided care to Resident #1, and while doing so he/she started to move his/her legs off the side of the bed again. CNA #2 said if she was not standing on that side of the bed (opposite side of CNA #1), Resident #1 could have fallen out of bed again.During an interview on 12/23/25 at 2:00 P.M., Unit Manager #1 said Resident #1 was completely dependent on staff for all his/her care needs and his/her Care Card indicated he/she required assistance from two staff members for care, including bed mobility and positioning.Unit Manager #1 said all CNAs should check the Care Card prior to providing care to a resident, and that the Care Cards are easily accessible in the CNA book located at the Nursing Station.During an interview on 12/23/25 at 4:20 P.M., the Director of Nurses (DON) said she was aware Resident #1 had fallen on 12/05/25.The DON said after the Administrator interviewed the two CNAs that were present in Resident #1's room during the fall (CNA #1 and CNA #2), she learned that while CNA #2 was in the room when Resident #1 fell, she was providing care to Resident #1's roommate and that CNA #1 was providing care to Resident #1 alone, despite his/her Care Card indicating she required two persons to assist with positioning and bed mobility.The DON said during the investigation, CNA #1 said she did not know Resident #1 required two caregivers because she did not consult his/her Care Card.During a telephone interview on 12/26/25 at 11:52 A.M., the Administrator said she learned in morning report on 12/05/25 that Resident #1 had experienced a fall and it was reported that he/she was lowered to the floor with no injuries.The Administrator said on 12/08/25, she interviewed all staff that were present during his/her fall, and said CNA #1 told her she was providing care to Resident #1 without assistance from another staff member when he/she fell, that she was unaware Resident #1 required two caregivers for positioning and bed mobility and had not checked his/her Care Card prior to providing care. The Administrator said Resident #1's Care Card clearly identified he/she was a two person assist with positioning, and said if there were two caregivers present, he/she would not have fallen.On the day of the survey, the facility provided the surveyor with a plan of correction, with an effective date of 12/16/25, that addressed the area of concern as follows:A) Resident #1 was assessed after his/her fall on 12/05/25, and he/she showed no signs of an injury or change in behavior as a result of the fall.B) On 12/08/25, when Resident #1 exhibited signs of discomfort, he/she was reassessed by nursing and the Nurse Practitioner, imaging studies were ordered, results were inconclusive, and he/she continued to be monitored by staff. C) On 12/08/25, the Administrator initiated an investigation into the circumstances surrounding Resident #1's fall and determined his/her fall was the result of Certified Nurse Aide (CNA) #1 providing care to him/her without the assistance of another caregiver present. CNA #1 was immediately re-educated on the importance of reviewing the Care Card and ensuring she provides care consistent with the Care Card. D) On 12/08/25, the Staff Development Coordinator (SDC) and/or her designee, initiated education for all clinical staff titled, Dependent Assist, one or two Caregivers, with the goal for nursing staff / CNAs to recognize and understand how to read and implement individual residents' needs in accordance with their Care Card. E) On 12/08/25, the Director of Nurses (DON) initiated a whole house audit of resident falls to determine accuracy of resident care plans, to determine whether the resident Care Cards were consistent with their care plans, and whether any falls were as a result of staff failing to implement residents' care plans. F) On 12/12/25, the Unit Managers initiated weekly audits to ensure residents who require two persons for bed mobility, positioning and transfers were provided the appropriate level of staff assistance to prevent falls. G) The incident was presented and discussed at the December 2025 Quality Assurance Performance Improvement (QAPI) committee meeting. Audit results were reported to the QAPI committee and will be continued to be reported to the committee and remain ongoing until 100% compliance is met.H) The Administrator and/or her designee are responsible for overall compliance.

Based on observation, interview, and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#75 and #54), out of five applicable residents, out of 34 medication pass opportunities. The medication error rate was observed to be 5.88%. Specifically, 1. For Resident #75, the Resident was not encouraged to rinse his/her mouth and spit after the administration of an oral inhalation corticosteroid medication. 2. For Resident #54, the Resident was administered an oral medication that was dropped on the contaminated surface of the medication cart. Findings include: Review of the facility policy titled Medication Pass Guideline, effective 6/1/2012, indicated the following: -Purpose: To assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely and sanitary manner. -Use sanitary techniques to place medications into a souffle or medicine cup. -The nurse is responsible for reading and following precautions and instructions on prescription labels. Review of professional standards article titled, Quick Guide to Using Your Symbicort Inhaler, Revised 2/2018, retrieved from https://www.symbicorttouchpoints.com/content/dam/physician-services/us/526-rwd-symbicort-hcp/pdf/03_using_the_symbicort_inhaler.pdf indicated:-After using the Symbicort inhaler: - After you finish taking SYMBICORT (two puffs), rinse your mouth with water. Spit out the water. Do not swallow it.-SYMBICORT may cause serious side effects, including:>Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using SYMBICORT to help reduce your chance of getting thrush.>Pneumonia and other lower respiratory tract infections. People with COPD may have a higher chance of pneumonia and other lung infections. 1.Resident #75 was admitted to the facility in May 2025 with diagnoses including Chronic Respiratory Failure with Hypoxia, Chronic Combined Systolic and Diastolic Congestive Heart Failure, Major Depressive Disorder, and bipolar disorder. Review of Resident #75's Physician's order dated 8/6/25, indicated the following: -Symbicort (Budesonide - Formoterol Fumarate Dihydrate) Inhalation Aerosol 80/4.5 microgram (mcg/act [actuation]), 2 puffs. Inhale orally two times a day for Shortness of Breath. Rinse mouth after use, initiated 7/28/25. On 8/6/25 at 7:33 A.M., during a medication administration pass, the surveyor observed Nurse #1 administer 2 puffs of Symbicort oral inhalation medication into Resident #75's mouth. The Resident closed his/her mouth for five seconds after the medication was administered. When Nurse #1 asked Resident #75 if he/she would like a drink of water, the Resident declined and Nurse #2 left Resident #75's room and placed the Symbicort inhaler back in the medication cart without requesting that the Resident rinse his/her mouth and spit. During an interview on 8/6/25 at 10:02 A.M., Nurse #1 said she should have encouraged Resident #75 to rinse his/her mouth after the use of the Symbicort Inhalation medication to avoid oral thrush, but she did not. 2. Resident #54 was admitted to the facility in December 2021 with diagnoses including Pure Hyperglyceridemia, Alcohol Induced Disorder, Unspecified Intercranial Injury, Bipolar Disorder, and Alcohol Dependence with Alcohol-Induced Persisting Dementia. Review of Resident #54's Physician's orders dated 8/6/25, indicated: -Keppra (Levetiracetam) Oral Tablet 750 milligram (mg), give 750 mg by mouth three times a day related to Epilepsy, initiated 5/1/25. On 8/6/25 at 8:06 A.M., during a medication administration pass, the surveyor observed Nurse #2 prepare medications to be administered to Resident #54. Nurse #2 was observed to drop the Keppra medication on the surface of medication cart. Nurse #2 was further observed to don gloves, use a spoon and picked up the dropped medication and then added the Keppra medication to the souffle cup which contained the other prepared medications to be administered to Resident #54. During an interview on 8/6/25 at 8:12 A.M., Nurse #2 said the medication administration cart had not been cleaned and/or disinfected prior to her beginning the medication pass procedure. Nurse #2 said she was unsure when the medication cart was last cleaned. Nurse #2 said she should have discarded the Keppra medication that had dropped on the top of the medication cart and should have administered a new Keppra medication but did not.

Based on interview, and record review, the facility failed to provide education on the benefits and risks of Pneumococcal Vaccination for one Resident (#15) of five applicable residents reviewed for vaccination, out of a total sample of 23 residents. Specifically, the facility failed to provide evidence that education was provided to the Resident #15's invoked Health Care Proxy (HCP) when the Resident was offered the Pneumococcal Vaccine and refused administration of the vaccine. Findings include: Review of the facility's policy titled Immunization and Vaccines- residents, last revised February 2022, indicated but is not limited to the following:-Vaccine information statements and consent for pneumococcal and influenza will be part of the resident's admission packet. Consent for these vaccinations will be obtained from the resident or resident representative at the time of admission. -Orders for administration of pneumococcal and annual influenza vaccine will be obtained/ or written by the resident's MD/NP (Medical Doctor/ Nurse Practitioner) on admission. -Persons with previous vaccination with PPSV23 (Pneumovax 23: vaccine used to help protect against serious infections caused by 23 types of pneumococcal bacteria): Adults 65 years or older who have previously received one or more doses of PPSV23 also should receive a single dose of PCV13 (Prevnar 13: vaccine used to protect against 13 types of pneumococcal bacteria that commonly cause serious infections) if they have not received it. A dose of PPCV23 should be given 1 year or > after the receipt of the most recent PPSV23 dose. For those whom an additional dose of PPSV23 is indicated this subsequent PPSV23 dose should be given 1 year or > after the PCV13 and 5 years after the most recent dose of PPSV23. -Before offering pneumococcal immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization: - And the resident or resident's legal representative has had the opportunity to refuse immunization; and -The resident's medical record includes documentation that indicates, at a minimum, the following: >The resident or resident's legal representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization: and >That the resident either received the pneumococcal immunization or did not receive the immunization due to medical contraindication or refusal. Resident #15 was admitted to the facility in December 2024 with diagnoses including Dementia and Dysphagia. Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #15: -was cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of nine out of a total possible 15. -Health Care Proxy (HCP) was invoked. -was over the age of 65. -had declined the Pneumonia Vaccine. Review of Resident #15's Vaccine Consent Form dated 12/3/24, indicated the form was signed by the HCP and consent was given for Pneumococcal Vaccination. Review of Resident #15's Immunizations Record indicated the following: -PPSV23: Received on 7/30/14. -PCV20: Resident Refused on 2/4/25. Review of the Resident's Progress Notes, dated 2/4/25, indicated Resident #15 was approached by Nursing staff twice and refused twice when the Pneumococcal Vaccine was offered. During an interview on 8/8/25 at 7:59 A.M., the Infection Preventionist (IP) said that if a Resident is offered a vaccine and refuses, staff should educate the Resident and their HCP on the risks and benefits of vaccination. During an interview on 8/8/25 at 8:30 A.M., Nurse #8 said that Resident #15 refused the offered Pneumococcal Vaccine twice on 2/4/25. Nurse #8 said he provided education to the Resident and had also contacted the Resident's HCP. Nurse #8 said that when a Resident refuses an offered vaccination, the refusal would be documented and include if education was provided. During an interview on 8/8/25 at 9:05 A.M., the IP said that she monitors resident immunizations by running a weekly report which also indicates refusals or acceptances of vaccines offered. The IP said that if a resident refused a vaccination, she would speak with the Unit Manager (UM), the Resident, and the Responsible Party regarding the benefits and risks of the vaccination and provide the Vaccine Information Sheets. The IP said they also will re-approach any residents that may refuse a couple of weeks later and involve family support or behavioral interventions as needed. Further review of Resident #15's medical record failed to indicate that the Resident or HCP were provided education on the benefits and risks of the Pneumococcal Vaccination when the Resident refused on 2/4/25.

Based on observations, interviews, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#2) out of a total sample of 23 residents and on one unit ([NAME]) out of four total units observed. Specifically, the facility failed to:1a.for Resident #2, ensure that staff performed hand hygiene as required between glove changes while providing wound care to the Resident.-b. ensure that staff wore the indicated Personal Protective Equipment (PPE: items such as gown and gloves used to mitigate the spread of infection) when providing care for a Resident who required Enhanced Barrier Precautions (EBP: protective barrier gowns and gloves used as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care).2. ensure that staff disinfected the glucometer machine between residents while performing finger stick blood sugar checks, increasing the risk for the potential spread of infection from one resident to another.Findings include: 1a. Review of the facility policy titled Hand Washing: Employee, dated February 2022, indicated the following: -Wash hands with soap and water when they are visibly dirty or soiled with blood or other body fluids. -If hands are not visibly soiled, an alcohol-based hand rub or gel may be used in place of soap and water. -Handwashing must be performed under the following conditions: >if hands will be moving from a contaminated body site to a clean body site during resident care. >after removing personal protective equipment (e.g., gloves, gown, facemask). Review of the facility policy titled Clean Dressing Change, dated September 2024, indicated the following: -.14. remove soiled dressing and gloves, place in bag for disposal -15. Perform hand hygiene -16. Put on clean gloves -17. Clean wound as ordered, carefully dry skin around wound. -18. Remove gloves -19. Perform hand hygiene -20. Put on clean gloves. Resident #2 was admitted to the facility in February 2025 with diagnoses including Metabolic Encephalopathy. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] indicated the following: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15 -has 2 stage 4 pressure ulcers that were present on admission Review of Resident #2's August 2025 Physician orders indicated the following: -an active order initiated on 2/13/25 to maintain Enhanced Barrier Precautions (EBP). On 8/7/25 at 10:30 A.M., the surveyor observed the following during wound care provided to Resident #2 by Nurse #7: -Performed hand hygiene and donned (put on) a gown and gloves. -Remove the soiled dressing from the Resident's right and left buttocks. -doffed (removed) gloves, performed hand hygiene and donned new gloves. -cleansed the wounds with normal saline soaked gauze. -doffed gloves and donned new gloves without performing hand hygiene. -patted dry the wounds with clean, dry gauze. -doffed gloves, set up dressing material supplies without performing hand hygiene, and donned new gloves without performing hand hygiene. -completed the dressing application to the right and left buttock. -doffed gloves and donned new gloves without performing hand hygiene. -repositioned the Resident to his/her left side and removed the dressing to the right gluteal fold. -doffed gloves and donned new gloves without performing hand hygiene. -cleansed the right gluteal fold wound with normal saline soaked gauze and then patted the wound dry with dry, clean gauze. -doffed gloves, set up dressing material supplies without performing hand hygiene, and donned new gloves without performing hand hygiene. -applied the dressing as ordered to the right gluteal fold. -cleaned up and discarded items into trash, removed gown and gloves, performed hand hygiene and exited Resident #2's room. During an interview on 8/7/25 at 11:00 A.M., Nurse #7 said that hand hygiene should be performed every time that gloves are changed to prevent cross-contamination, but she did not perform hand hygiene each time she changed her gloves. 1b. On 8/6/25 at 2:14 P.M., the surveyor observed the following from the hallway outside Resident #2's room: -Enhanced Barrier Precaution (EBP) sign and a three drawer Personal Protective Equipment (PPE) bin located outside of the Resident's room that contained multiple items including disposable gowns and gloves. -Resident #2's curtain was drawn but the Resident's feet and end of the bed were visible. -CNA #1 was observed coming around the bed with bed sheets in her gloved hands. -CNA #1 was not observed to don a gown. On 8/6/25 at 2:17 P.M, the surveyor requested Nurse #5's observation of personal care being provided to Resident #2. During an interview at the time, when Nurse #5 exited the Resident's room, she said the Resident was on EBP for multiple reasons that included infections but was not completely sure what those infections were. Nurse #5 said the Resident was also on EBP due to his/her wounds and urinary catheter. Nurse #5 said when she went into the room, she observed CNA #1 providing care for Resident #2 and the CNA should have had on a gown but did not have a gown on as required. 2. Review of the facility policy titled Blood Glucose Meter: Cleaning and Disinfecting, revised 9/1/24, indicated: -Cleaning and disinfection of fingerstick glucose machines are needed to help decrease infection prevention of bloodborne pathogens. Staff must follow infection control guidelines. -Equipment – blood glucose monitoring device with Isopropyl alcohol (70% - 85%) and 1:10 bleach solution or EPA – registered disinfectant detergent or germicide that is approved for healthcare settings. -Cleaning 1. Wear appropriate protective gear such as disposable gloves. 2. Open the cap of the disinfectant container and pull out one towelette and close the cap. 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 4. Dispose of the used towelette in a trash bin. 5. Pull out one new towelette and wipe the entire surface of the meter three times horizontally and three times vertically using a new towelette to remove blood borne pathogens. 6. Dispose of the used towelette in a trash bin. 7. Allow exteriors to remain wet for the corresponding contact time for each disinfectant. 8. After disinfection, the user's gloves should be removed to be thrown away and hands washed before proceeding to the next patient. On 8/6/25 at 8:08 A.M., the surveyor observed Nurse #2 perform a blood glucose finger stick check on a resident. Nurse #2 was observed cleaning the glucometer machine with a facility provided Sani Hand Wipes (pre-moistened wipes designed for quick and effective hand hygiene, particularly in situations where soap and water are not readily available). Nurse #2 was observed performing finger stick blood glucose checks on four other residents and using the Sani Hand Wipes as the cleaning agent between glucometer use. The surveyor observed that one of the four residents was on EBP, and Nurse #2 failed to clean the glucometer as required after use. During an interview on 8/6/25 at 8:45 A.M., Nurse #2 said she was a full-time employee at the facility and had always used the Sani Hand Wipes to clean the glucometer machine after performing finger stick blood glucose checks on any resident. During an interview on 8/6/25 at 9:02 A.M., Unit Manager (UM) #2 said facility staff are expected to use Super Sani-Cloth Germicidal disposable wipes (Isopropyl alcohol (70% - 85%) and 1:10 bleach solution or EPA – registered disinfectant detergent or germicide that is approved for healthcare settings) on equipment. During an interview on 8/6/25 at 9:06 A.M., with Nurse #2 and UM #2, Nurse #2 said that she had always used the Sani Hand Wipes to clean the glucometer machine after each finger stick blood glucose on residents.

Based on observation, interview, and record review, the facility failed to ensure care and services for respiratory equipment was maintained in accordance with professional standards of practice related to cleaning, storage, and infection control practices for one Resident (#86) out of a total sample of 23 residents.Specifically, for Resident #86, the facility failed to ensure that Resident #86's Bilevel Positive Airway Pressure (BiPAP) machine and accessory equipment were appropriately maintained and:-the humidifier chamber was cleaned per manufacturer recommendations to prevent growth of microorganisms and mineralization, putting the Resident at risk of inhaling microorganisms when the BiPAP device was in use.-the BiPAP mask and tubing was stored in a clean equipment bag when not in use to prevent contamination of equipment and potential sinus and respiratory infections for the Resident. Findings include: Review of the facility policy titled Chapter: Pulmonary, Care and Handling of Respiratory Equipment, revised 9/24, indicated the following:-Equipment should be changed based on the following schedule: >Daily: Empty and wipe clean before filing each day with distilled water. Wipe dust and debris from the external surface of machine. >Weekly: Wash chamber in warm water and mild soap (such as Dove unscented or Ivory). If the chamber does not open, soak with one part vinegar and 2 parts water. Rinse and dry before filling with distilled water.-When not in use, store masks and cannulas in plastic bags labeled with the resident's name and date. Resident #86 was admitted to the facility in June 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure with Hypoxia or Hypercapnia, contracture right and left hand, morbid obesity, Quadriplegia, and Obstructive Sleep Apnea (OSA). Review of the most recent Minimum Data Set (MDS) Assessment, dated 5/6/25 indicated Resident #86:-was cognitively intact as indicated by a Brief Interview of Mental Status (BIMS) score of 15 out of 15.-was dependent for upper body care and personal hygiene.-utilized noninvasive mechanical ventilation. On 8/5/25 at 10:31 A.M., the surveyor observed Resident #86 lying in bed and a BiPAP machine located on his/her bedside table. The surveyor observed the BiPAP mask was directly in contact with the Resident's bedside table and was not stored in a bag. The surveyor also observed the humidifier chamber was dry with debris on the bottom. During an interview at the time, Resident #86 said he/she wore the BiPAP machine each evening and nursing assisted him/her with putting it on and filling the humidifier chamber with water. Resident #86 said he/she could not remember when his/her BiPAP mask, tubing, and humidifier chamber had been cleaned by the nursing staff. Resident #86 further said he/she was physically not able to clean the BiPAP device him/herself. On 8/6/25 at 8:24 A.M., the surveyor observed Resident #86 lying in bed. During an interview at the time, Resident #86 said he/she was able to remove his/her BiPAP mask and laid it on the bed as no staff have been in to assist him/her as yet. The surveyor observed the humidifier chamber on the BiPAP machine had debris floating in the water. On 8/6/25 at 9:03 A.M., the surveyor observed Resident #86 lying in bed and his/her BiPAP mask was now laying in direct contact with the Resident's bedside table. During an interview at the time, Resident #86 said a Certified Nurse Aide (CNA) came in to provide care and moved the BiPAP mask to the bedside table and did not put it in a bag. Review of Resident #86's August 2025 Physician orders indicated the following:-Change Oxygen tubing that goes to BiPAP weekly on Saturday, every night shift 11:00 P.M. - 7:00 A.M., every Saturday, start date of 6/14/25.-BiPAP Orders: IPAP (Inspiratory Pressure) 14.0 cm (centimeter) H2O (water), EPAP (Expiratory Pressure) 6.0 cm H20, FiO2 - 2 Liters Per Minute (LPM) daily at bedtime and during naps, every shift, start date of 6/17/23Further review of the Physician's orders failed to indicate orders for the cleaning and maintenance of Resident #86's BiPAP machine and equipment. During an interview on 8/6/25 at 8:42 A.M., Unit Manager (UM) #3 said it was the Respiratory Therapist's (RT) job to ensure the BiPAP machine is cleaned weekly. UM #3 said nursing does not put in Physician's orders for cleaning of the BiPAP machine since it is taken care of by the RT. During an interview on 8/6/25 at 9:44 A.M., the RT said she came into the facility weekly to see any residents with respiratory needs. The RT said she does not see all residents in the facility every week. The RT said residents who have BiPAP machines are seen at least yearly, and she ensures that they are using their equipment appropriately and provides education to the residents if needed. The RT said she did not clean BiPAP equipment unless she was visiting a resident when she was in the facility. The RT said routine cleaning should be done by the nursing staff at the facility and this included cleaning the tubing and mask in warm soapy water weekly and emptying the humidifier chamber and wiping it clean daily. The RT said it is important to clean the BiPAP equipment on a regular basis as it reduced the risk for a resident acquiring a respiratory illness. The RT said it is also important to make sure debris was cleaned out of the humidifier chamber to ensure mineralization (buildup of minerals from water) did not occur. On 8/6/25 at 10:07 A.M., the surveyor and Nurse #4 observed Resident #86 lying in bed and his/her BiPAP mask was laying directly in contact with the bedside table. During an interview at the time, Nurse #4 said any staff member who assists the Resident with his/her BiPAP mask should bag the mask (in an equipment storage bag). Nurse #4 looked for a storage bag and said there was no bag in the room to store the BiPAP mask. The surveyor and Nurse #4 also observed the water in the humidifier chamber and Nurse #4 said there was debris in the chamber, and it should have been cleaned prior to the Nurse adding water the previous night. Nurse #4 said there should be Physician's orders in place for cleaning of the BiPAP machine which should include how to clean the different parts of the BiPAP machine. The surveyor and Nurse #4 reviewed Resident #86's current Physician's orders and Nurse #4 said Resident #86 did not have any orders in place for the cleaning of his/her BiPAP machine and orders should be in place. Nurse #4 said it was important to ensure respiratory equipment was maintained and cleaned regularly to reduce the chance of the Resident acquiring a respiratory infection. During an interview on 8/6/25 at 11:14 A.M., the Director of Nursing (DON) said there should be Physician's orders for BiPAP machine cleaning. The DON said those orders should include wiping down the mask and humidifier chamber daily and cleaning all parts with warm soapy water weekly. The DON said once an order was in place nursing would sign off each time cleaning was completed on the Treatment Administration Record (TAR) or Medication Administration Record (MAR). The DON said since Resident #86 did not have orders for the care of his/her BiPAP she could not be sure when the last time the equipment had been cleaned which put the Resident at risk for acquiring a respiratory infection.

Based on observations, interviews, and record reviews, the facility failed to provide a dignified existence for two Residents (#2 and #64), out of a total sample of 23 residents. Specifically, 1) For Resident #2, the facility failed to ensure privacy was provided before exposing the Resident's buttocks during a dressing change procedure, putting the Resident at risk of having their private parts viewed by others. 2) For Resident #64, the facility failed to ensure that the Resident was dressed in his/her clothing and not a hospital gown while in common spaces in the facility with other residents. Findings include: Review of the facility policy titled Resident Privacy and Dignity, dated 9/4/24, indicated the following: -Care for residents in a manner that maintains dignity and individuality: >Dress in appropriate and desired clothing. -Examine and treat residents in a manner that maintains their privacy. >Use a closed door, drawn curtain, or both to shield the resident during all personal care and treatment procedures. -Drape and dress residents appropriately at all times to avoid exposure and embarrassment. 1) Resident #2 was admitted to the facility in February 2025 with diagnoses including Metabolic Encephalopathy. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15. On 8/7/25 at 10:30 A.M., during a wound care observation being provided by Nurse #7, the surveyor observed the following: -Nurse #7 positioned Resident #2 on his/her right side facing the wall and exposed the Residents' buttocks to the open bedroom door, with the Resident's privacy curtain not pulled far enough to prevent visualization of the Resident's buttocks from the doorway. -the surveyor intervened and indicated visibility from the doorway to where Resident #2 was lying exposed in bed, and Nurse #7 immediately pulled the curtain far enough to prevent visualization of the Resident from the doorway. During an interview on 8/7/25 at 11:00 A.M., Nurse #7 said that she should have provided privacy for the Resident before exposing him/her. During an interview on 8/7/25 at 11:05 A.M., the Director of Nursing (DON) said that the expectation was that before exposing a Resident, staff should always provide privacy to maintain the Resident's dignity. 2) Resident #64 was admitted to the facility in February 2025 with diagnoses including Traumatic Subdural Hemorrhage. Review of Resident #64's MDS assessment dated [DATE], indicated the Resident had severe cognitive impairment as evidenced by a BIMS score of 0 out of a possible score of 15. Review of Resident #64's Care Plan failed to indicate that the Resident had a preference for wearing a hospital gown. On 8/5/25 at 12:30 P.M., the surveyor observed Resident #64 seated in his/her Broda chair in the day room on the unit. Resident #64 was observed wearing a hospital gown with no blanket or sheet present. The surveyor observed that multiple residents were present in the day room at this time. On 8/7/25 at 8:11 A.M., the surveyor observed Resident #64 seated in his/her Broda chair in the day room on the unit. The Resident was further observed dressed in a hospital gown with a blanket in place covering his/her lower torso to feet. On 8/7/25 at 11:47 A.M., the surveyor observed Resident #64 lying in bed dressed in a hospital gown and covered with a sheet and blanket. Nurse #6 was observed entering the room to assist another staff member in repositioning Resident #64. During an interview on 8/7/25 at 11:50 A.M., Nurse #6 said that Resident #64 typically wore clothing and not a hospital gown. The surveyor reviewed with Nurse #6 several observations of Resident #64 in commons spaces on the unit and dressed in a hospital gown. Nurse #6 said that the Resident should have been dressed in clothing when he/she came out of his/her room for breakfast this morning. On 8/7/25 at 12:00 P.M., the surveyor observed Resident #64 was in his/her Broda chair in the unit day room dressed in a t-shirt and pants. During an interview on 8/7/25 at 12:15 P.M., the surveyor reviewed with the Administrator observations of Resident #64 dressed in a hospital gown in the day room. The Administrator said there was a concern for dignity with the Resident wearing a hospital gown in a common space. The Administrator further said that the Resident was known to frequently move around and push blankets off increasing the potential that he/she could be further exposed.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards relative to an indwelling urinary catheter (a thin flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#2), of two applicable residents reviewed for indwelling urinary catheter care and services, out of a total sample of 23 residents.Specifically, for Resident #2, the facility failed to obtain Physician's orders for the use of an indwelling urinary catheter placing the Resident at risk for urinary tract complications. Findings include:Review of the facility policy titled Indwelling Urinary Catheter: Policy, revised 9/1/24, indicated the following:-A physician's order must be obtained for insertion of an indwelling catheter. The order must include catheter size, balloon size and frequency of change. Resident #2 was admitted to the facility in February 2025 with diagnoses including Metabolic Encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #2:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15-utilized an indwelling urinary catheter Review of Resident #2's August 2025 Physician's orders failed to indicate an order for use of an indwelling urinary catheter. On 8/7/25 at 10:30 A.M., during a wound care observation with Nurse #7, the surveyor observed an indwelling urinary catheter tubing was secured to Resident #2's right leg and the urinary collection bag was secured to the bed below the level of the bladder. During an interview on 8/7/25 at 2:45 P.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #2's Physician orders and UM #1 said there should be an order for the size of catheter, balloon size and what frequency the urinary catheter should be changed but there was not.

Based on observations, interviews, and record reviews, the facility failed to provide care consistent with professional standards of practice to prevent deterioration of a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one Resident (#2) of two applicable residents reviewed for pressure ulcer care and services, out of a total sample of 23 residents.Specifically, for Resident #2, the facility failed to ensure that the dressing change for a Stage 4 Pressure Ulcer of the left and right buttocks was completed per Physician's orders, when collagen powder and Calcium Alginate AG were not administered as ordered, placing the Resident at risk for complications related to the pressure ulcers. Findings included:Review of the facility policy titled Clean Dressing Change, dated September 2024, indicated the following:-Apply dressing and secure as ordered. Resident #2 was admitted to the facility in February 2025 with diagnoses including Metabolic Encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #2:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15.-has two Stage 4 Pressure ulcers that were present on admission. Review of Resident #2's August 2025 Physician orders indicated:-an active order initiated 6/18/25 for Dressing to left buttock: cleanse w/ns (with normal saline [solution of salt water used to clean wounds]), pat dry. Apply collagen powder (powder that is used to promote moist wound healing) to wound base, cover with Calcium Alginate AG (Silver: dressing material that is absorbent and due to the presence of AG/silver, has antimicrobial properties), then cover with foam border every day and evening shift.-an active order initiated 6/18/25 for Dressing to right buttock: cleanse w/ns, pat dry. Apply collagen powder to wound base, cover with Calcium Alginate AG, then cover with foam border every day and evening shift. On 8/7/25 at 10:30 A.M., the surveyor observed the following during wound care for Resident #2 provided by Nurse #7:-Nurse #7 performed hand hygiene and donned (put on) a gown and gloves-Nurse #7 removed the dressing from the Resident's right and left buttock-Nurse #7 doffed (removed) gloves and donned new gloves-Nurse #7 cleansed the wounds with normal saline soaked gauze-Nurse #7 doffed gloves and donned new gloves-Nurse #7 patted dry the wounds with clean, dry gauze-Nurse #7 doffed gloves, set up dressing material supplies, and donned new gloves-Nurse #7 placed a collagen matrix dressing material (solid dressing pad dressing material used to promote moist wound healing) on the wound beds of the right and left buttocks, covered it with Calcium Alginate (an absorbent dressing material that does not contain silver) and then covered the Calcium Alginate with a bordered foam dressing-Nurse #7 did not apply the collagen powder and Calcium Alginate AG as ordered by the Physician.-Nurse #7 doffed gloves and proceeded to complete the remaining dressing changes. During an interview on 8/7/25 at 11:00 A.M., Nurse #7 said that she had used collagen matrix dressing instead of the ordered collagen powder. Nurse #7 further said that she used a regular Calcium Alginate dressing instead of the ordered Calcium Alginate AG dressing. Nurse #7 said that the dressing order for the collagen had been changed from collagen matrix to collagen powder when the facility supply had changed to the collagen powder but when the facility supply available changed back to the collagen matrix, an order to resume use of the collagen matrix should have been obtained. Nurse #7 said that using the incorrect dressing could result in the wound worsening.

Based on observation, record review, and interview, the facility failed to provide services that met professional standards of quality relative to medication management for two Residents (#75 and #54), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #75, encourage the Resident to rinse his/her mouth as required after the administration of an oral corticosteroid inhalation medication, placing the Resident at risk of developing fungal infection of the mouth and airways. 2. For Resident #54, ensure that the Resident was not administered medication that was dropped on the medication cart surface, putting the Resident at risk of being administered contaminated medications. Findings include: Review of the facility policy titled Medication Pass Guideline, effective 6/1/12, indicated the following: -Purpose: To assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely and sanitary manner. -Use sanitary techniques to place medications into a souffle or medicine cup. -The nurse is responsible for reading and following precautions and instructions on prescription labels. Review of professional standards article titled, Quick Guide to Using Your Symbicort Inhaler, Revised 2/2018, retrieved from https://www.symbicorttouchpoints.com/content/dam/physician-services/us/526-rwd-symbicort-hcp/pdf/03_using_the_symbicort_inhaler.pdf indicated: -After using the Symbicort inhaler: After you finish taking SYMBICORT ., rinse your mouth with water. Spit out the water. Do not swallow it. >SYMBICORT may cause serious side effects, including: -Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using SYMBICORT to help reduce your chance of getting thrush. -Pneumonia and other lower respiratory tract infections. People with COPD may have a higher chance of pneumonia and other lung infections. 1.Resident #75 was admitted to the facility in May 2025 with diagnoses including Chronic Respiratory Failure with Hypoxia, Chronic Combined Systolic and Diastolic Congestive Heart Failure, Major Depressive Disorder, and bipolar disorder. Review of Resident #75's Physician's order dated 8/6/25, indicated the following: -Symbicort (Budesonide/Formoterol Fumarate Dihydrate) Inhalation Aerosol 80/4.5 micrograms (mcg/act) 2 puffs. Inhale orally two times a day for Shortness of Breath. Rinse mouth after use, initiated 7/28/25. On 8/6/25 at 7:33 A.M., during a medication administration pass procedure, the surveyor observed Nurse #1 administering two puffs of the Symbicort oral inhalation medication into Resident #75's mouth. The Resident was observed to close his/her mouth for approximately five seconds after the administration of the medication and Nurse #1 asked Resident #75 if he/she would like a drink of water. Resident #75 responded that he/she did not want a drink of water and Nurse #1 then walked out of Resident #75's room and placed the Symbicort Inhaler back in the medication cart without having the Resident rinse and spit as required after the medication use. During an interview on 8/6/25 at 10:02 A.M., Nurse #1 said she should have encouraged Resident #75 to rinse his/her mouth after the use of the Symbicort Inhalation medication to avoid oral thrush, but she did not. Nurse #1 said this not allowing Resident #75 to rinse his/her mouth after the use of the Symbicort Inhalation did not meet professional standards of care. 2. Resident #54 was admitted to the facility in December 2021 with diagnoses including Pure Hyperglyceridemia, Alcohol Induced Disorder, Unspecified Intercranial Injury, Bipolar Disorder, and Alcohol Dependence with Alcohol-Induced Persisting Dementia. Review of Resident #54's Physician's orders dated 8/6/25, indicated the following: -Keppra (Levetiracetam) Oral Tablet 750 milligram (mg), give 750 mg by mouth three times a day related to Epilepsy. Start date 5/1/25. On 8/6/25 at 8:06 A.M., during medication administration pass, the surveyor observed Nurse #2 to drop the Keppra medication on top of the medication administration cart. Nurse #2 was observed to don gloves and pick up the Keppra Medication using a spoon and placed the medication into a souffle cup with other medications prepared for Resident #54. Nurse #2 was observed to then administer the medications to Resident #54. During an interview on 8/6/25 at 8:12 A.M., Nurse #2 said the medication administration cart had not been cleaned and/or disinfected prior to the beginning of her medication pass and she was unsure of when the medication cart was last cleaned. Nurse #2 said she should have discarded the Keppra medication that was dropped, and administered a new Keppra medication, but she did not. Nurse #2 said this did not meet professional standards and/or quality of care.

Based on interviews, and record reviews, the facility failed to implement abuse prevention policies and procedures relative to alleged incidents of potential abuse for two Residents (#16 and #66) out of a total sample of 23 residents. Specifically, the facility failed to implement their abuse policies and procedures, relative to prohibition, identification, and investigation, to determine whether abuse had occurred:a. For Resident #16, who was allegedly pushed and sworn at by Resident #66, and Nurse #9 as an agent of the facility did not report the incident as required for the investigation of all allegations.b. For Resident #66, who had a known history of aggressive behavior toward other residents, had an altercation with Resident #16 and allegedly pushed and swore at him/her, and Nurse #9 as an agent of the facility failed to report the incident and prevent any further incidents from occurring. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation: Prohibition, revised 9/3/24, indicated: -Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined by Federal regulation. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Residents most at risk of neglect and abuse, i.e. residents who have dementia, ., or have needs or behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors . Review of the facility's policy titled Abuse, Neglect, and Exploitation: Identification, revised 9/3/24, indicated: -The purpose of the policy was to proactively identify any event that may be potential abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property. -The facility will be proactive in identification of any event that may potentially be or would lead a reasonable person to conclude that there was a potential for abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property. Review of the facility's policy titled Abuse, Neglect, and Exploitation: Investigation, revised 9/4/24, indicated: -The purpose of the policy was to gather pertinent information regarding an alleged, witnessed, or observed incident that will facilitate proper reporting and follow up as indicated. -The staff member to who such an allegation is reported either verbally or in writing, or who witnesses and/or suspects potentially inappropriate treatment . will report the event immediately to the nursing supervisor. -All alleged violations involving abuse, neglect, exploitation or mistreatment, ., shall be reported immediately: >but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or >not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to: >the Administrator and to other officials in accordance with State law. a. Resident #16 was admitted to the facility in May 2024 with diagnoses including Dementia with Mood Disturbance, Major Depressive Disorder, and Generalized Anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #16: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 total possible points. -required the use of a wheelchair for mobility. -required substantial/maximal assistance to wheel 50 feet. b. Resident #66 was admitted to the facility in September 2024 with diagnoses including Dementia with Behavioral Disturbance. Review of Resident #66's Behavioral Health Evaluation dated 10/22/24, indicated that facility staff requested the Resident be evaluated after the Resident had an altercation with another resident. Review of Resident #66's Behavioral Health Evaluations, dated 10/24/24 and 10/29/24, indicated the Resident exhibited aggressive behavior toward other residents. Review of Resident #66's Behavioral Health Evaluation, dated 11/29/24, indicated facility staff requested for the Resident to be evaluated after the Resident allegedly slapped and grabbed the hair of another resident. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66: -was severely cognitively impaired as evidenced by a BIMS score of six out of 15 total possible points. -exhibited wandering over one to three days during the observation period for the MDS Assessment. -exhibited verbal behavioral symptoms (threatening others, screaming at others, cursing at others) over four to six days during the observation period for the MDS Assessment. Review of Resident #66's Behavioral Symptoms Care Plan, initiated 9/12/24 and revised 10/3/24, indicated the following: -was at risk for behavioral symptoms due to Dementia. -mood lability with intermittent agitation. -can be combative with direct care. -history of altercations with other residents. -can be verbally and physically aggressive. -may yell or exit seek. -ensure when Resident is leaving the Dayroom, no other residents are in the doorway. -if the Resident becomes agitated with another resident, offer diversional activity . -observe for any changes in mood or behavior; document, notify MD/MP [sic. NP: Nurse Practitioner] . -Team review to assess. Review of Resident #66's June 2025 Behavior/Intervention Monthly Flow Record indicated the following for 6/1/25 on the evening (3:00 P.M. - 11:00 P.M.) shift: -The Resident experienced five episodes of yelling out. -The Resident experienced two episodes of hitting or bitting [sic]. -The Resident experienced three episodes of being verbally abusive. Review of Resident #66's Nursing Progress Notes, dated 6/1/25 indicated: -written at 4:02 P.M., indicated: . increased agitation, hitting, and yelling at residents. -written at 8:07 P.M., indicated the Resident was hitting and pushing other residents. During an interview on 8/6/25 at 5:00 P.M., the Administrator said that she was not made aware that Resident #66 had pushed and hit other residents on 6/1/25. The Administrator said if she had been made aware that Resident #66 had pushed and hit other residents, an investigation of the incident would have been initiated immediately to determine what occurred, who the residents involved in the incident were, and whether the incident needed to be reported. The Administrator said an investigation had not been conducted because she was not alerted by facility staff of the alleged incident between Resident #66 and other residents. The Administrator said she attempted to contact Nurse #9 after the surveyor's inquiry relative to Resident #66's alleged incident with other residents on 6/1/25, and Nurse #9 could not be reached, and she was still looking to get in touch with the Nurse. The Administrator said she needed to initiate an investigation to determine whether or not resident-to-resident abuse had occurred. During an interview on 8/7/25 at 12:09 P.M., UM #2 said that when an incident involving potential abuse occurred on a weekend, the Nurse was required to notify the supervising on-call Nurse of the incident. UM #2 said that the supervising on-call Nurse would then come into the facility to ensure the process for investigating the incident for alleged abuse was properly initiated. UM #2 said that 6/1/25 was a Sunday and that she was the supervising on-call Nurse. UM #2 said she did not receive any notification from the Nurse #9 relative to Resident #66 yelling at, hitting, and pushing other residents, and that Nurse #9 should have contacted the supervising on-call Nurse to ensure the incident was thoroughly investigated. During an interview on 8/7/25 at 4:20 P.M., Nurse #9 said Resident #66 experienced episodes of agitation. Nurse #9 said she was assigned to care for Resident #66 during the evening shift on 6/1/25. Nurse #9 said Resident #66 was agitated and attempted to enter the Dayroom. Nurse #9 said Resident #16 was seated in a wheelchair in the doorway of the Dayroom, in front of Resident #66. Nurse #9 said Resident #66 pushed Resident #16's wheelchair, while Resident #16 was sitting it, and was swearing at Resident #16. Nurse #9 said she did not alert a nursing supervisor or administration of Resident #66 pushing Resident #16's wheelchair and swearing at Resident #16 because Resident #66 did not make any physical contact with Resident #16.

Based on observation, interview and record review, the facility failed to ensure that medications were stored in a safe and secure manner for one Resident (#123) out of a total of 23 sample residents.Specifically, for Resident #123, the facility failed to ensure that:-two over-the-counter medications were secured and not left at the Resident's bedside and readily accessible to other residents on the unit.-a Physician's order was obtained for the use of two over-the-counter medications brought into the facility by the Resident's family.-an assessment was completed to ensure the Resident was capable of self-administering medications. Findings include:Review of the facility policy titled Medication Pass Guidelines, dated 6/1/2012, indicated:-Purpose: To assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely and sanitary manner.-Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication.-Medications are administered in accordance with written orders of the attending physician. Review of facility policy titled, Bedside Storage of Medications, dated 4/2024, indicated:-Bedside medication storage is permitted for residents who are willing and able to self-administer medications upon the written order of the prescriber, when it is deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team.-a written order for the bedside storage of medication is placed in the resident's medical record.-The nurse performs a self-administration assessment and determines the resident's capability to self-administer using a self-medication assessment form documenting any limitations.-Bedside storage of medications is indicated on the resident medication administration record for the appropriate medications.>For residents who self-administer some or all medications, the following conditions are met for bedside storage to occur:-locked drawer at bedside.-the resident will have a key to the drawer and will be able to unlock the drawer independently.-the resident is instructed in the proper use of bedside medications including what the medication is used for, how it is to be used, how often it may be used, proper cleaning of inhaler, proper storage. Resident #123 was admitted to the facility in July 2025 with diagnoses including Overactive Bladder, Hypertension and vertebrogenic Low Back Pain. Review of Resident #123's Minimum Data Set (MDS) assessment, dated 7/30/25, indicated that the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. On 8/6/25 at 8:02 A.M., during a medication administration pass, the surveyor observed Nurse #1 administer medications to Resident #123. The surveyor observed the following medications on the Resident's bedside table:-Biotene Dry Mouth Moisturizing Spray (two boxes) labeled with the Resident's name, with indications as saliva stimulant.-Simple Saline Nasal Spray Instant Relief, every day for congestion.During an interview at the time, Resident #123 said the Biotene Dry Mouth Moisturizing Spray and Simple Saline nasal spray were medications that were brought from home upon his/her admission to the facility. Resident #123 said he/she used the medications whenever he/she desired due to dry mouth and nasal stuffiness. During an interview on 8/6/25 at 8:30 A.M., the surveyor and Nurse #1 reviewed Resident #123's medications and Nurse #1 said Resident #123 did not have Physician orders for the Biotene and the Simple Saline nasal spray medications. Nurse #1 also said the Resident had not been assessed for safe self-administration of medications. Nurse #1 further said the Biotene dry mouth spray and saline nasal spray were not supposed to have been left at Resident #123's bedside and should have been locked up for safety. During an interview on 6/6/25 at 10:15 A.M., Unit Manager (UM) #3 said Resident #123 should have been assessed for indication for use of the medication. UM #3 said Resident #123 should have been assessed for self-administration of the medications, a Physician's order should have been obtained, and the medications should have been secured but none of these had been done.

Based on observation, interview, and record reviews, the facility failed to provide care and services consistent with professional standards of practice for dialysis (process that filters waste, salt, and fluid from your blood when the kidneys are unable to work adequately) services, for one Resident (#6) out of one applicable dialysis resident, out of a total sample of 23 residents. Specifically, for Resident #6, the facility failed to: -Accurately monitor daily fluid intakes as ordered by the Physician, when the Resident was dependent on Renal Dialysis, placing the Resident at risk for fluid status changes, difficulty breathing, edema (swelling caused by a buildup of fluids in the body's tissues) and dehydration (when the body uses or loses more fluid than it takes in). Findings include: Review of the Facility Policy titled Care of Renal Dialysis Resident, dated 9/1/14, indicated the following: -Dietary management involves restriction or adjustment of protein, sodium, potassium, or fluid intake. Staff to provide education on risk vs benefits of not adhering to restrictions. -Document the daily intake and output total on the 24-Hour Intake and Output (I & O) Record or Medication Administration Record. Review of the Facility Policy titled Intake & Output (I & O) Measurement, revised 9/4/24 indicated the following: >To ensure the resident's fluid balance is assessed and managed appropriately in order to prevent dehydration. -All nursing personnel are responsible for recording on the Intake and Output (I & O) Record. -The licensed nurse is responsible for totaling the intake and output each shift during his/her tour of duty and assessing the resident for necessary interventions. -Intake and Output may be ordered by the physician or by the licensed nurse to assess fluid balance. >Residents with the following risk factors/clinical characteristics will be placed on intake and output as indicated below: -Fluid Restriction - duration of therapy. -Renal/Peritoneal Dialysis - duration of therapy or as ordered by physician. -All oral (PO) fluids are recorded in the Intake column after consumption. -If a resident does not consume any oral fluids during a given shift, a zero of NPO (Nothing by Mouth) will be recorded in the shift total column. Never leave this column blank. -The Certified Nurse Aide (CNA) and licensed nurse are responsible for recording intake and output in the Daily Intake & Output Worksheet for identified residents. -The nurse calculates the 8-hour total on the I & O worksheet and records the total on the permanent 24-Hour Intake and Output Record/MAR (Medication Administration Record). -The 3:00 P.M. - 11:00 P.M or 11:00 P.M. - 7:00 A.M. shift nurse (to be determined by DON [Director of Nursing]) totals the I & O for all 3 shifts and records the total on the 24-Hour Intake and Output Record/MAR. Review of the Facility Policy titled MD (Medical Director) Notification, dated 9/1/24, included but not limited to the following: >Is to notify the resident's physician of any changes in the resident's condition, treatment, and/or medication issues. -At any point, the licensed nurse should immediately notify the resident's attending physician of an identified change in the resident's medical condition, treatment plan, or issues or medications concerns. Review of the Facility Policy titled Charting and Documentation, dated 9/1/24, indicated the following: >It is the policy of the facility that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. -All observations, medications administered, services performed, etc., (et cetera) must be documented in the resident's clinical records. >Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: -The assessment data and/or any unusual findings during the procedure/treatment. -Notification of family, physician or other staff, if indicated. Resident #6 was admitted to the facility in October 2024, with diagnoses including End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, and Hypertension. Review of the Minimum Data Set (MDS) Assessment, dated 7/17/25, indicated Resident #6: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15. -was on dialysis. -was on a Therapeutic diet. Review of Resident #6's Comprehensive Person-Centered Care Plan initiated 11/10/24, indicated:-was at risk for fluid imbalance secondary to ESRD on Hemodialysis (HD) and fluid restriction requiring therapeutic diet with interventions that included: >1500 milliliter (ml) fluid restriction - 840 ml via kitchen and monitor intake and record every (q) meal. -needed dialysis related to renal failure with intervention to monitor intake and output. Review of Resident #6's August 2025, Physician orders indicated: -No Salt Packet diet Regular (level 7) texture, thin consistency, 1500 cubic centimeter (cc: unit of volume that is equivalent to a milliliter) fluid restriction; 840 ml from kitchen, initiated 11/7/24. -1500 cc Fluid Restriction - 24 Hour Total to be totaled by 11:00 P.M. Nurse every night shift (11:00 P.M.- 7:00 A.M.) for Total Fluid Intake - Restriction Monitoring. Notify Provider if fluid restriction exceeded, initiated 6/13/25. -1500 cc Fluid restriction; (840 ml provided with meals from dietary) nursing breakdown is 220 ml: 7:00 A.M.- 3:00 P.M. (day shift), 220 ml: 3:00 P.M. - 11:00 P.M. (evening shift), 220 ml: 11:00 P.M. - 7:00 A.M. (night shift) every shift, initiated 6/13/25. -Intake & Output every shift for 1500 cc fluid restriction, initiated 3/8/25. -Dialysis Center Monday, Wednesday and Friday - pick-up at 7:15 A.M., Return 12:30 P.M., initiated 5/23/25 Review of Resident #6's Treatment Administration Record (TAR) for April 2025 through August 2025, indicated that Resident #6 exceeded the prescribed fluid restriction as follows: >April 2025 - 4/5/25: 1780 ml, 4/13/25: 1580 ml, 4/14/25: 1560 ml, 4/18/25: 2720 ml, 4/19/25: 2640 ml, 4/20/25: 1680 ml. >May 2025 - 5/3/25: 2180 ml, 5/4/25: 1680 ml, 5/16/25: 1580 ml, 5/17/25: 1700 ml, 5/18/25: 2400 ml, 5/22/25: 1840 ml, 5/23/25: 1800 ml, 5/29/25: 2140 ml, 5/31/25: 1620 ml. >June 2025 - 6/17/25: 2760 ml, 6/18/25: 1860 ml, 6/20/25: 1950 ml, 6/24/25: 1800 ml, 6/25/25: 2060 ml, 6/27/25: 1920 ml. > July 2025 - 7/1/15: 2000 ml, 7/2/25: 2000 ml, 7/3/25: 1940 ml, 7/4/25: 1600 ml, 7/5/25: 1680 ml, 7/9/25: 1550 ml, 7/19/25: 2540 ml, 7/24/25: 1880 ml, 7/25/25: 1680 ml, 7/26/25: 1720 ml. > August 2025 - 8/1/25: 1540 ml, 8/7/25: 1860 ml. Further review of Resident #6's Nursing Progress Notes failed to provide evidence that the Resident's Physician was notified of fluid intakes exceeding 1500 cc. Review of Resident #6's Physician Progress Notes from October 2024 through July 2025 indicated the Physician documented the Resident had low extremity edema: -November 2024: bilat (bilateral) 1-2+ (pitting [indentation] measurement) edema -March 2025: bilateral lower extremity edema was documented on 3/12/25 and 3/26/25: 1+, 3/14/25:1 - 2+, 3/28/25: 2+. -April 2025: bilateral lower extremity edema was documented on 4/2/25 and 4/23/25: 1+, 4/9/25: 2+, 4/13/25: 2 - 3+. -May 2025: bilateral lower extremity edema was documented on 5/11/25: 2+. -July 2025: bilateral lower extremity edema was documented on 7/25/25: 2+. During an interview on 8/8/25 at 12:35 P.M., Unit Manager (UM) #1 said that Resident #6 was prescribed a 1500 ml fluid restriction but sometimes had soda beverage at his/her bedside that the Resident drank. UM #1 said that the nursing staff added fluids to Resident #6 meal trays prior to serving the trays to the Resident. UM #1 said that the Physician should be notified when Resident #6 exceeds the 1500 ml fluid restriction order. UM #1 said that Resident #6 was at risk for weight gain when the 1500 ml Fluid Restriction is exceeded. During an interview on 8/8/25 at 12:41 P.M., the Director of Nursing (DON) said that the nursing staff should notify the Physician and the Dialysis Center each time Resident #6 was over the 1500 ml fluid restriction order. The surveyor and the DON reviewed Resident #6 progress notes and the DON said that there was no documentation in Resident #6's clinical records that indicated the Resident's Physician was notified about the Resident exceeding the fluid restriction order. The DON said when Resident #6 exceeds the fluid restriction order the Resident could be at risk for fluid overload and renal failure. During an interview on 8/8/25 at 1:20 P.M., with the Registered Dietician (RD) and the Administrator, the Administrator said if Resident #6 was exceeding the prescribed 1500 ml fluid restriction, then the team should have brought the concern forward at risk management meetings to discuss the situation, review the orders, and contact the Dialysis Center and the Resident's Nephrologist for recommendations. The RD said that she was unaware that Resident #6 was exceeding his/her fluid restriction because the nursing staff had not brought it to her attention. The RD said that the Resident's fluid restriction had been an ongoing education topic with nursing staff to ensure that the Resident's fluid restriction orders were followed.

Based on observation, interview, and record review, the facility failed to post required nurse staffing information daily that included the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. Specifically, the facility failed to post the required nurse staffing information and the actual hours worked by licensed and unlicensed nursing staff on 8/6/25, 8/7/25, and 8/8/25. Findings include: On 8/6/25 at 3:48 P.M., the surveyor observed a staff posting form in the lobby dated 8/6/25 that included the census and the number of staff broken down by job type per shift. The posted nurse staffing information failed to indicate the actual hours worked or hours in a shift for licensed and unlicensed staff. On 8/7/25 at 8:35 A.M, the surveyor observed a staff posting form posted in the lobby that was still dated 8/6/25 and included the census and number of staff broken down by job type per shift but failed to indicate the actual hours worked or hours in a shift for licensed and unlicensed staff. On 8/8/25 at 2:25 P.M., the surveyor observed a staff posting form posted in the lobby that was still dated 8/6/25 and included the census and number of staff broken down by job type per shift. The posted nurse staffing information failed to indicate the actual hours worked or hours in a shift for licensed and unlicensed staff. During an interview on 8/8/25 at 2:27 P.M., the surveyor and the Administrator reviewed the nurse staff posting form posted in the lobby. The Administrator said the nurse staff form should be updated every day but had not been updated. The Administrator said she was unaware of the requirement to post the actual hours worked for staff.

Based on record review, and interview, the facility failed to ensure that discharge tracking Minimum Data Set (MDS) Assessments were completed as required for three Residents (#25, #27, and #82) of four applicable residents, out of a total sample of 23 residents. Specifically, the facility failed to ensure that Discharge MDS Assessments were completed when Residents #25, #27 and #82 were discharged from the facility to the community. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual dated 10/1/24, reviewed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf Section 2.8 Skilled Facility Prospective Payment System Assessment Schedule indicated the following:-Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility . 1. Resident #25 was admitted to the facility in February 2025. Review of Resident #25's clinical record indicated he/she was discharged to the community on 3/10/25. Further review of the clinical record failed to indicate that a Discharge MDS was completed, as required. 2. Resident #27 was admitted to the facility in February 2025. Review of Resident #27's clinical record indicated he/she discharged to the community 3/10/25. Further review of the clinical record failed to indicate that a Discharge MDS was completed, as required. 3. Resident #82 was admitted to the facility in March 2025.Review of Resident 82's clinical record indicated he/she discharged to the community on 4/25/25. Further review of the clinical record failed to indicate that a Discharge MDS was completed, as required. During an interview on 8/8/2025 at 12:59 PM, the MDS Coordinator said that she utilizes the RAI manual which indicates a Discharge MDS is required when Residents discharge to the community. The surveyor and the MDS Coordinator reviewed Resident's #25, #27, #82 records and the MDS Coordinator said that Discharge MDS assessments should have been completed for the three Residents as required and had not been completed.

Based on observations, records reviewed, and interviews, for two of three sampled residents (#3 and #1), who required the use of a wheelchair for mobility, the facility failed to ensure each residents room was equipped with or located near toilet/commode that they can access quickly, both residents ability to quickly access their bathrooms were restricted because the bathroom door size was smaller than the wheelchair. Findings include: 1. Resident #3 was admitted to the facility July 2024, and resided on the [NAME] Unit. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #3 was cognitively intact as evidenced by a score of 14 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggest a resident is cognitively intact). Further review of the MDS indicated Resident #3 had lower extremity range of motion impairment on both sides, required partial/moderate assistance (helper does up to fifty percent of the effort) to move from sit to stand and required partial/moderate assistance for toilet transfers. Review of Resident #3's Activities of Daily Living Care Plan, reviewed and renewed with his/her 01/21/25 MDS assessment, indicated interventions included transfer assistance from one staff member for a stand pivot transfer. On 04/09/25 at 8:00 A.M., Surveyor #2 observed CNA #1 push Resident #3's wheelchair up to the bathroom door in his/her room. Surveyor #2 observed Resident #3 reach for the hand rail inside the bathroom on the wall and pull his/herself up to a standing position while CNA #1 stood behind the wheelchair outside of the bathroom door, but not within reach of Resident #3. Shortly afterwards, CNA #1 approached Surveyor #2 and said Resident #3's wheelchair did not fit into the bathroom. During an interview on 04/09/25 at 1:10 P.M., Resident #3 said that his/her wheelchair does not fit through the door into the bathroom in his/her room. Resident #3 said to use the bathroom in his/her room, he/she has to get his/her wheelchair as far into the doorway as possible, at an angle to reach the grab bar on the wall inside the bathroom and pull him/herself up. Resident #3 said that if he/she can get out of the wheelchair, he/she has to take two steps to turn toward the toilet. Resident #3 said that a CNA usually stands at the door behind his/her wheelchair, out of reach, until he/she is standing. Resident #3 said there is a bathroom in the hall that is easier for him/her to use but that everybody and their brother uses that bathroom, that he/she has to wait and wait, sometimes he/she almost don't make it. During an observation and interview on 04/09/25 at 1:35 P.M., the Maintenance Director and Surveyor #2 obtained the following measurements: -Resident #3's bathroom door opening- 27 inches. -Resident #3 ' s wheelchair width-28 inches. The Maintenance Director said Resident #3's wheelchair does not fit through the bathroom door. The Maintenance Director said the [NAME] and [NAME] Units of the facility were not up to current building codes. 2. Review of Resident #1's Incident Report, dated 09/12/24, indicated Resident #1 bumped his/her right knee on the bathroom door casing in his/her room when he/she attempted to enter his/her bathroom while seated in his/her wheelchair. The Report indicated Resident #1's right knee was slightly swollen, and Resident #1 said the space in his/her room was too tight. During a telephone interview on 04/08/25 at 12:06 P.M., Visitor #1 said Resident #1's wheelchair could not fit into his/her bathroom when he/she resided on the [NAME] Unit. Visitor #1 said that Resident #1 was instead given a container to empty his/her urinary catheter bag contents into, because he/she could not access his/her bathroom to empty the urine into the toilet. Visitor #1 said Resident #1 was also unable to wash his/her hands when done emptying that catheter bag because he/she could not access the sink in the bathroom. Resident #1 was admitted to the facility in May 2024, diagnoses included neuropathic bladder (causes difficulty with urinating), colostomy (surgical opening from the colon to a pouch for stool collection), and chronic kidney disease. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/08/24, indicated Resident #1 had moderate cognitive impairment and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the Assessment indicated Resident #1 was independent for wheelchair mobility, had an indwelling urinary catheter, and ambulating 10 feet was not attempted due to medical conditions or safety concerns. During an interview on 04/09/25 at 3:58 P.M., Nursing Supervisor #1 said she was on duty on 09/12/24 when Resident #1 bumped his/her right knee on his/her bathroom door casing. Nursing Supervisor #1 said the bathroom doors on the [NAME] and [NAME] Units were tiny and that most wheelchairs did not fit through the bathroom doorways. During an interview on 04/09/25 at 2:56 P.M., the Administrator said that they tried to place only residents who were ambulatory in the [small] rooms on [NAME]/[NAME] unit because the doorways to the bathrooms were small.

Based on observation, interviews and record reviews, for 14 resident rooms that housed two residents per room, located on two of four nursing units, the facility failed to ensure each resident room measured the required square footage of 80 square feet per resident in a multi-bed bedroom. Findings include: On 04/09/25, at 7:50 A.M., the surveyor observed room [ROOM NUMBER], (occupied by two residents) which measured 75 square feet per resident, instead of the required 80 feet. Observations made by the surveyor throughout the day on 04/09/25 indicated the size of the impacted rooms did not compromise the health and safety of the residents residing in the rooms. The surveyor reviewed a photocopied letter, written by the facility Administrator, dated 04/21/23, to the Department of Public Health, regarding a continued waiver request for Rooms 101-105, 118-122, 124-126 and 128. The letter indicated that the rooms were in the section of the facility constructed in 1958, and that any attempts to enlarge them would be cost prohibitive, and/or result in the loss of available resident beds. During an interview on 04/09/25 at 4:30 P.M., the Administrator said she had no return correspondence from the Department of Public Health and that the location and number of residents in these rooms meets the residents ' needs.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #3), who resided on a secure unit, had a history of wandering on the evening shift, and staff said they needed to have their eyes on Resident #3 while he/she was ambulating on the unit, the Facility failed to ensure he/she was provided an adequate level of staff supervision in an effort to maintain his/her safety and prevent a fall resulting in an injury, when on 08/25/24, although Resident #3 was out of bed and ambulating in the hallway, he/she was not being supervised by unit staff, Resident #3 fell in the hallway, complained of pain, was transferred to the Hospital Emergency Department (ED) and diagnosed with intertrochanteric (hip) fracture of the left femur, which required surgical intervention to repair. Findings include: Review of the Facility's Policy titled Activities of Daily Living (ADL) Support, dated June 2022, indicated the following: -Definition: Tasks related to personal care such as personal hygiene, toileting, feeding, ambulating, walking in the room and in the corridor. -Resident will perform self-care with ADLs at the level indicated on the Certified Nurse Aide (CNA) Care Plan or Care Card (used by CNAs to determine individual care needs). -Provide ambulation and transfer programs per the care plan. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 08/29/24, indicated that on 08/25/24 at 8:50 P.M., Resident #3 was observed on the floor in the hallway with his/her walker next to him/her. The Report indicated that Resident #3 was transferred to the Hospital ED and was found to have a (left) hip fracture. Review of the Facility's Investigation, which included written statements from the staff, indicated that on 08/25/24 at 8:50 P.M., Resident #3 was observed on the floor in the hallway with his/her walker next to him/her. The Investigation indicated Resident #3 required staff supervision (staff to have eyes on him/her) for ambulation, that he/she had ambulated in the hallway independently and fell . Review of Resident #3's Fall Report, dated 08/25/24 and completed by Nurse #1, indicated the following items were identified as factors relative to Resident #3's fall: -Predisposing Physiological Factors: confused, incontinent, gait imbalance, impaired memory, weakness. -Predisposing Situation Factors: ambulating without assistance, wanderer. Review of Resident #3's Hospital Discharge Summary, dated 08/29/24, indicated Resident #3 sustained a left hip fracture and underwent surgical repair. Resident #3 was admitted to the Facility in September 2021, diagnoses included insomnia, anxiety disorder and vascular dementia. Review of Resident #3's Fall Risk Assessment, dated 07/10/24, indicated he/she was at risk for falls. Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 07/10/24, indicated he/she scored a 3 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated that he/she required staff supervision for ambulation (staff provides verbal cues or touching/steadying assistance as resident completes the activity) and had episodes of wandering. Review of Resident #3's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with the most recent Quarterly MDS Assessment, indicated he/she required staff supervision for ambulation. Review of Resident #3's Elopement Risk Care Plan, reviewed with the most recent Quarterly MDS Assessment, indicated he/she was at risk for elopement and wandering due to impaired safety awareness. During an interview on 09/17/24 at 3:05 P.M., (which included review of her 08/25/24, Nurse Progress Note) Nurse #1 said on 08/25/24 at 8:50 P.M., she was in the Day Room reviewing Facility policies with a newly hired employee. Nurse #1 said it was her routine to spend most of the shift in the Unit Day Room. Nurse #1 said Resident #3 was well known to her and he/she often wandered the hallway of the unit. Nurse #1 said it was very common for Resident #3 to be up and about on the evening (3:00 P.M. to 11:00 P.M.) shift. Nurse #1 said Resident #3 had been in bed and had gotten up to use the bathroom in the hallway. Nurse #1 said that on 8/25/24, before Resident #3's fall, the two Certified Nurse Aides (CNAs) on duty for the evening on the shift had started their rounds, which they did together. Nurse #1 said because she was in the Day Room she could not see Resident #3 ambulating in the hallway. Nurse #1 said she heard a terrible crash in the hallway and ran out from the Day Room to see what happened. Nurse #1 said she observed Resident #3 on the floor in the hallway with his/her walker nearby. Nurse #1 said Resident #3 complained of significant left hip pain and was transferred to the Hospital ED for evaluation. On 09/17/24 at 9:38 A.M., the Surveyor made the following observation on the unit where Resident #3 resided. - The Day Room (where Nurse #1 was while Resident #3 was ambulating in the hallway) was located at the near end of the unit hallway. - The Unit hallway, or residents ambulating in the hallway, could not be seen (monitored) by staff from inside the Day Room. During a telephone interview on 09/17/24 at 2:07 P.M., (which included review of her 08/25/24, Post Fall CNA Report), Certified Nurse Aide (CNA ) #1 said she was familiar with Resident #3 and it was normal for him/her to be up at that time of night on the evening shift. CNA #1 said on 8/25/24, she and one other CNA (CNA #2) were on duty for the evening shift and were in a resident's room at the time of Resident #3's fall. CNA #1 said she heard Resident #3 yell and when she came out of the room, she saw Resident #3 on the floor in the hallway. CNA #1 said Resident #3 immediately complained of hip pain. During a telephone interview on 09/17/24 at 1:37 P.M., (which included review of her 08/25/24, Post Fall CNA Report), Certified Nurse Aide (CNA) #2 said Resident #3 was well known to her. CNA #2 said Resident #3 had also sustained a fall in July 2024 and since that fall, Resident #3 had been increasingly confused and had a shuffled gait, which was new for him/her. CNA #2 said not only did Resident #3 shuffle when he/she walked, but he/she also did so very quickly. CNA #2 said Resident #3 never stayed in bed, was up every 15 minutes, and was always looking to get up and go. CNA #2 said Resident #3 and all of the residents on the secured unit required supervision (having a resident within staff' members line of vision), but said it was not always possible because some residents required assistance of two staff members during care, which often left common areas (such as the hallway) unsupervised. During an interview on 09/17/24 at 1:20 P.M., (which included review of her 8/26/24, Falls Assessment Tool), Unit Manager #1 said she reviewed Resident #3's fall which occurred on 08/25/24 and she, along with other members of the Facility's clinical team, determined Resident #3 ambulated independently and did not have staff supervision at the time of his/her fall. Unit Manager #1 said Resident #3 should have been supervised by staff for ambulation. Unit Manager #1 said it was difficult with Resident #3 because he/she often spent time in the unit's Day Room where staff were able to adequately supervise him/her, but when Resident #3 was not in the Day Room staff may not have realized they needed to provide him/her with supervision during ambulation in the hallway. Unit Manager #1 said after Resident #3's fall on 8/25/24, his/her plan of care and care kardex's were updated and interventions included he/her requires assistance of one staff member with ambulation. During an interview on 09/17/24 at 4:02 P.M., the Director of Nurses (DON) said if a resident required supervision for ambulation, she expected staff to watch the resident from a safe distance during ambulation. The DON said in the case of Resident #3's fall on 08/25/24, the staff did not provide the required level of supervision during ambulation.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) whose behaviors included disrobing and unsafe rising, the Facility failed to ensure Resident #1 was treated in a dignified respectful manner which included being free from the use of a physical restraint imposed for the purpose of staff, when on 07/04/24 during the overnight shift, Certified Nurse Aide #1 placed a sheet across Resident #1's waist and tied it in the back of his/her reclining chair, to prevent Resident #1 from disrobing, while she left to provide care to other residents. Findings include: Review of the Facility Policy titled Physical Restraint, dated as revised on 06/10/16, indicated the resident has a right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms/conditions. The Policy defined a restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement that could ordinarily occur, or normal access to one's body. The Policy defined convenience as any action taken by the facility to control or manage a resident's behavior with lesser amount of effort by the facility and not in the resident's best interest. Resident #1 was admitted to the Facility in December 2023, diagnoses included neurocognitive disorder with Lewy body (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), dementia with behavioral disturbance, and delusional disorder. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/08/24, indicated Resident #1 was severely cognitively impaired with a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the Assessment indicated Resident #1 required substantial/maximum assistance from staff to transfer safely. Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her May 2024 Quarterly MDS, indicated his/her behaviors included impulsivity, disrobing, and resistance to care. Review of Resident #1's July 2024 Behavior Flowsheets indicated he/she frequently demonstrated episodes of unsafe rising from his/her chair and frequently disrobed during the evening and overnight shifts. During a telephone interview on 08/07/24 at 2:38 P.M., Certified Nurse Aide (CNA) #1 said that on 07/04/24 at 3:00 A.M., CNA #2 helped her transfer Resident #1 out of bed and into his/her reclining chair. CNA #1 said that around 3:30 A.M., while CNA #2 was on break, she supervised Resident #1 and two or more residents in the activity room. CNA #1 said that Resident #1 was restless and kept disrobing in his/her chair and a said another resident began yelling at him/her to put his/her clothes back on. CNA #1 said there were two residents that required immediate assistance with toileting, so she placed a sheet across Resident #1 waist area and tied it in the back of his/her chair to prevent him/her from disrobing, while she left to assist the other residents in the bathroom. CNA #1 said that at the time of the incident, CNA #2 was on break, and the nurse and a third CNA were on the other side of the locked doors. CNA #1 said she did not go to get help from the nurse or the CNA because she knew they were busy. CNA #1 said when she went back to check on Resident #1, she noticed he/she had fallen asleep in his/her chair. CNA #1 said that she was distracted while she was busy, and forgot to go back and untie the sheet from the back of Resident #1's chair before she left at the end of her shift. During an interview on 08/06/24 at 3:15 P.M., Certified Nurse Aide #2 said that on 07/04/24 at approximately 3:00 A.M., she helped CNA #1 transfer Resident #1 into his/her reclining chair, before she went on break. CNA #2 said that when she returned from break, Resident #1 was asleep in his/her chair, with a sheet placed over his/her lap. CNA #2 said that she did not notice anything out of the ordinary, because Resident #1 usually had a sheet or blanket on his/her lap, and said she had not noticed that the sheet was tied in the back. CNA #2 said that Resident #1 frequently disrobed during the overnight shift and that he/she was at risk for falling because he/she sometimes stood up from his/her chair without any assistance. Review of Certified Nurse Aide (CNA) #3's Written Witness Statement, dated 07/04/24, indicated that at 9:45 A.M. she attempted to transfer Resident #1 out of his/her chair, but he/she could not stand because he/she was restrained in the chair with a sheet. The Statement indicated that she (CNA #3) notified the nurse. During an interview on 08/06/24 at 1:40 P.M., Nurse #1 said that while he was working the day shift on 07/04/24, CNA #3 came to him at approximately 10:00 A.M., and reported that Resident #1 was tied in his/her chair. Nurse #1 said he observed that Resident #1 had a sheet across his/her waist that was tied behind the chair. Nurse #1 said the sheet become wedged in the side of the chair and he needed to cut the sheet to release it. Nurse #1 said that Resident #1's manner was calm at the time of the observation and said he/she was at his/her baseline for the remainder of the shift. During an interview on 08/06/24 at 12:58 P.M., Social Worker #1 said that she met with Resident #1 on 07/05/24, and said he/she had no recollection of the incident, and he/she did not appear to be in any distress. During an interview on 08/06/24 at 1:51 P.M., Unit Manager #1 said that on 07/04/24 when she and the Director of Nurses interviewed CNA #1 by telephone, CNA #1 admitted that she tied the sheet that was across Resident #1's waist, in the back of his/her chair, to keep him from disrobing and that CNA #1 had referred to the incident as a lapse in judgement. During an interview on 08/06/24 at 3:55 P.M., The Director of Nurses (DON) said that the Facility prides itself in being restraint free and said CNA #1 should not have tied the sheet, that was across Resident #1's waist, behind his/her chair as a way to prevent him/her from disrobing. The DON said that tying a sheet around a resident in his/her chair was not an appropriate behavioral intervention and said that it was considered a restraint. The DON said the Facility's investigation substantiated the improper use of a physical restraint and CNA #1 was terminated.

Based on record reviewed and interviews, for two of three sampled residents (Resident #1 who was severely cognitively impaired and required assistance from staff for mobility and Resident #2 who was cognitively intact and dependent on his/her call light to alert staff of his/her needs), the Facility failed to ensure they were free from abuse by a staff member when: A). On 03/28/24 at approximately 6:00 P.M., Certified Nurse Aide (CNA) #1, was witnessed by Visitor #1 as she forcefully transferred Resident #1 to his/her bed. CNA #1 was then witnessed by both Visitor #1 and Nurse #1, as she forcefully pushed Resident #1 down on his/her bed when he/she tried to get up. Resident #1 was visibly upset and trembling after the incident, was fearful during a skin assessment on the following day, and was found to have three new bruises and two reddened areas on his/her left hand and collarbone that were not present, prior to the incident. B). On 04/03/24 (exact times unknown) CNA #3, was witnessed by Nurse Aide #A as she removed the call light, more than once, away from and out of Resident #2's reach and was heard telling Resident #2 that he/she was in a time-out for using the call light too much, leaving him/her without a way to request staff assistance, if needed. Findings include: Review of the Facility Policy, titled Abuse Policy and Procedure, dated as revised in 2024, indicated it is the policy of the Facility to maintain an environment free of abuse, neglect, and exploitation. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, deprivation, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to any staff, other residents, consultants, volunteers, staff, or other agencies serving the residents, family members or legal guardians, friends, or other individuals, (caretakers). A) Resident #1 was admitted to the Facility in October 2023 with diagnoses including generalized anxiety disorder, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 03/20/24, indicated his/her cognitive skills for daily decision making were severely impaired. The Assessment also indicated Resident #1 required moderate assistance from staff for transfers and he/she was dependent on staff for activities of daily living (ADLs). Review of Resident #1's Nurses Note, dated 03/28/24, indicated Visitor #1 ran into the day room in distress and said, you need to come right now! The Note indicated Visitor #1 told Nurse #1 that she had witnessed a CNA (later identified as CNA #1) throw Resident #1 onto his/her bed. The Note indicated that as Nurse #1 approached Resident #1's bed, she heard Resident #1 say Stop that! and Don't hit me! The Note indicated that when Nurse #1 entered Resident #1's room she saw a CNA (CNA #1) push the resident[Resident #1] on the shoulder down onto the bed, hard. The Note indicated Nurse #1 dismissed CNA #1 and she took over Resident #1's care. The Note indicated Nurse #1 sat with Resident #1 until he/she calmed down. Review of the Police Department's Report, dated 03/28/24, indicated a Police Officer responded to a 911 call made by the Facility at 6:08 P.M. The Report indicated that Visitor #1 told the Officer that she witnessed CNA #1 abusing her family member's roommate (later identified as Resident #1). The Report indicated that Visitor #1 told the Officer that she witnessed CNA #1 throw Resident #1 onto his/her bed. The Report indicated that Visitor #1 told the Officer that when Resident #1 was laying on his/her bed, CNA #1 picked him/her up and threw him/her back down, causing him/her to bounce slightly on the bed. The Report indicated that Visitor #1 became upset and started crying while describing the incident to the Officer. The Report indicated CNA #1 told the Officer she put Resident #1's wheelchair next to his/her bed and quickly transferred him/her into the bed. The Report indicated that CNA #1 told the Officer that Resident #1 grabbed the back of her arm and pinched her. The Report indicated that CNA #1 told the officer that in response to the pain from being pinched, she sped up the transfer and placed Resident #1 onto the bed, harder than usual. Review of Resident #1's Medical Record indicated his/her Health Care Proxy (HCP) was activated on 10/14/23. Review of Resident #1's Skin Assessment, dated 03/28/24, indicated his/her skin was clean and intact. Review of Resident #1's Skin Assessment, dated 03/29/24 indicated the following: - Left shoulder (front) three medium purple areas along the collar bone. The anterior area was the largest (1 cm) and irregularly shaped, the second area was approximately .5 cm and irregular shaped and the third area was approximately .25 cm. - Two small, reddened areas on the left wrist and the back of the left hand, both less than .5 cm with irregular outlines. Review of Resident #1's Skin Assessment, dated 03/31/24 indicated the following: - Left shoulder (front) three medium purple areas along the collar bone. - Left, back of hand, erythema (redness of the skin from injury or irritation). Review of the Facility's Internal Investigation Narrative, undated, indicated the Director of Nurses (DON) received a call from the Facility, at approximately 6:04 P.M., notifying her that Visitor #1 was upset and had demanded the police be called to report an abuse allegation. The Narrative indicated the DON arrived at the Facility at 6:10 P.M., at which time CNA #1 had already been removed from the unit and was waiting in a separate room. The Report indicated that CNA #1 told the DON that she did not throw Resident #1 onto the bed but was simply transferring him/her from the wheelchair to the bed and it went quickly because Resident #1 was pinching her. The Narrative indicated that Visitor #1 told the DON that she witnessed CNA #1 forcefully throw Resident #1 onto his/her bed from his/her wheelchair. The Narrative indicated that Visitor #1 told the DON that when Resident #1 tried to sit up from his/her bed, CNA #1 pushed him/her back down onto the bed. The Narrative indicated Nurse #1 responded to Visitor #1's urgent request to go to Resident #1's room. The Narrative indicated that Nurse #1 said she saw CNA #1 push Resident #1 down onto the bed. The Narrative indicated that the Facility's Internal Investigation determined the incident was substantiated as physical abuse and CNA #1 was terminated. During a telephone interview on 05/02/24 at 10:39 A.M., Certified Nurse Aide (CNA) #1 (which also included a review of her written witness statement dated 03/28/24) said that on 03/28/24 during the evening shift, Resident #1 was more disruptive than usual, so she brought him/her to his/her room. CNA #1 said that when she transferred Resident #1 from his/her wheelchair into his/her bed, she (CNA #1) swooped [Resident #1] under the arms to move him/her and he/she pinched the back of her arm. CNA #1 said she plopped Resident #1 onto his/her bed in response to the painful pinch. CNA #1 said that a few minutes later, when Nurse #1 entered the room, Resident #1 popped up in bed and said she (CNA #1) used her right hand on Resident #1's left chest/shoulder area to push him/her back down onto the bed. During a telephone interview on 05/01/24 at 11:23 A.M., Visitor #1 said she was at the Facility visiting family on the evening of 03/28/24, when she went to get her family member a glass of juice, and she saw CNA #1 pushing Resident #1 in his/her wheelchair down the hall. Visitor #1 said that around 5:50 P.M., she saw Resident #1 try to grab the handrail while CNA #1 was pushing his/her wheelchair, and said she saw CNA #1 swat/slap Resident #1's hand away from the handrail. Visitor #1 said that later, at approximately 6:00 P.M., when she walked down the hall, intending to leave the Facility, she had forgotten something, doubled back and re-entered her family member's room (shared with Resident #1) where she saw CNA #1 slam Resident #1 down on his/her bed causing his/her head to bounce on the mattress. Visitor #1 said she immediately ran to get help and quickly returned to the room with Nurse #1. Visitor #1 said that when she re-entered the room with Nurse #1, she saw Resident #1 sit up in bed and CNA #1 forcefully pushed him/her back down onto the bed. Visitor #1 said CNA #1's actions were forceful and stern when she shoved [Resident #1] down on the bed. Visitor #1 said CNA #1's face was red and she appeared frustrated and overwhelmed during her interactions with Resident #1. During an interview on 05/01/24 at 3:40 P.M., Nurse #1 said that when she worked the evening shift on 03/28/24, Visitor #1 came running up to her and said, You to need to come with me, now! Nurse #1 said that as they hurried toward Resident #1's room, Visitor #1 told her that she had witnessed CNA #1 throw Resident #1 on his/her bed. Nurse #1 said that, from the hallway, she heard Resident #1 say stop hitting me and don't hit me, stop that! Nurse #1 said that Resident #1 sometimes repetitively called out for help when he/she was anxious, but said when she heard Resident #1 call out stop hitting me, she felt it was different from his/her normal behavior. Nurse #1 said as she rounded Resident #1's privacy curtain, she saw Resident #1 trying to get up from the bed and said she saw CNA #1 push him/her back down onto the bed, forcefully. Nurse #1 said she heard CNA #1 tell Resident #1, in an angry tone, You need to lay down! as she pushed Resident #1 down with her hand around his/her left upper chest/shoulder area. Nurse #1 described CNA #1's actions as angry and forceful and said CNA #1 appeared impatient, flustered and frustrated. Nurse #1 said that when she dismissed CNA #1 from the room and took over Resident #1's care, she noticed Resident #1 was visibly upset. Nurse #1 said Resident #1 snuggled against her and he/she was trembling. Nurse #1 said she stayed with Resident #1 for over an hour before he/she calmed down. Nurse #1 said she completed Resident #1's care after the incident and said there were no bruises or reddened areas present at that time. During an interview on 05/01/24 at 1:10 P.M., the Unit Manager said Resident #1 was often apprehensive and sometimes fearful during care, therefore, he/she required reassurance and a calm approach. The Unit Manager said Resident #1 becomes frightened and may resist care if the right approach is not used. The Unit Manager said that on 03/29/24 (the day after the incident), when she and Nurse #2 performed Resident #1's skin assessment, he/she was frightened and more jumpy than usual whenever they touched or moved him/her. The Unit Manager said that while performing a skin assessment, they noticed Resident #1 had bruises that were not present prior to the incident on 03/28/24. During an interview on 05/01/24 at 1:20 P.M., Nurse #2 said he performed a skin assessment on Resident #1, on 3/29/24 and noted three purple areas along his/her collar bone that were irregular in shape. Nurse #2 said he also noted red areas on the back of his/her hand. Nurse #2 said all of Resident #1's bruises, red areas were new and were not there prior to the incident on 3/28/24. Nurse #2 said that during the assessment, Resident #1 was more frightened and jumpy with repositioning, than he/she usually is. During an interview on 05/01/24 at 4:10 P.M., the Director of Nurses (DON) said that skin assessments conducted on Resident #1 by nursing after the incident showed new bruising, consistent with the witness accounts of Resident #1 being pushed on at his/her left shoulder. The DON said that based on statements from witnesses, Resident #1's bruising and CNA #1's unwillingness to participate any further with the Facility's internal investigation, the Facility substantiated the allegation of physical abuse and CNA #1 was terminated. 37086 B. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 04/04/24 at 8:16 A.M., indicated that on 04/03/24 during Resident #2's morning care (exact time unknown), Nurse Aide #A reported that Certified Nurse Aide (CNA) #3 placed Resident #2's call light out of his/her reach and heard CNA #3 say to Resident #2 that he/she was in a time-out. Resident #2 was admitted to the facility in May 2023, diagnoses included cerebral infarction (stroke) and adjustment disorder with depressed mood. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 03/06/24, indicated he/she scored a 13 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated that he/she was dependent for bathing, dressing, hygiene, transfers, incontinent care, and was non-ambulatory. Review of Nurse Aide #A's (nurse aide in training) Written Witness Statement, signed and dated 04/03/24, indicated she (Nurse Aide #A) was assigned to work with CNA #3 on 04/03/24 and upon completion of Resident #2's morning care, CNA #3 told Resident #2 that he/she was in a time-out and CNA #3 took away his/her call light and placed the call light next to his/her bed (out of Resident #2's reach). The Statement indicated that when Nurse Aide #A and CNA #3 re-entered Resident #2's room (exact time unknown), Resident #2 had his/her call light and CNA #3 told Resident #2 that she did not know who gave the call light back to him/her because he/she was still in a time-out and was not supposed to have it, and that CNA #3 took Resident #2's call light away from him/her again. The surveyor was unable to interview Nurse Aide #A as she did not respond to the Department of Public Health's telephone and letter requests for an interview. During a telephone interview on 05/02/24 at 2:37 P.M., Certified Nurse Aide (CNA) #3 said she had been terminated from the Facility and was not comfortable speaking about the incident on 04/03/24 regarding Resident #2. Review of Resident #2's Witness Statement, dated 04/03/24 and signed by the Director of Nurses (DON), indicated that the DON met with Resident #2 at 5:10 P.M. and he/she identified CNA #3 by name and said that she was the CNA who took care of him/her that day. The Statement indicated that Resident #2 said that sometimes CNA #3 took his/her call light away when he/she was in a time-out and that CNA #3 took his/her call light away that day because she said he/she used the call light too much. During an interview on 05/01/24 at 3:09 P.M., Resident #2 said that he/she used the call light when he/she was wet and needed to be changed, or when he/she needed to be repositioned in bed or needed something from staff. Resident #2 said that CNA #3 took care of him/her on the morning of 04/03/24 and that CNA #3 told him/her that she was taking the call light away because he/she used it too much. Resident #2 said he/she always holds onto the call light in his/her hand. Resident #2 said that it did not make me feel good, and he/she was upset when CNA #3 took his/her call light away. Resident #2 said he/she did not recall if CNA #3 said he/she was in a time-out. However, Resident #2's statement on the day of the incident to the DON included that Resident #1 had said he/she was told he/she was in a time-out. During an interview on 05/01/24 at 1:41 P.M. Certified Nurse Aide (CNA) #4 said that she was familiar with and provided care for Resident #2. CNA #4 said that Resident #2 used his/her call light to alert staff if he/she needed to be changed or repositioned. CNA #4 said that Resident #2 often held a tight hand grip on the call light and appeared afraid to let go of it. During an interview on 05/01/24 at 3:55 P.M., the Director of Nurses (DON) said that on the afternoon of 04/03/24, she received a report from Nurse Aide #A that following the completion of Resident #2's morning care with CNA #3, CNA #3 placed Resident #2's call light out of his/her reach and told him/her that he/she was in a time-out. The DON said Nurse Aide #A reported that CNA #3 told Resident #2 that he/she used the call light too much and needed a time-out. The DON said that Nurse Aide #A reported that once CNA #3 left Resident #2's room, she (Nurse Aide #A) gave the call light back to Resident #2. The DON said that she conducted an interview with Resident #2 on 04/03/24 at 5:10 P.M. and that he/she identified CNA #3 by name and told her that CNA #3 sometimes took his/her call light away when he/she was in a time-out. The DON said that Resident #2 indicated to her that this was not the first time CNA #3 had taken his/her call light away. The DON said the Facility substantiated the abuse allegation and CNA #3 was terminated.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was newly admitted to the Facility seven days post-surgical repair for a [MEDICAL CONDITION] with stent placement (a tube placed in the brain to act as an artery for supplying blood to the brain that requires an anti-platelet medication to prevent its occlusion), and was prescribed the medication Brilinta (anti-platelet medication used to prevent blood clots), the Facility failed to ensure nursing staff notified Resident #1's Physician that he/she missed two consecutive doses of his/her Brilinta medication. On [DATE], Resident #1 experienced a significant change decline in condition, was transferred to the Hospital Emergency Department for further evaluation and was diagnosed with [REDACTED]. herniation (pressure inside the skull that causes the movement of brain tissue most often due to brain swelling or bleeding), requiring an emergent decompressive craniectomy (removal of a small portion of the skull). Resident #1's condition continued to decline, he/she was made comfort care measures only and died six days later. Findings include: Review of the Facility's Policy, titled Physician Notification, dated [DATE], indicated that physicians will be notified of any changes in the resident's treatment and or medication issues which includes: - At any point, when there is an identified change in the resident's treatment plan or medication concerns, then the nurse should immediately notify the Resident's physician. - The Nurse must document the name of the physician, date and time identifying the content of the issue and the physician's response in the resident's record. Review of the National Institutes of Health, U.S. National Library of Medicine, Drug Label Information, updated February 2021, regarding Brilinta (Ticagrelor) an anti-platelet (keeps platelets in the blood from clotting), indicated the following: Do not stop taking Brilinta without talking to the doctor who prescribes it for you. The Update indicated people who are treated with a stent, and stop taking Brilinta too soon, have a higher risk of getting a blood clot in the stent with increased risk of stroke, [MEDICAL CONDITION], or dying. Resident #1 was admitted to the Facility in February 2021 with [DIAGNOSES REDACTED]. Review of Resident #1's Hospital Medication Record, dated [DATE], indicated that his/her physician's orders [REDACTED].M. and 9:00 P.M. Review of the Hospital Discharge Summary, dated [DATE], indicated Resident #1's last dose of Brilinta had been administered by the Hospital staff at 8:47 A.M., on [DATE], the day of his/her discharge. Review of Resident #1's Patient Medication List for discharge, dated [DATE], indicated to administer Brilinta 90 mg by mouth every 12 hours, and that the next scheduled dose was due at 9:00 P.M. Review of Resident #1's Hospital Discharge Patient Information sheet, dated [DATE], indicated that the discharging Hospital provided the Facility with the contact information for the attending Neurologist, should there be any questions or concerns related to Resident #1's post-operative care. Review of Resident #1's Hospital Discharge Summary Sheet, dated [DATE], indicated that the attending Neurologist's telephone numbers were included and provided to the Facility for any questions or concerns and the summary also indicated that the Hospital Neurology Service was also available by phone ,[DATE]. Review of the Facility's Admission Summary Note, dated [DATE], written by Nurse #2, indicated that Resident #1's admission medications were reviewed with the Physician. During an interview on [DATE] at 10:50 A.M., Nurse #2 said that on [DATE] at approximately 9:30 P.M., she spoke with the Physician to obtain admission medication and treatment orders for Resident #1, who was a new admission. Nurse #2 said she did not speak to the Physician regarding the Brilinta and said that she did not inform the Physician that the last time Resident #1 had received his/her Brilinta had been that morning, in the Hospital. Nurse #2 said she was not aware that Brilinta was a time-critical medication (a scheduled medication where delayed administration may cause harm) for maintaining the patency of the new brain stent. During an interview on [DATE] at 3:15 P.M., the Neurologist said it was a big deal missing even one dose of Brilinta and said that the two missed doses caused a clot to form in Resident #1's stent. The Neurologist said no one from the Facility contacted her or the Hospital Neurology Service about concerns with an inability to obtain the Brilinta or for recommendations for an alternative medication. Review of Resident #1's Medication Administration Record [REDACTED].M. and 9:00 P.M. The MAR indicated [REDACTED].M. and on [DATE] at 9:00 A.M. the doses were not administered as ordered (there was an X in the administration boxes, which indicated not administered). Review of Resident #1's Medical Record indicated, there was no documentation to support that his/her Physician was notified or that the Hospital Neurology Services was notified that the Brilinta was not available and was not administered to Resident #1 as ordered. During an interview on [DATE] at 2:30 P.M., Nurse #3 said, on [DATE] she spoke to the Nurse Practitioner around 10:00 A.M., and told her that Resident #1 had not received his/her 9:00 A.M. dose of Brilinta, and said she told the Nurse Practitioner the medication was unavailable for the medication pass. Nurse #3 said she did not ask the Nurse Practitioner for any instructions regarding the Brilinta, because she thought it was going to be delivered from the pharmacy. Nurse #3 said she did not inform the Nurse Practitioner that Resident #1 had not been administered his/her 9:00 P.M. dose of Brilinta from the night before, on [DATE], as ordered. During an interview on [DATE] at 12:15 P.M., the Nurse Practitioner said on [DATE], when she came in to see Resident #1, and said she was made aware by nursing at that time, that Resident #1 had not received his/her 9:00 A.M. dose of Brilinta. The Nurse Practitioner said she was told by nursing that the medication was due to be delivered, and would be given upon arrival from the pharmacy. The Nurse Practitioner said she did not give nursing an order for [REDACTED]. dose of Brilinta, had not been administered. The Nurse Practitioner said missing the two doses of Brilinta could have contributed to Resident #1's decline because he/she suffered a [MEDICAL CONDITION] (signs and symptoms associated with a blood clot in a vein or artery, can be life threatening event) stroke. Review of the Nurse Progress Note, dated [DATE] at 1:56 P.M., indicated that Resident #1 had difficulty swallowing his/her breakfast and had increased weakness on the left side. The Note indicated Resident #1 had a sudden decrease in his/her function on the left side and the Hospital Physician was contacted. The Note indicated Resident #1's Hospital Physician requested he/she be sent out to the Hospital for stroke like symptoms, and Emergency Medical Services were activated. Review of the Physician's Emergency Department Note, dated [DATE] at 2:30 P.M., indicated Resident #1 presented with left sided [MEDICAL CONDITION], sensory deficits (sense of touch and position), on Computerized Tomography (CT) scan he/she was found to have an acute stroke, large right middle cerebral artery infarct (dead tissue due to an occlusion with a clot) with a two millimeter (mm) midline brain shift. The Neurologist said Resident #1 had a major stroke, that it was a [MEDICAL CONDITION] stroke, and that the missed doses of his/her anti-platelet medication caused an occlusion of the stent which triggered the stroke. The Neurologist said on imaging, Resident #1's stroke was right where the stent was occluded with the clot. The Neurologist said Resident #1 had a devastating stroke, that caused his/her brain to herniate (puts extreme pressure on parts of the brain, cuts off blood supply to various parts of the brain, often fatal). Review of the Hospital Discharge Summary, dated [DATE], indicated Resident #1 had a large stroke with a midline shift, required an emergency decompressive craniectomy (on [DATE]), was admitted to the Intensive Care Unit for further management and received [MEDICATION NAME] (steroid, a medication for brain swelling). Resident #1 had further decompensation and was noted to be somnolent (drowsy) on [DATE], a CT scan was obtained which showed worsening midline shift of 18 mm, he/she was treated with mannitol (diuretic, administered via injection, used to reduce pressure and swelling around the brain). Resident #1's CT scan of the head on [DATE] showed a worsening midline shift of 23 mm. After discussion with the family, Resident #1 was made comfort care measures only and died on [DATE] in the Hospital.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was newly admitted to the Facility, seven days post-surgical repair for a [MEDICAL CONDITION] with stent placement (a tube implanted to function as an artery) and required Brilinta (an anti-platelet medication used to prevent occlusion of the stent) to be administered every 12 hours, the Facility failed to ensure nursing staff were competent with providing the necessary care and services to adequately treat Resident #1. The Facility failed to ensure nursing staff recognized the urgency of obtaining the Brilinta, failed to ensure nursing staff had the required understanding of the impact of omitting even one dose of Brilinta, failed to ensure nursing staff effectively communicated with the Pharmacy to ensure that Brilinta was ordered as a stat medication, and failed to ensure nursing effectively communicated with the Physician that the Brilinta was not available, and when nursing they did not administer the 9:00 P.M., failed to notify the Physician to obtain new orders. On [DATE] Resident #1 experienced a significant decline in condition, was transferred to the Hospital Emergency Department and was diagnosed with [REDACTED]. supply to various parts of the brain, often fatal), requiring an emergency decompressive craniectomy (removal of a small portion of the skull). Resident #1's condition continued to decline, and he/she was made comfort care measures only and died six days later. Findings include: Review of the Facility's Pharmacy Policy, Appendix 7, titled, Medications that should not be abruptly discontinued, dated [DATE], indicated that one types of the medications listed was anti-platelet medications (which included Brilinta). Review of the National Institutes of Health, U.S. National Library of Medicine, Drug Label Information, updated February 2021, regarding Brilinta (Ticagrelor) an anti-platelet (keeps platelets in the blood from clotting), indicated the following: Do not stop taking Brilinta without talking to the doctor who prescribes it for you. The Update indicated people who are treated with a stent, and stop taking Brilinta too soon, have a higher risk of getting a blood clot in the stent with increased risk of stroke, [MEDICAL CONDITION], or dying. Review of the Facility's Pharmacy Policy, titled Medication Orders, dated [DATE], indicated that when scheduling New Medication Orders on the Medication Administration Record [REDACTED]. Subsequent doses are scheduled according to Facility Policy. Review of the Facility's Policy, titled Physician Notification, dated [DATE], indicated that physicians will be notified of any changes in the resident's treatment and or medication issues, that when there is an identified change in the resident's treatment plan or medication concerns, then the nurse should immediately notify the Resident's physician. Review of the educational records for Nurse #1, Nurse #2, Nurse #3, Nurse #5, and the Unit Manager, indicated that there was no documentation to support that the Facility provided education regarding their Pharmacy Policy for ordering Non-Controlled Medications or for recognizing medications that should not be abruptly discontinued, such as anti-platelet medications, including Brilinta. During an interview on [DATE] at 9:48 A.M., the Unit Manager said she worked on the Rehabilitation Unit, and said nursing staff were not familiar with the medication Brilinta, or with post-surgical residents with cerebral aneurysm repairs with a stent, and said Resident #1 was their first case. During an interview on [DATE] at 10:30 A.M. and at 2:30 P.M., Nurse #3 and Nurse #5 said they had not received education or training related to the care and treatment of [REDACTED]. During an interview on [DATE] at 10:50 A.M. and on [DATE] at 1:50 P.M., Nurse #2 said that the Facility usually does not admit residents with this high level of acuity. Nurse #2 said she had not received any training during her orientation related to the care of a resident with a cerebral aneurysm repair or requiring treatment with an anti-platelet medication. Nurse #2 said she was unaware that a dose of Brilinta should not be missed. Nurse #2 said she did not know if there was an alternative anti-platelet medication to substitute for the Brilinta, if it is was unavailable. Nurse #2 said she was not aware that Brilinta was a time-critical medication (a scheduled medication where delayed administration may cause harm). Resident #1 was admitted to the Facility in February 2021 with [DIAGNOSES REDACTED]. Review of the Ambulance Run Sheet, dated [DATE], indicated Resident #1 was transported via ambulance from the Hospital at 6:59 P.M. and arrived at the Facility 7:58 P.M. Review of Resident #1's Hospital Medication Record, dated [DATE], indicated to administer Brilinta 90 milligrams (mg) by mouth every 12 hours, at 9:00 A.M. and 9:00 P.M. The Record indicated the last dose of Brilinta had been administered by the Hospital staff on [DATE] at 8:47 A.M. Review of Resident #1's Patient Medications List for discharge, dated [DATE], indicated to administer Brilinta 90 mg by mouth every 12 hours, starting on [DATE]. Review of Resident #1's Medication Administration Record [REDACTED].M. and 9:00 P.M. The MAR indicated [REDACTED].M. and on [DATE] at 9:00 A.M. the doses were not administered as prescribed (there was an X in the administration boxes, which indicated it was not administered). During an interview on [DATE] at 11:25 A.M., Nurse #1 said that on [DATE], during the 3:00 P.M. to 11:00 P.M. shift, she entered Resident #1's physician's orders [REDACTED].M., to tell them Resident #1 was a new admission. Nurse #1 said she asked for Resident #1's admission medications to be delivered, but said she did not tell the Pharmacy she needed the Brilinta, which had been scheduled to be administered that evening at 9:00 P.M., and was not available in the Facility. Review of the Consulting Pharmacy End of Shift Report, dated [DATE] at 10:00 P.M., indicated that Resident #1's medications were faxed over from the Facility after 10:00 P.M. The Report indicated that the Facility did not call and request Resident #1's medications as a stat order. Therefore Resident #1's medications were not due to be delivered to the Facility until the next scheduled Pharmacy delivery on [DATE]. During an interview on [DATE] at 9:21 A.M., Pharmacist #2 who worked on [DATE] during the 2:00 P.M. to 10:00 P.M. shift, said that no stat medications orders were requested from the Facility on [DATE]. During an interview on [DATE] at 12:00 P.M., Pharmacist #1 who worked on [DATE], during the 10:00 P.M. to 8:00 A.M. shift, said that no stat medications were requested from the Facility on [DATE] or on [DATE]. Pharmacist #1 said if the Pharmacy had been informed by the Facility that they required Resident #1's Brilinta stat, that it would have been delivered within 2 hours of the call. During an interview on [DATE] at 10:30 A.M., Nurse #5 (who had worked during the 11:00 P.M. to 7:00 A.M. shift on [DATE]) said that during the shift change report on [DATE] at 11:00 P.M., she was not made aware that Resident #1 had not received the 9:00 P.M. dose of Brilinta. During an interview on [DATE] at 2:30 P.M., Nurse #3 (who worked the 7:00 A.M. to 3:00 P.M. shift on [DATE]) said she had called Pharmacy for Resident #1's medications and was told they should be arriving. Nurse #3 said when she spoke to the Pharmacy, she said she needed Resident #1's medications as soon as possible, but said she did not inform the Pharmacy that she required the Brilinta stat. Review of Resident #1's medical record indicated, there was no documentation on either [DATE] or [DATE] to support nursing staff ordered Resident #1's Brilinta stat, there was no documentation to support the Physician was notified the Brilinta was not available in the Facility and therefore not administered as ordered, and the Facility was unable to provide the surveyor with any documentation to the contrary. Review of the Nurse Progress Note, dated [DATE] at 1:56 P.M., indicated that Resident #1 had difficulty swallowing his/her breakfast and had increased weakness on the left side. The Note indicated staff were alarmed at the sudden decrease in his/her function on the left side and the Hospital Physician was contacted. The Note indicated Resident #1's Hospital Physician requested he/she be sent out to the Hospital for stroke like symptoms, and Emergency Services were activated. Review of the Physician's Emergency Department Note, dated [DATE] at 2:30 P.M., indicated Resident #1 presented with left sided [MEDICAL CONDITION], sensory deficits (sense of touch and position), on Computerized Tomography (CT) scan he/she was found to have an acute stroke, large right middle cerebral artery infarct (dead tissue due to an occlusion with a clot) with a two millimeter (mm) midline brain shift. Review of the Hospital Discharge Summary, dated [DATE], indicated Resident #1 had a large stroke with a midline shift, required an emergency decompressive craniectomy (on [DATE]), was admitted to the Intensive Care Unit for further management and received [MEDICATION NAME] (steroid, a medication for brain swelling). Resident #1 had further decompensation and was noted to be somnolent (drowsy) on [DATE], a CT scan was obtained which showed worsening midline shift of 18 mm, he/she was treated with mannitol (diuretic, administered via injection, used to reduce pressure and swelling around the brain). Resident #1's CT scan of the head on [DATE] showed a worsening midline shift of 23 mm. After discussion with the family, Resident #1 was made comfort care measures only and died on [DATE] in the Hospital. During an interview on [DATE] at 3:15 P.M. and on [DATE] at 9:40 A.M., the Neurologist said Resident #1 had a major stroke, that it was a [MEDICAL CONDITION] stroke, and that the missed doses of his/her anti-platelet medication caused an occlusion of the stent which triggered the stroke. The Neurologist said on imaging, Resident #1's stroke was right where the stent was occluded with the clot. The Neurologist said Resident #1 had a devastating stroke, that caused his/her brain to herniate (puts extreme pressure on parts of the brain, cuts off blood supply to various parts of the brain, often fatal).

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was newly admitted to the Facility, was seven day post-surgical repair of a cerebral aneurysm with a stent placement (a tube placed in the brain to act as an artery for supplying blood to the brain), and whose physician's orders [REDACTED]. On [DATE], Resident #1 experienced a significant decline in condition, was transferred to the Hospital Emergency Department, was diagnosed with [REDACTED]. tissue most often due to brain swelling or bleeding), requiring an emergency decompressive craniectomy (removal of a small portion of the skull). Resident #1's condition continued to decline, he/she was made comfort care measures only and died six days later in the Hospital. Findings include: Review of the Facility's Policy, titled Medication Error: Severity Assessment Tool (for the significance of the medication error) dated [DATE], indicated that one type of medication error was the omission of the prescribed medication. Anti-coagulant, anti-platelet medications were rated as a high severity for medication errors. Review of the Facility's Policy titled, Medication Administration Guidelines, undated, indicated the nurse reviews each resident's Medication Administration Record [REDACTED]. Review of the Facility's Pharmacy Policy, Appendix 7, titled, Medications that should not be abruptly discontinued, dated [DATE], indicated that one of the types of the medications listed was anti-platelet medications (which included Brilinta). Review of the National Institutes of Health, U.S. National Library of Medicine, Drug Label Information, updated February 2021, regarding Brilinta (Ticagrelor) an anti-platelet (keeps platelets in the blood from clotting), indicated the following: Do not stop taking Brilinta without talking to the doctor who prescribes it for you. The Update indicated people who are treated with a stent, and stop taking Brilinta too soon, have a higher risk of getting a blood clot in the stent with increased risk of stroke, [MEDICAL CONDITION], or dying. Review of the Facility's Pharmacy Policy, titled Medication Orders, dated [DATE], indicated that when scheduling New Medication Orders on the Medication Administration Record [REDACTED]. Subsequent doses are scheduled according to Facility Policy. During an interview on [DATE] at 3:15 P.M. and on [DATE] at 9:40 A.M., Resident #1's Neurologist said it was a big deal missing even one dose of Brilinta, and said the two missed doses caused a clot to form in the (brain) stent. The Neurologist said it was a [MEDICAL CONDITION] stroke (signs and symptoms associated with a blood clot in a vein or artery, can be life threatening event) that was significant for not getting the Brilinta. The Neurologist said on imaging the stroke was right where the stent was occluded with the clot. Resident #1 was admitted to the Facility in February 2021 with [DIAGNOSES REDACTED]. Review of Resident #1's Hospital Medication Record, dated [DATE], indicated that his/her physician's orders [REDACTED].M. and 9:00 P.M. Review of the Hospital Discharge Summary, dated [DATE], indicated Resident #1's last dose of Brilinta had been administered by the Hospital staff at 8:47 A.M., on [DATE], the day of his/her discharge. Review of Resident #1's Patient Medication List for discharge, dated [DATE], indicated to administer Brilinta 90 mg by mouth every 12 hours, and that the next scheduled dose was due at 9:00 P.M. Review of Resident #1's Hospital Discharge Patient Information, dated [DATE], indicated that the discharging Hospital provided the Facility with the contact information for the attending Neurologist, should there be any questions or concerns related to Resident #1's post-operative care. Review of Resident #1's Hospital Discharge Summary Sheet, dated [DATE], indicated that the attending Neurologist's telephone numbers were included and provided to the Facility for any questions or concerns and the Summary also indicated that the Hospital Neurology Service was available by phone ,[DATE]. During an interview on [DATE] at 10:50 A.M., Nurse #2 said that on [DATE] at approximately 9:30 P.M., she spoke with the Physician to verify the new admission orders [REDACTED]. Nurse #2 said she was unaware that a dose of Brilinta should not be missed, and said she was also unaware that Brilinta was a time-critical medication (a scheduled medication where delayed administration may cause harm). Review of Resident #1's Medication Administration Record [REDACTED].M. and 9:00 P.M. The MAR indicated [REDACTED].M. and on [DATE] at 9:00 A.M. the doses were not administered as ordered (there was an X in the administration boxes, which indicated not administered). During an interview on [DATE] at 11:25 A.M., Nurse #1 said that on [DATE], during the 3:00 P.M. to 11:00 P.M. shift, she entered Resident #1's physician's orders [REDACTED].M., to tell them Resident #1 was a new admission. Nurse #1 said she asked for Resident #1's admission medications to be delivered, but said she did not tell the Pharmacy she needed the Brilinta, which had been scheduled to be administered that evening at 9:00 P.M., and was not available in the Facility. When the Surveyor asked Nurse #1 if she informed the Pharmacy during the call, that she needed the Brilinta, because it is a time critical medication, Nurse #1 said Well, I just asked for admission medications to be delivered. Nurse #1 said she did not inform the Pharmacy that Resident #1 had been scheduled to be administered Brilinta on [DATE] at 9:00 P.M. and that it was not available in the Facility. Review of Resident #1's medical record indicated, there was no documentation on either [DATE] or [DATE] to support nursing staff ordered Resident #1's Brilinta stat, there was no documentation to support the Physician was notified that the Brilinta was not available in the Facility and therefore not administered as ordered, and the Facility was unable to provide the surveyor with any documentation to the contrary. Review of the Consulting Pharmacy End of Shift Report, dated [DATE] at 10:00 P.M., indicated that Resident #1's medications were faxed over from the Facility after 10:00 P.M. The Report indicated that the Facility did not call and request Resident #1's medications as a stat order. Therefore Resident #1's medications were not due to be delivered to the Facility until the next scheduled Pharmacy delivery on [DATE]. During an interview on [DATE] at 9:21 A.M., Pharmacist #2, who worked on [DATE] during the 2:00 P.M. to 10:00 P.M. shift, said that no stat medications orders were requested from the Facility on [DATE]. During an interview on [DATE] at 2:50 P.M., the Pharmacy Technician, who worked on [DATE] during the 2:00 P.M. to 10:00 P.M. shift, said that no stat medications orders were requested from the Facility on [DATE]. During an interview on [DATE] at 12:00 P.M., Pharmacist #1, who worked on [DATE] during the 10:00 P.M. to 8:00 A.M. shift, said that no stat medications orders were requested from the Facility on [DATE] or on [DATE]. Pharmacist #1 said if the Pharmacy had been informed that Resident #1 required Brilinta stat, that it would have been delivered within 2 hours of the call. Pharmacist #1 said the Pharmacy shuts down at 10:00 P.M., and routine medication requests will be filled the next morning at 6:30 A.M., and then transported to the Facility at the scheduled delivery time (according to the estimated arrival sheets, that would be 12:00 P.M. on [DATE]). Review of Resident #1's Medication Administration Record [REDACTED].M. and 9:00 P.M. The MAR indicated [REDACTED].M. and on [DATE] at 9:00 A.M. the doses were not administered as prescribed (there was an X in the administration boxes). During an interview on [DATE] at 2:30 P.M., Nurse #3 said, on [DATE] she spoke to the Nurse Practitioner around 10:00 A.M., and told her that Resident #1 had not received his/her 9:00 A.M., dose of Brilinta, and said she told the Nurse Practitioner the medication was unavailable for the medication pass. Nurse #3 said she told the Nurse Practitioner she had called Pharmacy for Resident #1's medications and told the Nurse Practitioner they should be arriving. Nurse #3 said that when she spoke to the Pharmacy, she said she needed Resident #1's medications as soon as possible, but said she did not inform the Pharmacy that she required the Brilinta as a stat medication order. Nurse #3 said she did not inform the Nurse Practitioner that Resident #1 had not been administered his/her 9:00 P.M. dose of Brilinta from the night before, on [DATE], as ordered. Nurse #3 said she did not ask the Nurse Practitioner for any instructions regarding the Brilinta, because she thought it was going to be delivered from the pharmacy. During an interview on [DATE] at 12:15 P.M., the Nurse Practitioner said on [DATE], when she came in to see Resident #1, she was made aware by nursing at that time, that Resident #1 had not received his/her 9:00 A.M. dose of Brilinta. However the Nurse Practitioner said she was not told by nursing that Resident #1's [DATE] 9:00 P.M. dose of Brilinta, had not been administered as ordered. Review of the Nurse Progress Note dated [DATE] at 1:56 P.M., indicated that Resident #1 had difficulty swallowing his/her breakfast and had increased weakness on the left side, he/she had a sudden decrease in function on the left side and the Hospital Physician was contacted. The Note indicated Resident #1's Hospital Physician requested he/she be sent out to the Hospital for stroke like symptoms and that Emergency Services were activated. Review of the Physician's Emergency Department Note, dated [DATE] at 2:30 P.M., indicated Resident #1 presented as a stroke activation, with left [MEDICAL CONDITION] (paralysis of the left side of the body), sensory deficits (sense of touch and position), on Computerized Tomography (CT) scan he/she was found to have an acute stroke, a large right middle cerebral artery infarct (dead tissue due to an occlusion with a clot) with a 2 millimeter (mm) midline shift. Review of the Hospital Discharge Summary, dated [DATE], indicated Resident #1 had a large stroke with a midline shift, requiring an emergency decompressive craniectomy (on [DATE]), and was admitted to the Intensive Care Unit for further management. He/she received [MEDICATION NAME] (a steroid, used for brain swelling). He/she had further decompensation and was noted to be somnolent (drowsy) on [DATE], a CT scan was obtained which showed a worsening midline shift of 18 mm, he/she was treated with mannitol (diuretic, administered via injection, used to reduce pressure and swelling around the brain). However, a CT of the head on [DATE] showed a worsening midline shift of 23 mm. After discussion with the family, Resident #1 was made comfort care measures and died on [DATE].

Based on record review and interview, the facility failed to ensure that one resident (#22) received sufficient fluid intake to maintain hydration, in a total sample of 24 residents. Findings include: Resident #22 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment, with an Assessment Reference Date of 7/17/17, indicated a Brief Interview for Mental Status score of 7/15 (severe cognitive impairment). The resident exhibited verbal and physical behavior 4 to 6 days a week, required assist with eating and was not dehydrated. Review of the 8/6/17 Intake and Output (I and O) Daily Worksheet indicated that fluid intake was not recorded for all 3 shifts. The resident voided once on the 11:00 P.M. to 7:00 A.M. shift, once on the 7:00 A.M. to 3:00 P.M. shift, and the 3:00 P.M. to 11:00 P.M. shift was left blank. Review of Progress notes, of 8/6/17 at 9:39 A.M., indicated that the resident was unable to stand or bear weight., had increased confusion and was difficult to redirect. Review of the 8/7/17 I and O Worksheet indicated that fluid intake was not recorded for all 3 shifts. The resident voided 275 cubic centimeters (cc) on the 11:00 P.M. to 7:00 A.M. shift, was incontinent twice on the 7:00 A.M. to 3:00 P.M. shift, and the 3:00 P.M. to 11:00 P.M. shift was left blank. Review of Progress notes, of 8/8/17 at 5:00 A.M., indicated that the resident voided 125 cc of dark yellow urine. Continued on Intake and Output. Review of the 8/8/17 I and O Worksheet indicated that the resident consumed a total of 960 cc of fluid. The resident voided 125 cc on the 11:00 P.M. to 7:00 A.M. shift, was incontinent twice on the 7:00 A.M. to 3:00 P.M. shift, and was incontinent once on the 3:00 P.M. to 11:00 P.M. shift. Review of the 8/9/17 I and O Worksheet indicated that the resident had no fluid intake and voided once on the 11:00 P.M. to 7:00 A.M. shift. The resident consumed 60 cc of fluid and no output was recorded on the 7:00 A.M. to 3:00 P.M. shift. Review of Progress notes, of 8/9/17 at 9:45 A.M., indicated that the resident went out to a neurology appointment. The neurologist called the facility to inform them that the resident was sent to the emergency room due to a change in mental status. Review of the 8/9/17 hospital history and physical indicated the following blood work: a Blood Urea Nitrogen (BUN) of 113 (normal range 7 to 23), a Creatinine of 2.52 (normal range 0.6 to 1.3), a Calcium of 11.4 (normal range 8.7 to 10.7) and a Sodium of 149 (normal range 135 to 145). Family provided history and stated that since (8/4/17), they noticed a drastic decline in resident's functioning and increased agitation. Assessment/Plan: Presented with acute on chronic mental status change with worsening hallucination and lethargy. Multiple factors probably contributing: Dehydration, acute kidney injury (in the setting of no [MEDICAL CONDITION]), uremia, hypercalcemia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. CT scan was negative for [MEDICAL CONDITION]. On exam appeared significantly dehydrated. The resident received 4 liters of normal saline intravenously for rehydration, and then changed to [MEDICATION NAME] (D) 5 and 1/2 Normal Saline (NS). A nasogastric tube was inserted on 8/12/17, and the resident was given free water and nutrition. Review of the Nurse Practitioner's (NP) progress note (of 8/11/17) indicated that a family meeting was held. The resident was still in the hospital but anticipating return to the facility. The NP note indicated that the cause of the resident's altered activity appeared [MEDICAL CONDITION], and it was determined that it was caused by severe dehydration. The resident was hospitalized for [REDACTED]. Review of Progress Notes indicated that the resident was discharged to the hospital on [DATE]. During an interview, on 8/24/17 at 10:45 A.M., Unit Manager (UM) #3 said that she wasn't sure why I and O was initiated, because she had been off for 2 weeks. UM #3 said that the nurses were responsible on each shift to monitor for adequate intake and output. UM #3 said that the I and Os were incomplete. UM #3 said that she did not monitor the I and Os, but she would be monitoring them now.

Based on record review and interviews for 3 of 3 sampled Residents (Resident #1, #2, and #3), the facility failed to prevent emotional harm and intimidation when Certified Nursing Assistant (CNA) #1 and CNA #2 took photos while providing care and posting them on Snapchat (social media), without consent, and CNA #1 forwarded the photographs to Consumer #1, an individual who is not an employee. Findings include: The Quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #1 was moderately cognitively impaired and unable to make health care decisions and informed consent. The Quarterly MDS, dated [DATE] indicated Resident #2 was cognitively intact and made health care decisions and informed consent. The Quarterly MDS, dated [DATE] indicated Resident #3 was cognitively intact and unable to make health care decisions and informed consent. A letter received by the Department of Public Health from Complainant #1, dated 11/12/15 reporting a conversation with Consumer #1,who was the recipient of Snapchat photographs received from CNA #1. Complainant #1 stated that Consumer #1 said If only I had a dollar for every Snapchat of an old person on a toilet I get from (name of CNA #1). The Complainant then said that it was awful, have you said anything about it? Consumer #1 then said that (he/she) reminded CNA #1 of HIPAA (Health Insurance Portability and Accountability - regulation for ensuring privacy and security for Residents), but gets the photos like this all the time from (him/her). The Facility's investigation of 11/16/15 at 3:30 P.M., indicated that CNA #1 and CNA #2 confessed to taking photographs via Snapchat of Residents #1, #2, and #3 for the purpose of communicating where one another were working and sending the photographs only to each other. CNA #1 took photos of Resident #2 sitting on the toilet and Resident #3 ambulating in (his/her) room. CNA #2 took a photograph of Resident #1 ambulating in the Common Area. Interview questionnaires, a total of 45, were given to the employees to complete. The results indicated that the employees were not aware any staff taking photographs of residents. The Surveyor interviewed the Administrator and Director of Nursing at 7:45 A.M. on 1/14/16. The Director of Nursing and Administrator said that CNA #1 and CNA #2 confessed to taking the Snapshot photos of Residents #1, #2 and #3. CNA #1 and CNA #2 stated the photographs were taken by the CNA's (without the Resident's or Responsible party's) consent, as a method to keep track of one another. The Administrator and Director of Nursing were not aware if Residents #1, #2, and #3 were clothed or naked and did not have any information that the photographs were sent out of the facility. The Surveyor interviewed Complainant #1 at 12:30 P.M. on 1/21/16, Complainant #1 said that Consumer #1, (recipient of the photographs from the facility), stated to the Complainant, If I had a dollar for every naked person on the toilet from (CNA #1). The Surveyor interviewed CNA #1 on 1/22/16 at 12:16 P.M. and interviewed CNA #2 on 1/22/16 at 1:56 P.M., they denied taking photographs of Residents at the Facility, but stated they only took photographs of themselves and sent them to one another. The Facility took the following corrective action in response: 1. The Administrator and the Director of Nurses (DON) said CNA #1 and CNA #2 were immediately terminated from the facility on 11/16/15. 2. The Facility initiated an investigation regarding the allegations effective on 11/16/15. Forty-five staff members were interviewed via a questionnaire to ensure photographs of other residents were not occurring anywhere else in the Facility. 3. The Facility completed re-education of staff from 11/16/15 and 11/17/15. The DON provided the Surveyor with the orientation program and Facility's abuse prohibition policies and the cell phone policy with (HIPAA) Health Insurance Portability and Accountability Act requirements.

Based on observation, record review and interview the facility failed to ensure the environment remained free of accident hazards to prevent avoidable accidents for 1 (#18) of 14 applicable residents reviewed for falls in a total sample of 24 residents. Findings include: For Resident #18, the facility failed to provide effective interventions to prevent 3 of 7 falls. Resident #18 was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. Review of the facility's Fall Prevention Policy, dated 9/1/04, indicated; 1. Utilizing the facilities approved Fall Risk Assessment tool, assess the resident's risk for falling upon admission, quarterly, annually and with significant change of status. 2. If resident scores 10 or higher, initiate a preventative care plan that reflects the resident's individual strengths and vulnerabilities. 3. Ensure caregivers, resident and family are aware of care plan interventions to promote continuity of care. 4. Review the care plan quarterly, annually, with significant change of status and when a fall occurs to ensure appropriate, effective interventions are in place. Review of the resident's fall care plan, dated 11/24/13, indicated; -bed and chair alarm, -wanderguard, -motion sensor, -remind resident to call for assistance, -monitor for negative side effects from medication(s), and alteration in comfort. Review of the Admission Minimum Data Set (MDS) Assessment, dated 11/24/13, indicated the resident had severe cognitive impairment, needed extensive assist for bed mobility, transfer, dressing, toileting, personal hygiene, bathing, limited assist for ambulation in his/her room and had 1 fall with no injuries. Review of the Fall Risk Assessment, dated 11/24/13, indicated a score of 6, not considered a high fall risk. Review of the Accident/Incident Report, dated 11/24/13, indicated the resident had an unwitnessed fall at 1:45 P.M. The resident was found on the floor in the bathroom doorway and had no apparent injuries. The wheelchair was approximately 10 feet away and the alarm was sounding. Interventions initiated after the fall included; Physical Therapy screen, motion sensor, antibiotics for a urinary tract infection and screen by psychiatric services once the infection resolved. Review of the Accident/Incident Report, dated 11/28/13, indicated the resident had an unwitnessed fall at 8:15 P.M. The resident was found on the floor in the bedroom and had no apparent injuries. The report indicated the clip alarm had been disabled and no alarms were sounding. Interventions initiated after the fall included; Place alarm boxes out of reach of the resident and a follow-up urinalysis. Review of the Fall Risk Assessment, dated 11/28/13, indicated a score of 10, considered a high fall risk. Review of the Accident/Incident Report, dated 1/24/14, indicated the resident had a witnessed fall at 3:25 P.M. The resident slid from the wheelchair to the foot pedals and had no apparent injuries. Interventions initiated after the fall included; Physical Therapy evaluation and remove/change dycem on the wheelchair. Review of the Accident/Incident Report, dated 1/24/14, indicated the resident had an unwitnessed fall at 4:40 P.M. The resident slid from the wheelchair to the foot pedals and had no apparent injuries. The alarm was sounding. Interventions initiated after the fall included; Rehab screen, remove the foot pedals from the wheelchair when resident is self propelling. Review of both Fall Risk Assessments, dated 1/24/14, indicated scores of 10, considered a high fall risk. Review of the Fall Risk Assessment, dated 2/18/14, indicated a score of 10, considered a high fall risk Review of the Quarterly MDS Assessment, date 2/20/14, indicated the resident had severe cognitive impairment, needed extensive assist for bed mobility, transfer, ambulation, dressing, toileting, personal hygiene, bathing and had 2 or more falls with no injuries. Review of the Accident/Incident Report, dated 2/26/14, indicated the resident had an unwitnessed fall at 11:35 A.M. The resident was heard yelling and was found sitting on the bathroom floor with his/her head leaning against the door casing. The resident's left shoe was not on properly. The resident sustained [REDACTED]. No alarms were sounding. Interventions initiated after the fall included; Start a bladder diary to assess toileting needs, rehabilitation screen and put the motion sensor to the exit side of the bed (in the middle of the room). Review of the Fall Risk Assessment, dated 2/26/14, indicated a score of 12, considered a high fall risk Review of the Accident/Incident Report, dated 3/18/14, indicated the resident had an unwitnessed fall at 2:45 A.M. The resident was heard yelling for help and was found on the floor in the bedroom without any apparent injuries. The alarm was sounding. Interventions initiated after the fall included; A low bed, pad the environment, attempt hipsavers and rehabilitation screen. Review of the Fall Risk Assessment, dated 3/18/14, indicated a score of 12, considered a high fall risk Review of the Accident/Incident Report, dated 3/21/14, indicated the resident had an unwitnessed fall at 11:00 A.M. The resident was heard yelling for help and was found lying on the floor of a bedroom next to his/her room. No alarms were sounding. He/she initially complained of head pain and approximately 10 minutes later complained of left hip pain. The resident was sent to the hospital and was admitted with a left hip fracture requiring surgical repair. Interventions initiated after the fall included; Move the bed against the wall (at the foot of the bed and to the right side), mount the motion sensor alarm and pad the environment. Review of the Fall Risk Assessment, dated 3/21/14, indicated a score of 10, considered a high fall risk On 4/18/14 at 10:45 A.M., the resident was observed lying in bed on his/her right side. The two quarter side rails were up and padded. The bed was in a low position with the right side and the foot of the bed was against the wall. On the left side of the bed, the surveyor observed an alarmed mat on the floor and a Foley catheter drainage bag in a privacy cover, attached to the bed side. On 4/18/14 at 3:10 P.M., the resident was observed in bed, eyes closed and wearing oxygen via nasal cannula. The bed remained against the wall, in the low position and had the padded quarter side rails up. The alarmed floor mat remained in place to the left side of the bed. During an interview with Unit Manager (UM) #3 on 4/22/14 at 12:45 P.M., she said alarms checks were done at the start of every shift. The type of alarms the resident had were indicated on the check sheet. She said she was unsure why the motion sensor alarm did not sound for the falls on 11/28/13, 2/26/14 and 3/21/14. She said the motion sensor was put in place due to the resident's high fall risk, but if it was not sounding to detect the resident's movement, it wasn't effective at minimizing the risk of falls.

Based on record review and interview, the facility failed to follow the resident's plan of care for 1 resident (# 18) out of a total sample of 24 residents. Findings include: For Resident #18, the facility failed to follow the resident's fall care plan relative to the use of a motion sensor for 3 of 7 falls. Resident #18 was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. Review of the resident's fall care plan, dated 11/24/13, indicated; -bed and chair alarm, -wanderguard, -motion sensor, -remind resident to call for assistance, -monitor for negative side effects from medication(s), and alteration in comfort. Review of the Accident/Incident Report, dated 11/24/13, indicated the resident had an unwitnessed fall at 1:45 P.M. The resident was found on the floor in the bathroom doorway and had no apparent injuries. The wheelchair was approximately 10 feet away and the alarm was sounding. Review of the Accident/Incident Report, dated 11/28/13, indicated the resident had an unwitnessed fall at 8:15 P.M. The resident was found on the floor in the bedroom and had no apparent injuries. The report indicated the clip alarm had been disabled and no alarms were sounding. Review of the Accident/Incident Report, dated 2/26/14, indicated the resident had an unwitnessed fall at 11:35 A.M. The resident was heard yelling and was found sitting on the bathroom floor with his/her head leaning against the door casing. The resident sustained [REDACTED]. No alarms were sounding. Review of a physician's orders [REDACTED]. Review of the Accident/Incident Report, dated 3/21/14, indicated the resident had an unwitnessed fall at 11:00 A.M. The resident was heard yelling for help and was found lying on the floor of a bedroom next to his/her room. No alarms were sounding. He/she initially complained of head pain and approximately 10 minutes later complained of left hip pain. The resident was sent to the hospital and was admitted with a left [MEDICAL CONDITION] requiring surgical repair. During an interview with Unit Manager (UM) #3 on 4/22/14 at 12:45 P.M., she said alarm checks were done at the start of every shift. She said she was unsure why the motion sensor alarm did not sound for the falls on 11/28/13, 2/26/14 and 3/21/14 and should have sounded when the resident was moving around in his/her room unassisted. Refer to F323

Based on observation, record review and interview the facility failed to follow the plan of care to prevent falls for 1 (#8) out of 13 applicable residents out of a total sample of 24. Findings include. For Resident #8 the facility failed to apply a chair alarm to prevent a fall that resulted in a fracture. Resident #8 was admitted to the facility in 2/5/13 with [DIAGNOSES REDACTED]. Review of the Admission Initial Care Plan, dated 2/6/13, indicated the resident was a fall risk. The interventions included; - Assess gait, standing/sitting, pain, need to void and medications, - Encourage to use call light, - PT referral, - Instruct on safety measures. Review of the Admission Minimum Data Set (MDS) Assessment, dated 2/12/13, indicated the resident was cognitively impaired, an assist for transfer and ambulation, and had not experience a fall since admission. Review of the Certified Nursing Assistant (CNA) Plan of Care Card, dated 3/5/13, indicated the resident was an assist of 1 with ambulation and transfer, and utilized a chair and bed alarm. Review of Resident #8's falls care plan, dated 3/10/13, included the following interventions; - Transfer with rolling walker, gait belt and 1 assist, - Bed and Chair alarm, - Motion Alarm, - Voiding Diary (initiated 4/18/13), - Hip savers (initiated 4/20/13), and - Toilet every two hours and check and change at night while in bed. If awake may need to be toileted (initiated 4/30/13). Review of the Accident/Incident Report, dated 5/5/13, indicated the resident had an unwitnessed fall at 5:10 A.M. The report indicated the resident was sitting in the main dining room in a recliner. The resident stood up and fell . The report indicated the resident was observed on the floor with the right leg over the left. When the resident stood up, the resident would not put weight on the left leg. The Physician was notified and an order was obtained to send the resident to the emergency room for an evaluation. At the time of the fall, the resident did not have the chair alarm in place as indicated in the plan of care. Review of a X-ray report from the hospital, dated 5/5/13, indicated Resident #8 had a new compression fracture mid [MEDICATION NAME] vertebral body. On 5/14/13 at 2:00 P.M., the surveyor observed Resident #8 in the dining room attending an activity. The resident was sitting in a wheelchair with a chair alarm. The resident was not wearing hip savers, per plan of care. On 5/15/13 at 7:15 A.M., the surveyor observed the resident in the dining room asleep in a recliner. During an interview on 5/15/13 at 7:30 A.M., with Unit Manager #1, the surveyor reviewed the circumstances surrounding Resident #8's fall and fracture (on 5/5/13). UM #1 said the nurse had toileted Resident #8 and when the resident was placed in the recliner, she forgot to apply the chair alarm. UM#1 said it was staff error and the fall could have been prevented. During an interview on 5/15/13 at 9:00 A.M., with Unit Manager #1, the surveyor explained that during an observation of Resident #8 (on 5/14/13) the resident did not have the hip savers on as care planned. UM #1 said the the resident's hip savers were in the laundry and were damp. She said the resident is supposed to wear the hip savers at all times. Please refer F323.

4. The facility failed to ensure that the residents' environment remained as free from potential accident hazards as possible. On all days of the survey, the hallways on the Enfield and Greenwich units were cluttered and lined with wheelchairs, mechanical lifts, treatment and medication carts, laundry carts and housekeeping carts. During the initial tour on 5/14/13, at 8:45 A.M., the hallway on the Enfield Unit was cluttered and lined with 8 wheelchairs, a medication cart and a mechanical lift. The hallway on the Greenwich Unit was cluttered with 9 wheelchairs, a medication cart, a treatment cart and a mechanical lift. The handrail on one side of the hallway was blocked by these items. On 5/15/13, at 9:00 A.M., the hallway on the Enfield Unit was cluttered and lined with 7 wheelchairs, 2 mechanical lifts and a medication cart. The hallway on the Greenwich Unit was cluttered and lined with 9 wheelchairs, a medication cart, a treatment cart and a mechanical lift. The handrail on one side of the hallway was blocked by these items. On 5/15/13, at 10:07 A.M., the hallway on the Enfield Unit was cluttered and lined with 7 wheelchairs, a mechanical lift and a medication cart. The hallway on the Greenwich Unit was cluttered and lined with 5 wheelchairs, 2 mechanical lifts and a medication cart. A staff member was observed assisting a resident with a walker. The resident's walker bumped into a wheelchair that was in the hallway and the staff member had to move the wheelchair to make room for the resident to pass by. The handrail on one side of the hallway was blocked by these items. On 5/15/13, at 2:00 P.M., the hallway on the Enfield Unit was cluttered and lined with 11 wheelchairs, 2 mechanical lifts, a laundry cart, a medication cart and a treatment cart. The hallway on the Greenwich Unit was cluttered and lined with 2 wheelchairs, a medication cart, a treatment cart and 2 mechanical lifts. The handrails on one side of the hallway was blocked by these items. On 5/16/13, at 10:45 A.M., the hallway on the Enfield Unit was cluttered and lined with 10 wheelchairs, a mechanical lift, a treatment cart, a medication cart and a laundry rack. A staff member attempted to get by with a snack cart and was unable to pass through without moving 2 wheelchairs. A housekeeping cart was in the middle of the hallway and prevented any passage in the hallway. The hallway on the Greenwich Unit was cluttered and lined with 7 wheelchairs, a treatment cart, a medication cart, a mechanical lift and a snack cart. The handrails on one side of the hallway was blocked by these items. During an interview on 5/16/13 at 2:00 P.M., the Administrator said that storage space was limited. 2. For Resident #12, the Facility failed to provide the necessary therapeutic diet for a Resident with dysphagia on 4/12/13. Review of the Diet Manual for Dsyphagia and consistency modified diets for chewing and swallowing problems, stated under description, "Dysphagia is the impairment or loss of skills involved in swallowing foods and/or liquids. The following diets provide a progression of foods and liquids based on ease of manipulation and chewing to facilitate safe swallowing. The goal of these interventions is to minimize and prevent choking, aspiration, malnutrition and dehydration." Resident #12 was admitted to the facility in 8/2012. This Resident had the following pertinent Diagnoses: [REDACTED]. Review of the quarterly Minimum Data Set (MDS) Assessment of 3/21/13 indicated for the Brief Interview for Mental Status this Resident was cognitively intact and needed set up help with eating. Under Section K Swallowing/Nutritional Status, was on a mechanical altered diet. Review of the physician's orders [REDACTED]. Review of the SBAR (Situation Background Assessment Recommendation) note of 4/12/13 at 6:30 P.M., indicated on 4/12/13 at 6:15 P.M., stated, "Pt. (Patient) noted to be choking in resident dining area this nurse perform 3 himlic (sic) thrusts food coughed out of mouth MD notified new order speech consult full ground diet." Review of the investigation report of 4/12/13 indicated this Resident was choking on a cut up piece of meat. The interventions initiated were a ground diet and speech evaluation. There was no mention in this investigation that this Resident received a regular consistency Salisbury steak instead of ground consistency. During an interview on 5/14/13 at 3:40 P.M., During an interview with Unit Manager #3 she was asked by the Surveyor, "What did this Resident choke on?" She stated, "It was a piece of meat, I believe it was Salisbury steak." The Heimlich maneuver was performed three times by the licensed nurse." During an interview on 5/14/13 at 3:50 P.M. Nurse #8 (the Nurse who performed the Heimlich maneuver) via telephone, the Surveyor asked her to recall the choking incident. Nurse #8 stated, "I performed the Heimlich and a piece of Salisbury steak came out (came out of his mouth after performing the Heimlich)." The Surveyor asked, "Was it ground Salisbury steak that (he/she) choked on?" Nurse #8 said, "I do not believe it was. He ate a few pieces, his/her (family member) was with (him/her), (the family member) cut it up into pieces." The Surveyor asked, "Did (he/she) get the right diet?" Nurse #8 said, "I left a message with the supervisor and his/her family member wanted a full ground diet and he/she could eat cheerios." The Surveyor stated again, "Did (he/she) get the right diet"? Nurse #8 said she did not know." During an interview on 5/14/13 at 4:10 P.M. with the Food Service Director he was asked "If the resident is on a ground diet did the Salisbury steak need to be ground from a regular consistency to a ground consistency in the kitchen?" He said, "It would need to be ground in the kitchen and you would not have to use a knife and fork to cut it up." During an interview on 5/15/13 at 7:15 A.M., with the Food Service Director, the Surveyor asked, "What happened with the choking incident with (Resident #12), did he get the correct diet?" The Food Service Director responded, "No, we started a PI (performance improvement) on it. The meal was suppose to be ground; we don't know how it happened." 3. Based on record review, interview and observation, the Facility failed to provide a resident environment which was free of accident hazards for other residents on the Dana Unit related to leaving a medication cart unlocked. Findings include: Review of the facility's policy on Medication Pass with the Medication, dated 6/1/12, under security it stated, "During routine administration of medications, the cart may be kept in the doorway of the resident's room with: - draws unlocked and facing inward, and within sight of the nurse... The cart must be clearly visible to the person administering medications, and all outward sides must be inaccessible to persons passing by." During a medication pass on 5/14/13 at 4:28 P.M., the medication cart was left unlocked and not in the visual field of Nurse #4 when she obtained Resident #17's finger stick blood sugar and administered insulin injection. During an interview on 5/14/13 at 5:00 P.M., with Nurse #4 she said that the medication cart was unlocked but she thought it was visible to her from this Resident's room. The Surveyor indicated when Nurse #4 performed a finger stick blood sugar and then administering the insulin the medication cart was not visible when she was performing an injection and fingerstick. Based on observation, record review and interview, the facility failed to ensure that the resident environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. The facility failed to prevent a fall with a fracture for 1 resident (#8) out of 13 applicable residents and failed to follow a dietary recommendation that caused a choking episode for 1 resident (#1) out of a total sample of 24. In addition, the facility failed to lock a medication cart when it was out of the nurse's field of vision and the facility failed to keep the hallways free of clutter. Findings include. 1. For Resident #8 the facility failed to prevent a fall that resulted in a fracture. Resident #8 was admitted to the facility in 2/2013 with [DIAGNOSES REDACTED]. Review of the facility Fall Prevention Policy, dated 9/2004, indicated; - A fall risk assessment will be conducted upon admission, - A score of 10 or greater indicates that the resident may be at high risk for falling, - Residents with a score of less than 10 still may be at risk, - A preventative care plan should be implemented, and - Ensure caregivers, resident and family are aware of the care plan interventions to promote continuity of care. Review of the admission assessment, dated 2/5/13, indicated the primary [DIAGNOSES REDACTED]. The resident had experienced a fall with in the last 30 days and was at risk for falling. The fall risk assessment had a total score of 6, but was considered a high risk for falls. Review of the Admission Initial Care Plan, dated 2/6/13, indicated the resident was a fall risk. The interventions included; - Asses for gait, standing/sitting, pain, need to void and medications, - Encourage to use call light, - PT referral, and - Instruct on safety measures. Review of the Admission Minimum Data Set (MDS) Assessment, dated 2/12/13, indicated the resident was cognitively impaired, an assist for transfer and ambulation, and had not experienced a fall since admission. Review of the Care Assessment Area (CAA), dated 2/18/13, indicated the resident was at risk for falls related to a history of falls, decreased strength, endurance and balance. Other risks included the use of medications, behaviors, anxiety and a new environment. Review of the Certified Nursing Assistant (CNA) Plan of Care Card, dated 3/5/13, indicated the resident was an assist of 1 with ambulation and transfer, and utilized a chair and bed alarm. Review of Resident #8's falls care plan, dated 3/10/13, included the following interventions; - Transfer with rolling walker, gait belt and 1 assist, - Bed and Chair alarm, - Motion Alarm, - Hip savers, and - Voiding Diary (initiated 4/18/13). Review of the Accident/Incident Report, dated 3/10/13, indicated the resident had a witnessed fall at 7:40 A.M. The resident's bed alarm sounded, the nurse responded and observed the resident climbing out of the bed. A motion sensor alarm was initiated and a request for a Physical Therapy (PT) screen. Review of the PT screen, dated 3/11/13, indicated the bed and chair alarm should continue, and place the call bell within the resident's visual field to assist with recall to use the call bell. Review of the Accident/Incident Report, dated 4/14/13, indicated at 6:30 A.M., the resident was being ambulated by a CNA, lost his/her balance and was lowered to the floor. Review of the Accident/Incident Report, dated 4/18/13, indicated that the resident was in the main dining room and had a witnessed fall at 12:20 P.M. The resident stood up, the alarm sounded, but staff could not reach the resident to prevent the fall. The resident was incontinent at the time of the fall. A toileting pattern was initiated and the resident was placed on a toileting schedule. Review of the Accident/Incident Report, dated 5/5/13, indicated the resident had an unwitnessed fall at 5:10 A.M. The report indicated the resident was sitting in the main dining room in a recliner. The resident stood up and fell . The report indicated the resident was observed on the floor with the right leg over the left. When the resident stood up, the resident would not put weight on the left leg. The Physician was notified and an order was obtained to send the resident to the emergency room for an evaluation. At the time of the fall, the resident did not have the chair alarm in place, per plan of care. Review of a X-ray report from the hospital, dated 5/5/13, indicated Resident #8 had a new compression fracture mid thoracic vertebral body. On 5/14/13 at 2:00 P.M., the surveyor observed Resident #8 in the dining room attending an activity. The resident was seated in a wheelchair with a chair alarm. On 5/15/13 at 7:15 A.M. the surveyor observed the resident in the dining room asleep in a recliner. The resident had a chair alarm and a sensor alarm present. During an interview on 5/15/13 at 7:30 A.M., with Unit Manager #1, the surveyor reviewed the circumstances surrounding Resident #8's fall and fracture (on 5/5/12). UM #1 said the nurse had toileted Resident #8 and when the resident was placed in the recliner she forgot to apply the chair alarm. UM#1 said it was staff error and the fall could have been prevented.