Every finding on record at RegalCare at Wakefield

Based on observation, records reviewed and interviews, the facility failed to ensure one Resident (#77), out of a total sample of 23 residents, received the necessary care and treatment, consistent with professional standards of practice, to prevent the development of pressure ulcers. Specifically for Resident #77 who was assessed by nursing to be at high risk for skin breakdown and who experienced pain and limited mobility in his/her left lower extremity following a surgical repair, the facility failed to a. ensure nursing consistently implemented diabetic foot care, implemented weekly skin checks, and implemented interventions when the Physical Therapy Assistant (PTA) identified an area of red and non-blanchable skin on Resident #77's left heel, consistent with a stage one pressure injury (intact skin with non-blanchable redness of a localized area usually over a bony prominence) on 2/2/26, and the facility failed to provide a recommended prevalon boot for Resident #77's left heel wound, subsequently the left heel wound deteriorated to an unstageable pressure ulcer (known but not stageable due to coverage of wound bed by slough and/or eschar) on 2/11/26. Despite the PTA identifying the skin breakdown on 2/2/16 and again on 2/11/26 nursing did not identify the area until 2/19/26 and b. once the area was identified the facility failed to ensure that nursing consistently implemented an air mattress as ordered by the physician. Findings include: Review of the facility policy titled Pressure Ulcer/ Injury Risk Assessment, dated 3/2022, indicated the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk for developing pressure injuries. Steps in the Procedure 1.Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate.2.If necessary, allow the resident to take rest periods during the assessment.3.Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool.4.Conduct a comprehensive skin assessment with every risk assessment.a. When conducting a skin assessment, provide for the resident's privacy.b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool.c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin.5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals.a. The interventions must be based on current, recognized standards of care.b. The effects of the interventions must be evaluated.c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Resident #77 admitted to the facility in January 2026 with diagnosis including diabetes, disorders of bone density, obesity, heart failure, and periprosthetic fracture around internal prosthetic left knee joint. Review of Resident #77's most recent Minimum Data Set assessment, dated 2/2/26, indicated the Resident had a moderate cognitive impairment as evidenced by a Brief Interview of Mental Status score of 12 of 15. Resident #77 did not reject care, and he/she was coded as experiencing pain as almost constantly: which impacted sleep, therapy activities, and day to day activities. Resident #77 experienced functional range of motion on the lower extremity on one side and he/she was dependent on facility staff for lower body dressing and putting on and taking off footwear. The MDS assessment indicated Resident #77 was assessed to be at risk for developing pressure injuries and was admitted with one stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister). On 2/25/2026 at 10:08 A.M., the surveyor observed Resident #77 in bed on a standard mattress. Resident #77 said I am in so much pain, you need to get someone for me, I have an appointment I cannot miss, I haven't seen my orthopedic yet, I am supposed to go to the hospital at 11:00 A.M., to get my sutures removed!. The surveyor observed a dressing on Resident #77's knee area that was peeling, there were two occlusive dressings, covered by ABD pads, and wrapped coban (a lightweight, breathable, and water-resistant bandage). The surveyor observed a black area on Resident #77's left heel, and he/she said he/she got the wound at the facility. Review of Resident #77's plan of care titled Resident is at risk for skin breakdown related to pain, diabetes, and limited mobility with a goal of Resident will not show signs of skin breakdown, dated as initiated 1/28/26, indicated:-Weekly skin check by licensed nurse.-Pressure redistribution surface to bed and chair.-Observe skin condition daily with activities of daily living (ADL) care and report abnormalities.-Provide preventative skin care i.e lotions barrier creams as ordered.-Turn and reposition to meet needs. Review of Resident #77's plan of care titled Wound Management Post-Surgical - General, dated 1/28/26, indicated: - Encourage Resident to elevate legs Review of Resident #77's plan of care titled Documented Pressure Ulcer Documented Pressure Ulcer (on admit) _X_ Wound on coccyx [sic], dated as 1/28/26, indicated:- Encourage the use of lifting devices while in bed - Monitor bony prominences for redness Review of Resident #77's SECTION Custom Skin & Wound - Norton Plus Assessment, dated 1/30/26, indicated Resident #77 scored a 7 indicating that he/she was assessed by nursing to be at high risk for skin breakdown. Review of Resident #77's physician's orders, dated 1/28/26, indicated:-Diabetic Foot Care/Check Daily Observation of feet, toes, ankles, soles noting any alteration in skin integrity, color, temperature, and cleanliness. Inspect shoes for proper fit and excessive wear, check pedal pulses. CODE: 1= no alteration noted CODE: 2= New alteration noted CODE: 3= Previously noted alteration Pedal Pulse (PP): P=Palpable NP=Non-Palpable every evening shift for diabetes. Review of Resident #77's Treatment Administration Record (TAR), dated 2/1/26 through 2/28/26, indicated Nursing documented the diabetic foot care as code 1 - no alteration noted. However, record review indicates Resident #77 had documented a left heel pressure ulcer on 2/19/26. During an interview on 2/27/26 at 6:40 A.M., Nurse #3 said that Resident #77 was admitted to the facility after a fall with fracture. Nurse #3 said that Resident #3 had limited mobility in the left leg and he/she had lots of pain in his/her left leg. Nurse #3 said that although he documented that he completed diabetic foot care for Resident #77, he did not complete diabetic foot care because Resident #77 had a surgical incision around his/her left knee and he was not allowed to take off the ace wrap that was located from the thigh down to the toes on the left foot. Nurse #3 and the surveyor reviewed Resident #77's physician's orders and there was no order for an ace wrap. Nurse #3 said that at times the ace wrap would come loose and he would need to reapply the ace wrap to Resident #77's left leg, but he did not assess Resident #77's left heel. Nurse #3 said he was surprised that Resident #77 got a new pressure ulcer on his/her left foot because he thought the ace wrap would have protected the heel. Record review indicated between 2/1/26 and 2/18/26 Nurse #3 documented eight times he completed diabetic foot care and coded '1- no issues.' Review of Resident #77's physician's order, dated 1/28/26, indicated:-Monitor dressing with wound to left femur (thigh bone, upper leg) related to status post-surgery. Keep dressing dry and intact. If become saturated remove immediately and apply dry sterile dressing and monitor for continued drainage. every shift for status post-surgery. Further review of the order failed to include the use of an ace wrap. Review of Resident #77's physician's order, dated 1/28/26, indicated:- Skin check and complete UDA (user defined assessment), every evening shift, every Friday. Review of Resident #77's Treatment Administration Record (TAR), dated 2/6/26, 2/13/26, and 2/20/26 indicated Nurse #2 documented that she completed a skin check under the UDA assessment however there was no documentation to support these assessments were completed. Review of Resident #77's Skin Check. - V 4 assessment, dated 1/27/26, indicated:- Redness purple bruises noted over the left hip and bilateral abdominal folds. Bruising observed on bilateral upper extremities; patient reports bruising is secondary to intravenous (IV) insertion. Heels dry. Left knee to ankle unable to be assessed. Review of Resident #77's Admit/Readmit Screener* - Copy V3 assessment, dated 1/27/26, indicated:-skin warm and dry with normal turgor. Redness noted on left hip and abdominal folds. open, erythematous area noted on the coccyx. Heels dry. Bruising observed on bilateral lower extremities (BLE); bruising due to IV insertion. Review of Resident #77's SECTION Custom Skin Check - V 4 assessment, dated 2/3/26, indicated:- Redness purple bruises noted over the left hip and bilateral abdominal folds. Bruising observed on bilateral upper extremities; patient reports bruising is secondary to IV insertion. Heels dry. Left knee to ankle unable to be assessed. During an interview on 3/3/26 at 6:39 A.M., Nurse #2 said that she was familiar with Resident #77 and had been his/her nurse for quite some time. Nurse #2 said that Resident #77 was admitted to the facility after a fall, he/she had pain from a fracture, and had a surgical incision on the left knee. Nurse #2 said that Resident #77's left leg was wrapped in an ace wrap, and she was unable to visualize his/her left foot, and this ace wrap was not to be removed. Nurse #2 said that at times Resident #77's left leg ace wrap would come off, and the ace wrap would need to be reapplied, and she said she did not look at the heels each time she needed to reapply the ace wrap. Nurse #2 and the surveyor reviewed the physician's orders and there was no order to apply an ace wrap to Resident #77's left lower leg. Nurse #2 said she completed the skin check on 2/3/26 and said that Resident #77's heels were dry and intact, as documented, and she was able to see the heels since the ace wraps were off. Nurse #2 said that she does not recall completing any additional skin check for Resident #77 during his/her stay, but she said that skin checks are supposed to be documented on the TAR and an assessment is to be opened and completed in the assessment tab of the electronic health record (EHR). Record review indicated Nurse #2 documented she completed skin checks on the TAR on 2/6/26, 2/13/26, and 2/20/26 however there was no supporting documentation these were completed. Nurse #2 said that Resident #77 is diabetic, and he/she requires diabetic foot care. Nurse #2 said that nurses complete diabetic foot care and they document the findings on the TAR. Nurse #2 said she was unable to complete diabetic foot care on Resident #77's left foot because it was covered with an ace wrap. Record review indicated Nurse #2 documented she completed diabetic foot care on the TAR eight times between 2/1/26 and 2/18/26, and coded '1-no issues'). Nurse #2 said that after the left heel pressure ulcer was identified on 2/19/26 Resident #77 now required prevalon boots and an air mattress. Review of Resident #77's, Occupational Therapy Evaluation and Plan of Treatment, dated 1/28/26, indicated: - Functional Skills: putting on/ taking off footwear, coded as dependent.- Condition Assessment: Sensation / Sensory Processing - impaired (neuropathy in feet). Review of the Physical Therapy Encounter note, dated 2/2/26, indicated the following:- Discussed with morning Certified Nursing Assistant (CNA) for left lower extremity support of pillowcase to improve patient's comfort.- Patient and caregiver training: Ongoing staff training. Discussed patient's left heel for benefit of prevalon boot (a specialized heel protector designed to prevent pressure ulcers by keeping the heel elevated and off the bed surface) while in bed. Review of the Physical Therapy Encounter note, dated 2/11/26, indicated the following:- Provided nursing/patient with two prevalon boots to improve heel circulation for off-loading weight on heels. Patient pending ultrasound for left heel according to nursing. Patient present with left heel eschar and ace wraps removed from left lower extremity. During an interview on 2/26/26 at 1:33 P.M., the Physical Therapy Assistant (PTA) said that he was familiar with Resident #77's care. The PTA said that Resident #77 had an ace wrap on his/her left leg, and he said that the ace wrap was not consistently applied in the same manner to Resident #77' left foot. The PTA said that there were times the ace wrap was not applied below the ankle and that during his assessments of Resident #77's circulation, sensation, and motor function (CSM) of Resident #77's left lower extremity he could see Resident #77's left heel. The PTA said that Resident #77 admitted without a pressure injury on his/her left heel.The PTA and the surveyor reviewed the encounter notes for Resident #77 and he said that on 2/2/26 Resident #77 presented with a red non-blanchable area to his/her left heel, which was new. The PTA said he discussed his concerns with nursing staff, and he told them that Resident #77 needed offloading and he wanted Resident #77 to have a prevalon boots. The PTA said that during his treatment on 2/11/26 and previous treatments between 2/2/26 and 2/11/26, he noticed there were no prevalon boots for Resident #77 and his/her heels were directly touching the standard mattress. The PTA said on 2/11/26 he provided Resident #77 with prevalon boots, and he needed to search for some in the facility since nursing did not obtain any prevalon boots, and he said the left heel wound was now eschar, as documented in his note. The PTA said that he makes recommendations verbally to nursing staff and he cannot put orders or recommendations into the electronic health record (EHR). Review of Resident #77's Nurse Practitioner note, dated 2/10/26, indicated:Chief Complaint: Reporting decreased sensation in distal lower extremities. He/she is feeling hopeless about his/her back pain and future ambulating.Review of systems: Bilateral Lower Extremity leg, decreased mobility.Skin: Surgical incision with sutures intact.Plan: Surgical Incision Open to Air with approximated with sutures. Review of Resident #77's Nurse Practitioner note, dated 2/11/26, indicated:-Chief Complaint: Pain in the left lower extremity, guarding with palpation.-Review of systems: Bilateral Lower Extremity pain, decreased mobility, and anxiety.-Assessment/Plan: Fracture - reporting pain on palpation, adding ultrasound to assess for deep vein thrombosis. Review of Resident #77's Nurse Practitioner note, dated 2/17/26, indicated:Chief Complaint: Reporting nerve pain with numbness and tingling. During an interview on 2/27/26 at 10:52 A.M., the Nurse Practitioner said she had evaluated Resident #77 multiple times during his/her admission to the facility. The NP said that Resident had pain in the left lower leg and Resident #77 was admitted after a fall with surgical repair. The NP said that Resident #77 had a surgical incision and a dressing on his/her left leg and that dressing was supposed to be removed at the orthopedic follow up on 2/4/26, which the appointment was missed. The NP said she was not supposed to take the dressing off Resident #77's leg, but on 2/10/26 Resident #77 had begun to complain about numbness in the left lower foot and he/she had increased edema. The NP said on 2/10/26 she removed the ace wrap and gauze layers from Resident #77's left leg, and she said she left the initial surgical dressing intact. The NP said that she did not assess Resident #77's left heel, but she ordered diagnostic testing to rule out deep vein thrombosis due to Resident #77 increased edema in the left lower extremity. The NP said that she did not assess Resident's 77 heels until after the pressure ulcer was discovered on 2/19/26. The NP said that Resident #77's left heel pressure wound is managed by the Wound NP. During an initial interview on 2/26/26 at 3:06 P.M., the Assistant Director of Nursing (ADON) said that she completes weekly wound rounds on the residents with the Wound Nurse Practitioner. The ADON said that Resident #77 admitted to the facility he/she did not have any pressure injuries on his/her heels. The ADON said on 2/19/26 while doing a routine wound care round with the Wound NP, she said she observed a pressure ulcer on Resident #19's left heel. The ADON said that the area looked like a blister that had reabsorbed. The ADON said that on 2/19/26 the ace wrap that was on Resident #77's left leg was loose and his/her left heel was visible. The ADON said that she reviewed the incident report for the pressure ulcer, and she said that during some interviews with direct care staff such as CNAs, she said that the CNA's said that they had observed the pressure injury shortly after Resident #77 admitted to the facility. The ADON said that prevalon boots should have been implemented upon admission to prevent skin breakdown. Review of Resident #77's nursing note, dated 2/19/26, indicated:- Unstageable pressure injury noted to left heel this day. Review of Resident #77's SECTION Custom Weekly Skin Check assessment, dated 2/19/26, indicated:- unstageable wound noted to left heel.During an interview on 2/26/26 at 3:13 P.M., the Unit Manager said Resident #77 was admitted to the facility with a Norton Score of 7 which indicated he/she is at high risk for skin breakdown. The Unit Manager said that Resident #7 had a surgical incision and had a lot of pain in his/her left leg which was limiting his/her mobility and he/she was working with therapy on getting in and out of bed to help prevent pressure ulcer development. The Unit Manager said wound rounds are completed weekly by the ADON and Wound NP. The Unit Manager said that Resident #77 was admitted to the facility without a pressure injury on his/her left heel and she was made aware of the new area on 2/19/26 by the ADON. The Unit Manager said that Resident #77 was being seen weekly by the Wound NP for a pressure ulcer on his/her coccyx that evolved into moisture associated skin damage (MASD). The Unit Manager said that it is important for weekly skin checks and diabetic foot care to be completed accurately so that nursing can identify potential areas of skin breakdown and put interventions in place. The Unit Manager and the surveyor reviewed Resident #77's physician's orders she said there was no order for an ace wrap for Resident #77's left leg. The Unit Manager said that there were no formal interventions put in place to prevent skin breakdown upon admission. The Unit Manager said that once the pressure ulcer on the left heel was discovered on 2/19/26, she obtained physician's orders and implemented prevalon boots and an air mattress. The Unit Manager said Nurses are aware of new interventions by report each shift and by physician's orders. The Unit Manager said that CNAs are aware of interventions by verbal report each and reading the electronic care card. Review of the CNA care card on 2/26/26 failed to include documentation to support that Resident #77 required an air mattress or prevalon boots. Review of Resident #77's Wound Assessment Report, dated 2/19/26, indicated left heel pressure ulcer, unstageable, measurements:Length: 3.5 centimeters (cm)Width: 5 cm Review of the Wound Care Specialist note, dated 2/19/26, indicated:- Additionally, there is a new wound noted to the left heel. The patient has a recent history (1/22/26) of left lower extremity surgery - increasing the patient's immobility and risk of pressure related injuries. The left heel is covered with stable, dry eschar obscuring the wound base, consistent with an unstageable pressure injury. There is no overt drainage or malodor; however, the patient reports significant localized pain to the heel, raising concern for possible underlying soft tissue infection or osteomyelitis, particularly in the postoperative setting. Given the presence of heel eschar and reported pain, I recommend obtaining an x-ray of the left heel to evaluate for bony involvement, as well as laboratory studies. I will initiate an appropriate local wound care plan today, maintaining the eschar intact if it remains dry and stable, as heel eschar may serve as a biologic cover in the absence of infection. Continue aggressive offloading with Prevalon boots at all times and place patient on pressure-redistributing air mattress. During an interview on 2/27/26 at 12:07 P.M., the Wound NP said that she was familiar with Resident #77, and she had seen him/her on 2/5/26 and 2/12/26 for Moisture Associated Skin Damage (MASD) to his/her buttocks. The Wound NP said that she does not conduct a comprehensive skin assessment during her weekly evaluations and she only looks at areas that the facility staff ask her to look at. The Wound NP said that she did not assess Resident #77's heel until 2/19/26 when the ADON requested her to evaluate the wound. The Wound NP said that she recommended pressure relieving booties and an air mattress once the wound was found. The Wound NP said that she did not remove the left leg surgical incision dressing. Review of Resident #17's Social Service note, dated 2/24/26, indicated:- Interdisciplinary team (IDT) family meeting held this date with Resident and family in attendance. Rehab continues to work with Resident with Medicare part B services. Skilled services complete with last covered day 2/26/26. Resident declined to appeal. Goal of care to remain and discharge home to community with services when rehab goals met and medically stable. Wound on lower extremity limiting progress with non-weight bearing status. During an interview on 2/26/26 at 4:10 P.M., CNA #3 said that Resident #77's left heel has had an area since around the time of his/her admission. CNA #3 said that Resident #3 had an ace wrap on his/her left leg and the ace wrap would come off and the area was there. CNA #3 said that she would notify the nurses and the nurses would need to come in and put the ace wrap back on his/her foot. CNA #3 said that Resident #77 wears prevalon boots now and he/she likes the boots. CNA #3 said that Resident #77 has a regular air mattress. CNA #3 said that she is aware of Resident #77's care needs by reading the electronic care card. During an interview on 2/26/26 at 12:59 P.M., CNA #2 said that Resident #77 has an area on his/her left heel, and she said it's been there for a while but couldn't remember how long. CNA #2 said that Resident #77 uses a regular mattress and does not have an air mattress. CNA #2 said that she is aware of Resident #77's care needs by reading the electronic care card. During an interview on 3/3/26 at 8:05 A.M., the Director of Rehabilitation (DOR, an Occupational Therapist) said he was familiar with Resident #77. The DOR said that he was made aware of the PTAs concerns on 2/2/26 and again on 2/11/26, and he had seen the wound. The DOR said that the PTA reported these concerns to nursing and the PTA requested nursing to apply prevalon boots. The DOR said that therapy does not have any writing privileges in the EHR and all communication is verbal. The DOR said that he is part of the IDT, and he knows that the left heel pressure ulcer was discussed with nursing prior to 2/19/26. During a follow up interview on 3/3/26 at 8:55 A.M., the ADON said that Resident #77's left heel was unavoidable because of his/her comorbidities. The ADON said she was involved with reviewing the incident accident report for the new pressure ulcer and she said that the Unit Manager gathered statements and she was aware that there were some inconsistencies of when the wound was discovered and by whom. The surveyor along with the ADON reviewed Resident #77's TAR for diabetic foot care, weekly skin checks, left femur dressing order, and the PT encounter notes with the ADON. The ADON said she was not aware that nursing was not completing the diabetic foot care as ordered, nursing was not conducting skin checks as ordered, and the ADON said she was not aware the PTA found the area on 2/2/26 as a red non-blanchable area and again on 2/11/26 as eschar. The ADON then said that if interventions were not followed the wound would have been avoidable and the ADON said that interventions should have been put in place immediately when the PTA found the area to prevent avoidable breakdown. During an interview on 2/26/26 at 2:09 P.M., the Physician said that he did not see Resident #77 until 2/22/26 and at that time Resident #77 had a thick black necrotic area on his/her left heel and this was the first time he evaluated the Resident. The Physician said that due to the size of the pressure ulcer when he first evaluated it on 2/22/26 he wanted nursing staff to obtain an x-ray to rule out osteomyelitis to ensure the wound would heal. The Physician said the wound is followed and managed by Wound NP, and he would expect nursing to implement recommendations by the wound nurse. The Physician said that Resident #77 was admitted with limited mobility of the left leg, and he would have expected the nursing staff to implement interventions such as booties for Resident #77 to prevent skin breakdown upon admission. The Physician said for Resident #77 that the left heel that pressure ulcer is avoidable since the Resident was not provided interventions upon admission. The Physician said that if Physical or Occupational Therapy made recommendations to nursing, nursing should have implemented interventions. The Physician said he wound want the air mattress implemented. b.) Review of Resident #77's physician's order, dated 2/19/26, indicated:-May have therapeutic air Mattress in place. Set to patient's comfort level. check function and placement. every shift for maintenance. On 2/25/26 at 7:53 A.M., 9:22 A.M., and at 10:08 A.M., the surveyor observed Resident #77 in bed, he/she was on a regular mattress. There was an air mattress on and functioning in the empty bed next to Resident #77's bed. On 2/26/26 at 6:36 A.M. and 9:24 A.M., the surveyor observed Resident #77 in bed, he/she was on a regular mattress. During an interview on 2/26/26 at 12:35 P.M., Resident #77 was up in the wheelchair, wearing a regular shoe. Resident #77 said that he/she did have an air mattress and Resident #77 the air mattress stopped working around a week ago and they put it on the other bed to see if they could get it to work. Resident #77 said he/she would like the air mattress. On 2/26/26 at 4:30 P.M., the surveyor observed Resident #77 in bed, he/she was on a regular mattress. On 3/2/26 at 8:40 A.M., the surveyor observed Resident #77 in bed, he/she was on a regular mattress. On 3/3/26 at 6:37 A.M., the surveyor observed Resident #77 in bed, he/she was on a regular mattress. During an interview on 2/26/26 at 2:46 P.M., Nurse #3 said that Resident #77 refuses his/her air mattress. During an interview on 3/3/26 at 6:39 A.M., Nurse #2 said that Resident #77 uses an air mattress for pressure ulcer care. During an interview on 3/3/26 at 9:38 A.M., the ADON said that Resident #77 requires an air mattress for his/her left heel pressure ulcer and MASD on the buttocks. The ADON said she was not aware Resident #77 was not using the air mattress. On 3/3/36 at 9:40 A.M., the surveyor and the ADON observed Resident #77 in bed on a regular mattress. Review of the Treatment Administration Record, dated 2/19/26 through 3/2/26, indicated nursing documented yes that there was an air mattress for Resident #77 35 shifts. Further review indicated Nurse #3 document yes on 14 shifts and Nurse #2 documented yes 9 shifts.

Based on records review, and interviews, the facility failed to obtain diagnostic services as ordered by the provider for one Resident (#77), out of a total sample of 23 residents. Specifically for Resident #77 who experienced pain in the left lower extremity the facility failed to obtain a left lower extremity ultrasound (non-invasive imaging test used to detect blood clots, evaluate venous flow, and assess venous valve function in the leg). Findings include: Review of the facility policy titled, Labs and Diagnostics, dated as revised 5/2025, indicated:Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requirements and arrange for tests.3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Resident #77 admitted to the facility in January 2026 with diagnosis including diabetes, disorders of bone density, obesity, heart failure, and periprosthetic fracture around internal prosthetic left knee joint. Review of Resident #77's most recent Minimum Data Set assessment, dated 2/2/26, indicated the Resident had a moderate cognitive impairment as evidenced by a Brief interview of mental status score of 12 of 15. Resident #77 did not reject care, and he/she was coded as experiencing pain as almost constantly: which impacted sleep, therapy activities, and day to day activities. Resident #77 experienced functional range of motion on the lower extremity on one side and he/she was dependent on facility staff for lower body dressing and putting on and taking off footwear. Review of Resident #77's Nurse Practitioner note, dated 2/11/26, indicated:- Chief Complaint: Pain in the left lower extremity, guarding with palpation.- Review of systems: Bilateral Lower Extremity pain, decreased mobility, and anxiety.- Assessment/Plan: Fracture - reporting pain on palpation, adding ultrasound to assess for deep vein thrombosis. Review of Resident #77's physician's order, dated 2/11/26, indicated: - Ultrasound to left lower extremity to rule out deep vein thrombosis. Scheduled 2/11/26 duration 4 days. Review of Resident #77's laboratory and diagnostic studies tab in the electronic health record failed to include documentation to support the facility obtained the ultrasound. During an interview on 2/27/26 at 6:40 A.M., Nurse #3 said that he obtained the order to obtain an ultrasound for Resident #77 left lower extremity, Nurse #3 said he was supposed to call the vendor to order the diagnostic study, but he did not. Nurse #3 reviewed the vendor portal and said that the diagnostic test was not ordered, and he must have forgotten to schedule it. During an interview on 2/27/26 at 7:16 A.M., the Unit Manager said she was unable to locate results from Resident #77's left lower extremity ultrasound and that she would notify the Nurse Practitioner to see if she still wanted the diagnostic test completed. During an interview on 2/27/26 at 10:52 A.M., the Nurse Practitioner (NP) said that Resident #77 was experiencing increased edema and decreased sensation in his/her left lower extremity after a surgical repair. The NP said that Residents who have surgical repairs are at risk for blood clot formation and she wanted Resident #77 to have an ultrasound on the left lower extremity due to his/her symptoms. The NP said that she was not aware that nursing did not obtain the left lower extremity ultrasound until 2/27/26 (16 days after the initial order), and she said she had to reorder the exam. During an interview on 3/3/26 at 9:17 A.M., the Assistant Director of Nursing said that nursing should have ordered and obtained the left lower extremity ultrasound but they did not.

Based on observation, record review and interview the facility failed to ensure for one Resident (#4), out of a total sample 23 residents, that informed consent, including risk and benefits, was obtained from Resident #1's legal guardian prior to administering antipsychotic medication. Findings include: Review of the facility's policy titled, Subject: Psychotropic Medication, revised 2/2025, indicated: Guidelines 1. Obtain physician's order. Note: A physician's order and appropriate diagnosis is required for all psychoactive medications. Note: An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychoactive medication.Resident #4 was admitted to the facility in February 2026 with diagnoses including, but not limited to, aphasia (a language disorder) following cerebral infarction (stroke), major depressive disorder, recurrent and moderate, unspecified dementia with unspecified severity and with agitation, and history of suicidal ideation.Review of the Minimum Data Set assessment dated [DATE] indicated Resident #4 scored 2 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. Further, the MDS indicated Resident #4 is dependent on staff for all care activities including bathing, dressing and eating. The MDS indicated Resident #4 was administered antipsychotic medication with indication for use.Review of Resident #4's care plans indicated the following:- focus cognition, revision date 2/15/26, Resident benefits form a secured unit with a structured daily flow is necessary form of treatment due to cognitive loss/dementia/communication deficit with poor decision-making ability and decreased safety awareness. [SIC]- focus, Advanced Directives: Resident has a guardian, (named) with [NAME] (a court ordered treatment plan for the administration of antipsychotic medication). revision on 2/23/26, goal Guardian and Resident will engage in the decision making of his/her medical and mental health needs, target date 3/3/26. Interventions include allow opportunity to participate in decisions regarding care, date initiated 2/9/26On 2/25/26 at 8:04 A.M, Resident #4 was in bed and made eye contact when greeted but did not continue to participate in further conversation with the surveyor. Review of the physician's orders for Resident #4 indicated the following: Zyprexa (an antipsychotic medication) Oral tablet 5MG (milligrams) (Olanzapine) Give 2.5 mg by mouth two times a day for psychosis, order date 2/17/26, start date 2/18/26. Review of the progress notes indicated a note dated 2/17/26 documented by the Nurse Practitioner, Nursing reporting he/she is agitated during morning care, found to have injured a staff member. Adding Zyprexa BID for paranoia related to care. Review of Resident #4's medical record failed to indicate that an informed consent including the risk and benefits of the use of the Zyprexa was documented as occurring with Resident #4's guardian. During an interview on 3/2/26 at 2:34 P.M., Nurse #11 said Resident #4 is dependent on staff for all care, wakes up early and has behaviors of screaming and once he/she is up after breakfast he/she will be fine. Nurse #11 said Resident #4 recently started on Zyprexa 2.5 mg 2 times a day for his/her behaviors. Nurse #11 said the Resident's guardian would need to give consent prior to administering the medication. Nurse #11 said the nurse who enters the order should confirm there is consent for the medication. Nurse #11 and Nurse #5 looked in Resident #4's medical record and only found consents obtained on admission and not for the use of Zyprexa ordered 2/17/26.During an interview on 3/3/26 at 7:58 A.M., Social Worker #1 said there was no consent for Resident's #4 for the administration of the Zyprexa and there should have been. During an interview on 3/3/26 at 9:47 A.M. via telephone Resident #4's legal guardian said she was not informed of the order to be administer Zyprexa, dated 2/17/26, for Resident #4 until she was called by a nurse yesterday (3/2/26). The guardian said she gave consent because the medication was already started and that she would like to have a discussion with the provider because this is Resident #4's third prescribed antipsychotic.

Based on observations and interviews, the facility failed to ensure a homelike environment was maintained on one of three units. Specifically, on the [NAME] Unit, the facility failed to ensure that the unit refrigerator that was on the unit in a resident space was kept in a manner that was consistent of a reasonable homelike environment as evidenced by a brown, rusted color that was stained across the entire bottom part of the front of the refrigerator.Findings include:Review of the facility policy titled Resident Home, dated and revised April 2022, indicated the following: - Residents are provided with a safe, clean, comfortable and homelike environment.On 2/26/26 at 9:14 A.M., on the [NAME] Unit, the surveyor observed the unit refrigerator in the hallway which was a part of the Resident's shared space. The entire bottom part of the refrigerator was stained with a brown substance that resembled rust that did not rub off.Throughout the survey period, multiple residents would pass by the refrigerator as they enter and exit the shared dining room space.During an interview on 2/26/26 at 7:02 A.M., two residents who reside on the unit told the surveyor they wished the refrigerator looked better since we live here and it bothers them.During an interview on 2/27/26 at 8:06 A.M., Nurse #5 said the refrigerator looks nasty and the facility should buy a new one.During an interview on 2/27/26 at 7:48 A.M., a staff member told the surveyor that the refrigerator has looked this way for years and it is gross and we would love to have a new one.During an interview on 2/27/26 at 12:03 P.M., another resident who resides on the unit told the surveyor that he/she wishes it looked nicer.During an interview on 3/2/26 at 9:15 A.M., the Housekeeping Manager said she has tried cleaning the refrigerator and the brown stains do not come off.During an interview on 3/2/26 at 10:35 A.M., the Assistant Director of Nursing said she is aware of the state of the refrigerator, and the facility is ordering a new one.Review of the facility's reviews online indicated a review dated 3 months ago with a photo of the unit refrigerator with the entire bottom part of the refrigerator resembling the same observations the surveyor made during the survey period.

Based on observations, record review and interview, the facility failed to assess the use of a potential restraint for one Resident (#34) out of a total sample of 23 Residents. Specifically, for Resident #34, the facility failed to assess the use of a scoop mattress as a potential restraint. Findings include:Review of the facility policy titled Use of Restraints, dated and revised April 2022, indicated the following:- Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms.- Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.Resident #34 was admitted to the facility in June 2020 with diagnoses including paranoid schizophrenia and chronic kidney disease. Review of Resident #34's most recent Minimum Data Set assessment dated [DATE] indicated that the Resident had a Brief Interview for Mental status score of 15 out of 15 indicating the Resident is cognitively intact. Further review of the MDS indicated that the resident requires substantial/maximum assistance with all transfers and does not use restraints. During an interview on 2/25/26 at 7:50 A.M., Resident #34 told the surveyor that he/she recently was getting out of bed and slipped off the side of it. The surveyor then observed that Resident #34's mattress was a scoop mattress.During observations on 2/26/26 at 6:53 A.M. and 2/27/26 at 6:53 A.M., Resident #34 was sleeping in his/her bed with a scoop mattress in place, his/her wheelchair was within arm's reach of the bed.Review of Resident #34's Unwitnessed Fall Incident Report, dated 12/29/25 at 9:45 P.M., indicated the following:- Incident Description: Call light was on in room, this writer went for assistance and noticed the resident was in sitting position on the floor. Resident explained that he/she was trying to reach over for something then slid off the bed.- Notes: 12/30/25 - Intervention: Scoop mattress to prevent slipping out of the bed.Review of Resident #34's most recent fall risk evaluation dated 1/6/24 indicated that the resident scored a13 indicating that he/she is at risk for falls. Review of Resident #34's physician's orders failed to indicate an order for the use of a scoop mattress.Review of Resident #34's care plans, including his/her falls care plan, failed to indicate an intervention for the use of a scoop mattress.Review of Resident #34's medical record failed to indicate that the facility completed an assessment for the use of a scoop mattress as a potential restraint prior to use.Review of Resident #34's mobility care plan, dated and revised 11/19/23 indicated that the Resident requires substantial/maximum assistance from staff for lying-to-sitting on the side of bed, rolling left and right as well as sitting to lying and standing.During an interview on 2/26/26 at 1:16 A.M., Nurse #6 said Resident #34 is a partial assistance for care activities of daily living staff and he/she can sometimes get out of bed on his/her own if his/her wheelchair is next to the bed. Nurse #6 then said Resident #34 has a scoop mattress to prevent him/her from falling out of bed but she is not sure when the Resident received the scoop mattress.Shortly after the Surveyor interviewed Nurse #6, Nurse #6 proceeded to input a physician's order and update Resident #34's care plan for the use of a scoop mattress.During an interview on 2/27/26 at 6:54 A.M., Nurse #7 said Resident #34 uses a scoop mattress to keep herself/himself in bed and the Resident sometimes gets out of bed on his/her own at nighttime. Nurse #7 said he believes that Resident #34 received the scoop mattress about one month ago and Resident #34 told Nurse #7 that he/she did not like the scoop mattress at first because he/she said he/she cannot get out of bed.During an interview on 2/27/26 at 8:08 A.M., Nurse #5 said Resident #34 sometimes get out of bed on his/her own. Nurse #5 then said she thinks Resident #34 received the scoop mattress after his/her fall in December. Nurse #5 said if a Resident is on a scoop mattress there needs to be a physician's order and care plan as well a restraint assessment to determine if the device is a restraint or not.During a follow up interview on 2/27/26 at 8:54 A.M., Resident #34 said he/she believes that he/she received the scoop mattress about six weeks ago.During an interview on 2/27/26 at 9:54 A.M., the Maintenance Director said he has been filling in as the Maintenance Director for four months. He said he was never made aware of Resident #34 receiving a scoop mattress and he does not remember any maintenance requests for a scoop mattress.During an interview on 3/2/26 at 10:22 A.M., the Assistant Director of Nursing (ADON) said Resident #34 can sometimes get out of bed on his/her own and she does not remember the last time the Resident had a fall. The ADON then said after a Resident has a fall, the facility will conduct an investigation, and any new interventions will need a physician's order, and the care plan will be updated. The ADON then said if a resident needs a scoop mattress, then the facility must first determine why it is necessary and then put in an order and care plan for it as well as make sure a restraint assessment is completed prior to its use. The ADON said she was not aware Resident #34's scoop mattress was implemented from the 12/29/25 fall and said that an order, care plan, and restraint assessment should have been completed.

Based on observation, record review and interviews, the facility failed to ensure for one Resident (#1), out of a total sample of 23 residents, that recommended services were implemented in accordance with the Pre-admission Screening and Resident Review (PASRR) Level II Evaluation Determination Summary. Specifically, Resident #1 was screened to meet PASRR criteria for SMI (serious mental illness) with recommended behavioral health services, individual psychotherapy. Findings include: Review of the facility's policy subject; Preadmission Screening and Resident Review (PASARR), dated revised 5/2022 indicated: It is the policy of the facility to comply and state PASARR requirements to ensure that individuals with Serious Mental Illness (SMI), Intellectual Disability (ID), or Related conditions receive appropriate screening, placement, and specialized services prior to and during admission to the facility. Further, review of the policy indicated if Level 1 is positive a level II evaluation must be completed and approved prior to admission unless an allowable hospital exemption applies. 2. Level II Evaluation Conducted by the state-designated authority, Determines: Appropriateness for nursing facility placement. Need for specialized mental health or developmental disability services. The facility must: Await Level II determination prior to admission. Implement all recommended specialized services upon admission. Resident #1 was admitted to the facility in November 2025 and has diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, adult failure to thrive, dysphagia, delusional disorder, major depressive disorder recurrent severe with psychotic symptoms, anxiety disorder, post-traumatic disorder, borderline personality disorder. Review of the most recent Minimum Data Set assessment dated [DATE] indicated Resident #1 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #1 as cognitively intact. Review of Resident #1's clinical record indicated the following:-A Pre-admission Screening and Resident Review (PASRR) level II Evaluation Determination Summary, dated 11/19/25, which indicated Resident #1 meets the PASRR criteria for a SMI (serious mental illness) and nursing facility services are appropriate up to 90 days. Recommended behavioral health services including Individual Psychotherapy. -An active physician order, dated 11/26/25, Behavioral health contracted provider to evaluate and treat for psychiatric and psychological health -A document signed by Resident #1, dated 11/26/25 titled 'authorization to screen, evaluate and treat for behavioral health services dated 11/26/25 During an interview on 2/26/26 at 9:03 A.M., Resident #1 said since admission to the facility he/she has talked with his/her physical therapists and doctor and has not been seen by a psychotherapist and would like to be able to talk with someone. During an interview on 2/26/26 at 11:33 A.M., Nurse #8 said Resident #1 will report he/she is anxious but may not be specific about what he/she is anxious about. Nurse #8 said she was not sure if Resident #1 was receiving behavioral health services. Nurse #8 reviewed the notes under miscellaneous in the medical record and said she did not see any behavioral health notes and would need to check further. During an interview on 2/26/26 at 9:25 A.M., the contracted behavioral health Nurse Practitioner (NP) said she provides medication review services, and that talk therapy is provided by a clinician via telehealth on Thursdays. The NP said she is not familiar with Level II PASRR determinations, but for a resident to be seen by behavioral health a physician's order and consent is needed. During an interview on 2/26/26 at 1:11 P.M., the behavioral health NP said Resident #1 was referred today for services and had not been seen by the talk therapist since admission. During an interview on 2/26/26 at approximately 1:00 P.M., Social Worker (SW) #1 said she is the regional SW and is currently covering the facility. SW #1 said the facility social worker would be responsible to review a resident's PASSR Level II determination letter. SW #1 said the facility SW would coordinate the recommendations from the [NAME] II determination by developing a care plan to include the recommended services to continue support a resident's behavioral health needs. SW #1 said behavioral health services, including psychotherapy therapy, should have been put in place for Resident #1 before now and that the admitting SW did not implement the recommended PASSR Level II services.

Based on observation, record review and interviews, the facility failed to ensure standards of professional nursing practice for one Resident (#1) out of a total sample of 23 residents. Specifically, the nursing staff documented in Resident #1's medical record that 1:1 supervision was being provided during meals when it was not provided in accordance with the physician's orders. Findings include: Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019 indicated the following:- The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #1 was admitted to the facility in November 2025 and has diagnoses that include but are not limited to chronic obstructive pulmonary disease, adult failure to thrive, delusional disorder, major depressive disorder, recurrent and severe, with psychotic symptoms, and dysphagia (a swallowing disorder). Review of the most recent Minimum Data Set assessment dated [DATE] indicated Resident #1 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #1 is cognitively intact. Review of Resident #1's medical record indicated the following physician's order:-1:1 supervision/feed with meals for Aspiration precaution (sic), start date 1/21/26. During the survey the following the surveyor made the following observations: -On 2/25/26 at 12:57 P.M., Resident #1 was eating in the dining room with other residents. Resident #1 was eating a meal that consisted of a hot dog in a bun with a cup of beans and condiments. Resident #1 was sitting at a table with 2 other residents, a total of 16 residents in the room with 2 staff present. No staff was observed providing 1:1 supervision to Resident #1 while he/she ate his/her meal. The Speech Language Pathologist did sit near Resident #1 after most of his/her meal was consumed. -On 2/25/26 at 4:27 P.M., Resident #1 was provided with crackers by staff in his/her room. The staff exited the room and Resident #1 was behind the curtain eating crackers, while resting in bed, not sitting up. -On 2/26/26 at 9:05 A.M., Resident #1 was in the dining room, sitting at a table alone. Nine other residents were present, and one staff member was sitting at a table feeding a resident. At 9:19 A.M., Resident #1 remained eating his/her breakfast meal. At 9:31 A.M., staff approached Resident # 1 and removed his/her breakfast tray. At no time during the observation did staff provide 1:1 supervision during the observation. During an interview on 2/26/26 at 7:18 A.M., Resident #1 said he/she had pneumonia not too long ago. Resident #1 said I can swallow now but I had a problem swallowing before. During an interview on 2/26/26 at 12:12 P.M., Certified Nursing Assistant (CNA #4) said Resident #1 is independent with eating his/her meals and will ask for food items that he/she wants. During an interview on 2/26/26 at 12:46 P.M., the Speech Language Pathologist (SLP) said Resident #1 is on SLP services and his/her diet has been upgraded to a regular diet. The SLP reviewed the orders and said the Resident does have a 1:1 supervision order for meals and that it was not discontinued and could be. Review of the Medication Administration Record (MAR) dated February 2026 indicated from 2/1/26 through the 1230 (12:30 P.M.) meal on 2/25/26 indicated that all three meals were documented by nursing staff as provided per the order 1:1 supervision/feed with meals for aspiration precautions was being provided. The documentation on 2/25/26 meal at 1700 (5:00 P.M.) and 8300 (8:30 A.M.) conflicts with the surveyor's observations. During an interview on 2/26/26 at 2:15 P.M., Nurse #10 said Resident #1 was in the hospital sometime in January and came back, was on rehabilitation and was at risk for aspiration. Nurse #10 said staff observes and supervises Resident #1 during meals, but nursing staff is not providing 1:1 supervision as the order reads. Nurse #10 said she documented the MAR on 2/24/26 for all three meals. Nurse #10 said by checking off the MAR means the order was completed as written. Nurse #10 said nurses should not be checking off something they did not provide. During an interview on 3/2/26 at 10:42 A.M., the Assistant Director of Nursing said nursing staff should not sign off on an order that they did not provide or validate.

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#77) received treatment and care in accordance with professional standards of practice, out of total sample of 23 residents. Specifically for Resident #77 who had surgery on 1/22/26, the facility failed to send the Resident #77 to his/her orthopedic follow up appointment on 2/4/26 for suture removal and the sutures were not removed until 2/24/26, 35 days after surgery, potentially placing the resident at risk for complications. Findings include:Resident #77 admitted to the facility in January 2026 with diagnosis including diabetes, disorders of bone density, obesity, heart failure, and periprosthetic fracture around internal prosthetic left knee joint. Review of Resident #77's most recent Minimum Data Set assessment, dated 2/2/26, indicated the Resident had a moderate cognitive impairment as evidenced by a Brief interview of mental status score of 12 of 15. Resident #77 did not reject care, and he/she was coded as experiencing pain as almost constantly: which impacted sleep, therapy activities, and day to day activities. Resident #77 experienced functional range of motion on the lower extremity on one side and he/she was dependent on facility staff for lower body dressing and putting on and taking off footwear. The MDS assessment indicated Resident #77 had a surgical wound. Review of the hospital after visit summary orthopedic Discharge summary, dated [DATE] through 1/27/26, indicated but was not limited to the following:You were admitted to the hospital for a fracture of your left knee; you underwent surgery on 1/22/26.1. Activity/Restrictions - Weight bearing as tolerated 2. Wound Care - Keep dressing clean dry and intact, monitor daily for saturation. If dressing remains dry keep intact until follow up visit. If saturated remove immediately. 3. DVT Prophylaxis: Lovenox 40 milligrams (mg), one daily for 4 weeks.4. Follow Up: 2/4/26. Review of Resident #77's physician's orders, dated 1/28/26, indicated: - Monitor dressing with wound to left femur related to status post-surgery. Keep dressing dry and intact. If become saturated remove immediately and apply dry sterile dressing and monitor for continued drainage every shift for status post (S/P) surgery.- Do not shower. Do not get dressing wet. every shift for S/P surgery. Review of Resident #77's plan of care related to is at risk of complications related to fractured hip [SIC], dated as initiated 1/28/26, indicated:- Dressing as ordered. On 2/25/26 at 10:08 A.M., Resident #77 said I am in so much pain, you need to get someone for me, I have an appointment I cannot miss, I haven't seen my orthopedic yet, I am supposed to go to the hospital at 11:00 A.M., to get my sutures removed!. The surveyor observed a dressing on Resident #77's knee area that was peeling, there were two occlusive dressings, covered by ABD pads, and wrapped coban (a lightweight, breathable, and water-resistant bandage). Review of Resident #77's progress note, dated 2/25/26, indicated: -Patient back from Post-op appointment. Per progress note from Surgeon: Suture were removed this day. Pt (patient) can get incisions wet and pat dry. Avoid fully submerging. Continue current pain management. WBAT with left lower extremity (LLE) using assistive device. Can continue with Physical therapy. Follow up in 5 weeks. 4/1/26 at 12:45pm.Review of Resident #77's department of orthopedic surgery form, dated 2/25/26, indicated: -Sutures were removed today. Can get incisions wet and pat dry. Avoid fully submerging. During an interview on 2/25/26 at 3:59 P.M., Resident #77 said he/she just returned from the orthopedic appointment, and he/she said the orthopedic doctor was not happy that I still had my original dressing, and I missed my follow up. The surveyor observed Resident #77's left knee area which was open to air, there were steri-strips across the surgical wounds. On 2/26/26 at 2:00 P.M., the surveyor requested Resident #77's ortho follow up paperwork from the Unit Manger. The paperwork was not located in the medical record or at the nursing station. During an interview on 2/27/26 at 7:16 A.M., the Unit Manager said she couldn't find Resident #77's paperwork from ortho. During a subsequent interview on 2/27/26 at 10:29 A.M., the Unit Manager said she is still unable to find the follow-up paperwork from the visit on 2/25/26, and she was not sure why Resident #77 did not go on her ortho follow up appointment on 2/4/26. She said she would follow up with the receptionist to find out why. The Unit Manager said that the process for follow-up appointments is for the admitting nurse to write down the appointment in the appointment book, make a copy of the appointment, and fill out the transport request form and provide this information to the receptionist to book the transport. Unit Manager #1 said that the night nurses are supposed to review the appointment book on the night shift and fill out paperwork for every appointment. During a subsequent interview on 2/27/26 at 11:48 A.M., the Unit Manager #1 said Resident #77's initial dressing indicated not to remove until the ortho follow up. The Unit Manager said that she had no excuse for why the appointment on 2/4/26 was missed. The Unit Manager said the next available ortho appointment was on 2/11/26 and the resident wasn't ready when the ride came and the ride came and went and didn't wait and left for the resident to get ready. The Unit Manager said that the Receptionist rebooked the ride for 2/18/26 with receptionist, and the company brought in a wheelchair not a stretcher and the Resident wasn't tolerating being up for too long, so the facility had to rebook that day for 2/25/26. The Unit Manager said that the initial surgical dressing was not to be removed and for them to ensure the dressing remained dry and intact. The Unit Manager said that the facility Nurse Practitioner removed the dressing one day since Resident #77 was having issues. The Unit Manager said that she did not contact the ortho place to obtain orders for dressings changes after the dressing was removed. During an interview on 2/27/26 at 12:04 P.M., the orthopedic office said that Resident #77 was supposed to have a follow up appointment to have his/her sutures removed on 2/4/26. The Orthopedic Office said Resident #77 did not show up for appointments on 2/4/26, 2/11/26, and 2/18/26. Review of Resident #77's Nurse Practitioner note, dated 2/10/26, indicated:Chief Complaint: Reporting decreased sensation in distal lower extremities. He/she is feeling hopeless about his/her back pain and future ambulating.Review of systems: Bilateral Lower Extremity leg, decreased mobility.Skin: Surgical incision with sutures intact.Plan: Surgical Incision Open to Air with approximated with sutures. Review of Resident #77's Nurse Practitioner note, dated 2/11/26, indicated:-Chief Complaint: Pain in the left lower extremity, guarding with palpation.-Review of systems: Bilateral Lower Extremity pain, decreased mobility, and anxiety.-Assessment/Plan: Fracture - reporting pain on palpation, adding ultrasound to assess for deep vein thrombosis. Review of Resident #77's Nurse Practitioner note, dated 2/17/26, indicated:Chief Complaint: Reporting nerve pain with numbness and tingling. During an interview on 2/27/26 at 10:52 A.M., the Nurse Practitioner said she had evaluated Resident #77 multiple times during his/her admission to the facility. The NP said that Resident had pain in the left lower leg and Resident #77 was admitted after a fall with surgical repair. The NP said that Resident #77 had a surgical incision and a dressing on his/her left leg and that dressing was supposed to be removed at the orthopedic follow up on 2/4/26, which the appointment was missed. The NP said she was not supposed to take the dressing off Resident #77's leg, but on 2/10/26 Resident #77 had begun to complain about numbness in the left lower foot and he/she had increased edema. The NP said on 2/10/26 she removed the ace wrap and gauze layers from Resident #77's left leg, and she said she left the initial surgical dressing intact. The NP said it was very important for Resident #77 to have his/her orthopedic follow up for suture removal 14 days post operative. During an interview on 2/27/26 at 12:07 P.M., the Wound NP said that she did not remove the left leg surgical incision dressing. The Wound NP said that the dressing needed to be removed by the orthopedic. During an interview on 3/3/26 at 7:49 A.M., the Receptionist said there are several people who book appointments for Residents', she said all appointments are booked when she receives paperwork from nursing. During an interview on 3/3/26 at 8:45 A.M., the Assistant Director of Nursing said that Resident #77 had a left leg surgical dressing and missed an appointment on 2/4/26. The ADON said the follow ups are important to follow to follow the surgeon would want to see the site itself and do a follow up imaging. The ADON said she was not aware off all the missed appointments and she said I heard about it after them the fact. She said the Unit Manager rescheduled. The ADON said negative impacts from missing the appointment would include infection of the surgical site and delay in care. On 3/3/25 at 8:50 A.M., the surveyor and the ADON reviewed Resident #77's medical record. Resident #77 still had active physician's orders to 1. Monitor dressing with wound to left femur related to status post-surgery. Keep dressing dry and intact. If become saturated remove immediately and apply dry sterile dressing and monitor for continued drainage. every shift for status post (S/P) surgery and 2. Do not shower. Do not get dressing wet. every shift for S/P surgery, despite the follow up recommendations on 2/25/26. The ADON said that nursing was still documenting that nursing was monitoring and assessing Resident #77's dressing and Resident #77 when these orders should have been discontinued by the Unit Manager.

Based on interview and observation the facility failed to ensure medications were secure on two of three resident units. Specifically, the facility failed to:Secure a narcotic medication in the Solerna Unit medication room.a.Secure medications which were left unsupervised at the [NAME] Unit nursing station and b. secure a treatment cart on the [NAME] Unit.Findings include:1.Review of the facility policy Medication Storage, dated as revised March 2022, indicated there was no reference to the securing of narcotics in the medication room refrigerator. On 3/3/26 at 9:15 A.M., the surveyor observed the Solana dementia unit medication storage room, accompanied by Nurse #9. Nurse #9 unlocked the medication room door. Inside the room was a small, unlocked refrigerator. The surveyor opened the refrigerator and observed one large, white box and one smaller black box. The white box was locked and affixed to the shelf by nylon cable ties. The black box locked but not affixed to the refrigerator. The surveyor lifted the box out of the refrigerator and Nurse #9 unlocked the box. Inside was one unopened vial of liquid Ativan 2 milligrams/ml, a schedule IV narcotic. Nurse #9 said he did not know that the locked box containing the Ativan was required to be secured to the refrigerator. During an interview with the Assistant Director of Nurses (ADON) on 3/3/26 at 9:52 A.M, she said that refrigerated narcotics should be stored in a locked box and the box should be securely affixed to the inside of the refrigerator. The DON said that the box should be affixed to the refrigerator to prevent anyone from removing the box from the medication room and possibly diverting the narcotic medication. 2. Review of the facility policy titled, Medication Storage, dated 3/2022, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. a. On 2/25/26 at 6:55 A.M., the survey team entered the [NAME] Unit and there were no staff present. There was a resident self-propelling up and down the hallway. The surveyor observed at the nursing station the following: - two bags of medications that were sealed, - a tote box sealed with medications in it, - two blue bags with medications that indicated perishable open immediately, - one box of prescription strength lidocaine jelly, - four medication cards containing 120 tablets of fluvoxamine, an antipsychotic medication, - one medication card containing 14 tablets of quetiapine, an antipsychotic medication, - three medication cards containing 90 tablets of sevelamer, a phosphate binder, - two medication cards containing 60 tablets of levetiracetam, and - one medication card containing 14 capsules of tamsulosin. b. On 2/25/26 at 7:12 A.M., the surveyor was able to gain access to an unlocked and unattended treatment cart on the [NAME] Unit. The surveyor observed the following: - two bottles of ketoconazole 2% shampoo, - one container of silver sulfate cream 1%, - one tube of ketoconazole crem 2%, - one tube of nystatin powder, - one tube of clobetasol propionate, and various treatment supplies including but not limited to hydrocortisone 1%, packets, medihoney, xeroform dressings, and hydrogel. On 2/25/26 at 7:10 A.M., Nurse #1 arrived at the [NAME] Unit nursing station, and he said he was not sure why there were medications left unattended at the nursing station. Nurse #1 said that mediations are usually delivered around 3:00 A.M. and 4:00 A.M., and he said the medications in the blue bags were room temperature and should have been immediately placed in the refrigerator once delivered. Nurse #1 said he would put the medications away in the medication cart. During an interview on 2/25/26 at 8:10 A.M., Nurse #2 she just returned to the facility and said she had left to get coffee and another nurse in a different Unit was covering the [NAME] Unit. Nurse #2 said that she left the medications out at the nursing station because they were supposed to go back to the pharmacy because the Residents were no longer here (conflicting with Nurse #1's interview and observation). Nurse #2 said that treatment carts should be always locked. During an interview on 3/3/26 at 8:42 A.M., the Assistant Director of Nursing (ADON) said that nursing should put the medications away upon delivery from the pharmacy, and nursing should ensure medications are secure to ensure staff and residents don't have access. The ADON said nursing should refrigerate medications immediately based on the manufacture's recommendations.

Based on observations, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two Residents (#72 and #80) with a history of suicidal ideation (SI) and depression, out of a total sample of 26 residents. Specifically: 1. For Resident #72 the facility failed to provide Resident #72 with appropriate behavioral health services following verbalizations of SI and psychosocial distress. 2. for Resident #80 the facility failed to indicate any behavioral health care plan or interventions were implemented after identifying Resident #80's history of attempted suicide or suicidal ideations. Findings include: Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, dated revised March 2019 indicated that the facility will provide and the residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment. Further review indicated that the nursing staff will identify, document and inform the physician about specific details regarding changes in the individual's mental status, behavior and cognition. Review of the document titled Facility Assessment, dated 8/1/2024, indicated that on a daily average, 40-47 residents with behavioral health needs reside in the facility. Further review indicated that the facility is able to manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior and identify and implement interventions, including non-pharmacological interventions, to help support individuals with issues such as dealing with psychotic disorder, schizophrenia, anxiety, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. Resident #72 was admitted to the facility in October 2023 and had diagnoses that include Suicidal Ideation, Major Depressive Disorder, Psychotic Disorder with Delusions, Anxiety Disorder, Bipolar disorder and Schizophrenia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/15/24, indicated that Resident #72 has a diagnosis of suicidal ideations. The MDS further indicated that Resident #72 scored a 6 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment and had expressed feelings of sadness/depression more than half of the time in the past week. Review of Resident #72's medical record failed to indicate a care plan for suicidal ideation had been developed. Review of the hospital discharge summary dated 12/12/24 indicated that Resident #72 was admitted to the hospital on 11/1/24 with suicidal ideations and discharged 6 weeks later to the facility on [DATE]. Further review indicated that Resident #72 had multiple previous hospitalization s for a similar presentation. Review of the facility documents titled Nursing Documentation Note, dated 12/13/24, 12/14/24, 12/16/24, and 12/17/24, indicated the following: mental health/behavior reviewed; Pt. (patient) is experiencing agitation/restlessness, suicidal ideations, and excessive crying. Review of Resident #72's Behavioral Health Service notes indicate the following: -An initial psychological evaluation, dated 12/20/24, conducted by a psychological (Psych) therapist. Psych Therapist #1, indicated Resident #72 has a life long history do (sic) Schizophrenia and multiple suicide attempts and multiple psych hospitalization s. Psych Therapist #1 indicated Resident #72 reported I am so upset with how I feel right now. I need my medication to kick in so I can feel good again. Psych Therapist #1 indicated that Resident #72 is currently back to his/her emotional baseline in the mornings but shows great improvement after 10:00 A.M. -A psych therapy note, dated 12/23/24. Psych Therapist #2 documented that tearfulness and anxiety is prominent in the mornings but subsides after morning medications are given. -A psych therapy note, dated 1/13/25. Psych Therapist #2 indicated that Resident #72 is usually tearful and anxious in the morning before medication administration, and improved mood after. -A psych therapy note, dated 1/24/25, Psych Therapist #2 indicated Resident #72 said that I know I feel better now but I feel so terrible in the morning. Review of the record failed to indicate the time of Resident #72's morning medications had been assessed or that the Physician had been notified of Resident #72's mood state until medications were administered. On 1/28/25, at 8:07 A.M., the surveyor observed Resident #72 crying in bed, yelling out to call an ambulance because he/she was having extreme suicidal thoughts and was afraid he/she was going to snap. There were a long call light cords and a bed adjustment cord hanging from the wall next to Resident #72's bed. The surveyor observed several staff members in the hallway and 2 nurses sitting at the nurse's station not responding to the distress calls from Resident #72. The surveyor informed Nurse #10 of Resident #72's verbalizations. Nurse #10 said this is Resident #72's normal behavior and brought Resident #72 to the dining room to eat. On 1/28/25, at 3:45 P.M., the surveyor observed Resident #72 alone in his/her room. The long call light cords and a bed adjustment cord were hanging from the wall next to Resident #72's bed. On 1/29/25 at 8:00 A.M. the surveyor observed Resident #72 standing in his/her room doorway crying out I don't feel good inside, I want to kill myself. Resident #72 was observed to be agitated and shaking, in acute psychosocial distress. There were several staff members in the hallway however none responded to Resident #72. During an interview on 1/29/25 at 8:12 A.M. Nurse #11 said that he worked the 11 P.M.-7 A.M. shift last night. Nurse #11 said that it had not been reported to him that Resident #72 had verbalized SI the previous day and had requested a ambulance be called. Nurse #11 said that the physician should be notified if a resident verbalizes SI, and that a progress note should be in the clinical record indicating the physician's instructions. Review of the clinical record failed to indicate that the physician had been notified of Resident #72's verbalization of SI on 1/28/25 or that Psych Services had been notified or assessed the Resident's mood state to determine a plan to keep the Resident safe. During an interview on 1/29/25 at 8:02 A.M., with Resident #72's Certified Nursing Assistant (CNA) #7 said that Resident #72 wakes up around 6:00 A.M. and often says he/she doesn't feel good inside, but she has never heard Resident #72 claim to want to commit suicide. CNA #7 said that Resident #72 usually feels better by lunch. During an interview on 1/29/25 at 8:14 A.M., Nurse #4 said that Resident #72 just told her that he/she wanted to commit suicide. Nurse #4 then said that she would expect that a resident with active suicidal ideations to have an active care plan in place. During an interview on 1/29/25 at 8:22 A.M., the Director of Nursing (DON) said that the physician and psych services should be notified immediately if a resident verbalizes SI, exhibits psychosocial distress and is requesting an ambulance be called. The DON also said that she would expect that a progress note would have been entered into the medical record. The DON said that said nursing should document in the clinical record the plan to keep the resident safe. The DON said all residents with a history of SI should have a care plan, with resident specific triggers and interventions, to address the SI. On 1/30/25 the surveyor observed the following: At 7:58 A.M. Resident #72 yelled out I am going to kill myself (three times), I feel like I am suicidal, I don't feel good, I am going to do it. Nurse #12 was in the hallway however walked away and did not acknowledge the Resident's verbalizations of SI. Housekeeping was in the room at the time and also, did not intervene. At 8:01 A.M. Resident #72 yelled out I need help, I'm suicidal. I'm going to kill myself. Resident #72 was observed to be crying, and pleading with Nurse #12, who had briefly entered the room, not to leave him/her. Nurse #12 did not acknowledge the Resident's request and exited the room to resume working at his medication cart. At 8:05 A.M. Resident #72 said I feel suicidal, I need help. Nurse #12 went into Resident #72's room and said give me 5 min. Resident #72 responded I don't feel good inside, I am going to kill myself. Nurse #12 ignored Resident #72. At 8:07 A.M. Resident #72 was observed tearful and crying as he/she said I am suicidal I want to kill myself. Nurse #12 entered Resident #12's room with a breakfast tray, then walked out closing the door shut to 3-4 inches behind him and exited. Resident #72 was left alone in the room crying. Between 8:08 and 8:41 A.M., the surveyor observed Resident #72 alone in his/her room, crying out feelings of SI and no staff intervened or checked on him/her. observed in bed moving, weeping, saying I am going to kill myself, I am suicidal please help me please. No staff responded During an interview on 1/30/25 at 8:38 A.M., Resident #72 told the surveyor 'I'm having anxiety attacks, I put the call light on because mornings are difficult, I want to kill myself, I need help. During an interview on 1/30/25 at 8:41 A.M., Nurse #12 said Resident #72 says I don't feel good inside all the time and explained it's a behavior thing, eventually he/she stops saying he/she wants to kill him/herself. During an interview on 1/30/25 at 8:46 A.M., the Administrator was updated on the observations of Resident #72 since 1/28/25. The Administrator said Resident #72 should not be left alone after making threats to harm him/herself and a plan should have been established immediately to ensure his/her safety. During an interview on 1/30/25, at 10:20 A.M., the Medical Director said that she was. not notified of Resident #72's verbalizations of SI on 1/28/25 and his/her request for an ambulance to be called. The Medical Director said that it is her expectation that she be notified whenever a resident verbalizes SI so that she can make a determination of a treatment plan. In this case, the Medical Director said that the facility notified her of a verbalization of SI on 1/29/25, but that if she had been made aware that the verbalizations began on 1/28/25 and continued on 1/29/25 she would have ordered Resident #72 be sent to the hospital for evaluation and treatment. During an interview on 1/30/25 at 11:10 A.M. the Director of Nursing said that no plan had been put in place since she was notified of the Resident's suicidal ideation's yesterday. She said that she thought that the Resident was put on 1:1 supervision but couldn't be sure. The DON said that a plan should have been implemented immediately when the Resident made the acute statements of suicidal ideation. During an interview on 1/30/25, at 11:18 A.M. Social Worker (SW) #1 said she was Informed on 1/29/25 that Resident #72 had verbalized SI and that she never heard him/her say this before. SW #1 said #72 should have immediately been offered behavioral health services. During an interview on 1/30/25 at 12:04 P.M., CNA #6, said she is Resident #72's regular CNA and that she was his/her CNA last night, (1/29/25 11 P.M.-7 A.M.) and that therefore no plan had been put in place to ensure safety. CNA #6 said that she did not get a report that Resident #72 was having suicidal ideations. CNA #6 said that Resident #72 always says he/she doesn't feel good inside and was very anxious last night and this morning. CNA #6 said that Resident #72 was more anxious last night and again this morning and just kept saying he/she doesn't feel good inside and needs his mother. he was not on 1:1 and was left alone in his room during the night. CNA #6 said she was upset that she was not told and said that that is not good if he/she was saying he/she was going to kill him/herself. During an interview on 1/31/25 at 7:27 A.M. Psych Therapist #1 said that Resident #72 is upset and says that all the time (that he/she is going to kill him/herself and that he/she is suicidal). Psych Therapist #1 said If you go back at 11 A.M. he/she will be much better. Psych Therapist #1 said that it was not possible to change Resident #72's medication to earlier in the morning because this is a nursing home you know. Review of Psych Therapist #2's note dated 2/3/25, indicated to change morning medication administration timing to 6:00 A.M. Review of the physician orders dated February 2025 indicated that all morning medications, including antipsychotic and antianxiety medication administration times were changed from 8:00 A.M. to 6:00 A.M. On 1/4/25, at 7:05 A.M. the surveyor observed Resident #72 resting quietly in bed without observed psychosocial distress. During an interview on 1/4/25, at 9:00 A.M., Nurse #10 said that Resident #72 is usually highly agitated in the mornings until around 10:00 A.M. (4 hours since waking up) and today he/she is calm, not verbalizing anxiety or SI. Nurse #10 then said that he believes that changing the Resident's medication time to 6 A.M. has helped Resident #72 a lot. 48671 2. Resident #80 was admitted to the facility in January 2024 with diagnoses including major depressive disorder, mood affective disorder, anxiety disorder, insomnia and dementia. Review of Resident #80's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored 13 out of a possible 15 on the Brief Interview for Mental Status Exam indicating intact cognition. Further review of the MDS indicated Resident # 80 has a psychiatric/mood disorder including anxiety and depression. Review of the Resident's hospital discharge paperwork, dated January 2024, indicated that Resident #80 was admitted to the facility after history of suicide attempt, chronic mental illness, and recent discharge from inpatient psychiatric unit for severe major depression disease and received 12 rounds of ECT (Electro-Conclusive Therapy (electrical impulses used to treat depression and other mental health conditions). History of trauma, abuse and discharged with protective factors. Safety Assessment included strong social support, engagement with treatment, Risk factors including hopelessness, personal loss, limited coping skills. Review of the hospital discharge Safety Plan included: -Warning signs (thoughts, image, mood, situation, behavior) that a crisis may be developing: 1. Feeling aggravated. 2. Thoughts of leaving the situation/environment. -Internal coping strategies- Things I can do to take mind off my problem without contacting another person (relaxation technique, physical activity). 1. Focus on something else that is more positive. 2. Self-reflect on what is bothering you. 3. Focus on the fact that things get better -People whom I can ask for help: family. Review of Resident #80's care plans on 1/28/25 failed to indicate any behavioral health care plan or interventions were implemented identifying Resident #80's history of attempted suicide or suicidal ideations. Review of the Nurse Practitioner note dated 2/2/24, indicated: Patient presented to Hospital on 11/22/2023 due to depressive symptoms. The patient was transferred from Psychiatric Hospital where he was admitted for 22 days due to depression. Upon evaluation the patient was impacted by significant grief, loss of independence, loss of companionship and isolation contributing to a loss of identity and motivation to live when his wife passed away. The patient received 12 ECT treatments and his mood and energy significantly improved. Assessment and Plan: ADL (activities of daily living) and mobility dysfunction secondary to major depressive disorder. Will continue discussion with the therapy team, family, and social worker. Review of the Social Services progress note dated 11/4/24, indicated: This Social Worker met with (Resident) today related to the resident to resident altercation he/she was involved in last week. He/she recalled the incident and reported that he has no psychosocial issues at this time. Social Services will continue to follow and support. Review of the Physician Progress noted dated 11/6/24, indicated: Follow-up depression, generalized weakness chronic pain occasional psychotic features. Psychiatric: Not agitated. Depressed mood. Follow-up generalized weakness, chronic pain anxiety depression involved in recent altercation with another resident, psych evaluating follow-up with dementia management of other medical problems and rehabilitation. Review of the Behavioral Health Services Nurse Practitioner note dated, 11/11/24, indicated: -Reports depression is fairly stable though tearful when discussing wife, denies SI. Recently was victim of resident altercation, reports he feels safe and is doing fine now but has some back pain from incident of being pushed. -Pertinent Current Medications: None -History of Trauma: No-denies. -Affect: Tearful, appropriate. -Diagnostic Assessment: Resident with hx (history) of MDD (major depressive disorder), severe without psychosis, anxiety and dementia. AO (alert and oriented) x2-3 with some forgetfulness. S/p (status post) 12 rounds of ECT in January of this year. Managed on Zoloft (antidepressant) and Remeron (antidepressant). Mood and behavior stable, no SI/HI (suicidal ideation/homicidal ideation) -Non-pharmacological recommendations include: -Provide reassurance and redirection as able. -Continue with behavioral recommendations that facility currently has in place. -Continue to document changes in mood or behavior -Continue to engage resident in facility activities. -Encourage good sleep hygiene habits - lights on in room, time during day spent out of bed, engage in activities, limit caffeine intake especially in the afternoons, avoid late afternoon naps. -GDR (gradual dose reduction) Rational: GDR not indicated at present time due to patient being recently referred; GDR will be evaluated once care is established. Review of Resident #80's active physician orders indicated the following: -Zoloft Oral Tablet 100 MG (milligrams) (Sertraline HCI) Give 2 tablet by mouth one time a day for Depression Total Dose 200 mg. Start Date 2/1/24. -Mirtazapine Oral Tablet Give 15 mg by mouth at bedtime for appetite stimulant, depression. Start Date 2/13/24. Review of the Behavioral Health Services Psychologist note dated 11/22/24 indicated: -Patient engaged in this initial evaluation while in his room. Reports challenges with depression and anxiety related to the death of his wife and health challenges. History of significant depression and mild anxiety. Reports use of medication to help manage his/her emotions but is also requesting emotional support while in the facility. -Progress towards goals: N/A (not applicable)- First visit -Recommendations: Patient would benefit from continued Cognitive Behavioral Therapy interventions, positive action planning, continued medication, management, encourage social engagements, grounding when needed, encourage time with family and/or friends, encourage attending activities, encourage time outside when weather allows. Review of the medical record failed to indicate a care plan was implemented for history of suicide attempts or suicidal ideations upon admission or after Resident #80 returned from the hospital on 10/31/24. Further, the medical record failed to indicate a referral was made, or that Resident #80 was assessed by the behavioral health team for psychotherapy to address his/her history of suicide attempts or suicidal ideations upon admission. During an interview on 1/30/25 at 11:18 P.M. Nurse #1 said Resident #80 had a history of SI and should have been evaluated by behavioral health on admission and said the Resident should have a behavior care plan in place. During an interview on 1/30/25 at 11:39 A.M., the Director of Nursing said when a resident is admitted with a history of suicidal ideation, and attempted suicide they should be assessed upon admission by psych services for both medication management and psychotherapy and a care plan must be in place. The DON said the Resident must be monitored appropriately and staff should know the history of the Resident. During an interview on 1/31/25 at 12:55 A.M., the Administrator said Behavioral Health Services must be implemented and in place and said Resident #80 should have been care planned on admission due to his/her history of suicide attempt and suicidal ideations.

Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically: The facility failed to ensure licensed nursing staff who were on the schedule on 1/28/25, 1/29/25 and 1/30/25, were trained and competent to identify, assess, and intervene when one Resident (#72), who was admitted with Suicidal Ideation's, made repeated statements of wanting to commit suicide. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the facility policy titled Staffing, Sufficient Competent Nursing, dated 2001 indicated that the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Review of the facility policy titled Facility Assessment, dated revised December 2023 indicated that the facility assessment includes a breakdown of the training, licensure, education, skill level and measures of competency for all personnel. Review of the document titled Facility Assessment, dated 8/1/2024, indicated that on a daily average 40 plus residents with behavioral symptoms reside in the facility. Further review indicated that the facility provides for residents with mental health and behavioral health needs that require intervention. Further review indicated that all personnel are required to be trained in behavioral health including but not limited to review of the behavioral health program's written policies, review of competencies and skills necessary to provide person-centered care and services that promote mental and psychosocial well-being. Resident #72 was admitted to the facility in October 2023 with diagnoses that include Suicidal Ideation (SI), Major Depressive Disorder, Psychotic Disorder with Delusions, Anxiety Disorder, Bipolar disorder and Schizophrenia. Review of the Minimum Data Set, dated dated dated [DATE], indicated that Resident #72 has a diagnosis of SI. Further review indicated that Resident #72 scored a 6 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that Resident #72 expressed feelings of sadness/depression more than half of the time in the past week. Review of Resident #72's Behavioral Health Service notes indicate the following: Review of the initial psychological evaluation 12/20/24, at 7:22 A.M., Psych Therapist #1, indicated the following: has a life long history do (sic) Schizophrenia and multiple suicide attempts and multiple psych hospitalization s. On 1/28/25, at 8:07 A.M., the surveyor observed Resident #72 crying in bed, yelling out to call an ambulance because he/she was having extreme suicidal thoughts and was afraid he/she was going to snap. The surveyor observed several staff members in the hallway and 2 nurses sitting at the nurse's station, not responding to the distress calls from Resident #72. The surveyor also observed long call light cords and a bed adjustment cord hanging from the wall next to Resident #72's bed. The surveyor informed Nurse #10 of Resident #72's SI. Nurse #10 failed to demonstrate competency in behavioral health and said that this is his/her normal behavior. Nurse #10 failed to acknowledge Resident #72's continued expressions of mental distress. On 1/29/25 at 8:00 A.M. the surveyor observed Resident #72 standing in his/her room doorway crying out I don't feel good inside, I want to kill myself. Resident #72 was observed to be agitated and shaking, in acute psychosocial distress. The several staff members in the hallway failed to demonstrate behavioral health competency as none of the staff responded to Resident #72's verbalizations of mental distress. During an interview on 1/29/25 at 8:22 A.M., the Director of Nursing (DON) said that all nursing staff should be trained in behavioral health and nursing failed to respond to Resident #72 appropriately. On 1/30/25 the surveyor observed the following: At 7:58 A.M. Resident #72 yelled out I am going to kill myself (three times), I feel like I am suicidal, I don't feel good, I am going to do it. Nurse #12, who was in the hallway, failed to demonstrate competency in behavioral health when he walked away and did not acknowledge the Resident's verbalizations of SI. Housekeeping was in the room at the time and also, did not intervene. At 8:01 A.M. Resident #72 yelled out I need help, I'm suicidal. I'm going to kill myself. Resident #72 was observed to be crying, and pleading with Nurse #12 not to leave him/her. Nurse #12, who had briefly entered the room, again failed to demonstrate competency in behavioral health when Nurse #12 did not acknowledge the Resident's request and exited the room to resume working at his medication cart. At 8:05 A.M. Resident #72 said I feel suicidal, I need help. Nurse #12 went into the Resident's room and said give me 5 min. Resident #72 responded; I don't feel good inside, I am going to kill myself. The Resident was crying out begging the Nurse #12 for help from the doorway as Nurse #12 ignored Resident #72. At 8:07 A.M. Resident #72 was observed tearful and crying as he/she said I am suicidal I want to kill myself. Nurse #12 entered Resident #12's room with a breakfast tray, then walked out closing the door shut to 3-4 inches behind him and exited. Resident #72 was left alone in the room crying. Between 7:58 and 8:41 A.M., the surveyor observed Resident #72 to make multiple statements about wanting to kill him/herself, while no staff intervened or checked on him/her. Review of all 24 of the licensed nursing staff training records, working in the facility on 1/28, 1/29 and 1/30/25, failed to indicate behavioral/mental health service training was completed. During an interview on 1/31/25, at 12:55 P.M., the Administrator said that all staff should have been trained on behavioral health as indicated in the facility assessment as the facility has a significant number of residents that have behavioral health concerns.

Based on observations, record review and interview, the facility failed to protect two Residents (#72 and #17), from abuse and neglect, out of a total sample of 26 residents. Specifically: 1. For Resident #72 the facility neglected to provide psychosocial support including ongoing monitoring, intervention and notification of the physician timely in a Resident who has a known history of suicidal ideation (SI) and observed to be making statements of SI by multiple staff without intervention. 2. For Resident #17 the facility failed to prevent verbal abuse. Findings include: Review of the facility policy titled Abuse and Neglect-Clinical Protocol, dated revised 2018 indicated that abuse is defined as the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being and it includes verbal abuse. Further review indicated that neglect is defined as the failure of the facility, its' employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 1. Resident #72 was admitted to the facility in October 2023 with diagnoses that include Suicidal Ideation (SI), Major Depressive Disorder, Psychotic Disorder with Delusions, Anxiety Disorder, Bipolar disorder and Schizophrenia. Review of the Minimum Data Set, dated dated dated [DATE], indicated that Resident #72 has a diagnosis of SI. Further review indicated that Resident #72 scored a 6 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that Resident #72 expressed feelings of sadness/depression more than half of the time in the past week. Review of Resident #72's medical record failed to indicate a care plan for suicidal ideation had been developed. Review of the physician's orders dated January 2025 indicated the following psychotropic medications: Clonazapam 0.5 MG (milligrams) give one tablet three times a day for anxiety. Clozapine 25 MG give three tablets by mouth three times a day for schizophrenia. Mirtazapine 45 MG give one tablet by mouth at bedtime for insomnia. Risperdal 0.5 MG give one tablet by mouth one time a day for agitation. Venlafaxiine HCL ER (extended release) 24 hour 75 MG give three capsules by mouth one time a day for anxiety. Further review failed to indicate an order to monitor for SI. Review of the behavior sheets dated January 2025 failed to indicate monitoring for SI. Review of the medical record failed to indicate that an assessment of the timing of the administration of his/her psychotropic medications was effective in preventing severe mental anguish in the morning due to the continued mental anguish exhibited in the morning before medication administration. Review of Resident #72's Behavioral Health Service notes indicate the following: Review of the initial psychological evaluation 12/20/24, at 7:22 A.M., (8 days after re-admission to the facility), Psych Therapist #1, indicated the following: has a life long history do (sic) Schizophrenia and multiple suicide attempts and multiple psych hospitalization s. Resident #72 is requesting emotional support while in the facility. Further review indicated that Resident #72 informed Psych Therapist #1 that I am so upset with how I feel right now. I need my medication to kick in so I can feel good again. Further review indicated that Resident #72 is currently back to his/her emotional baseline in the mornings but shows great improvement after 10:00 A.M. Further review failed to indicate a review of psychotropic medications for efficacy. Review of the psychotherapy note dated 12/23/24, Psych Therapist #2 indicated that tearfulness and anxiety is prominent in the mornings but subsides after morning medications are given. Further review failed to indicate a review of medications for efficacy. Review of the psychotherapy note dated 1/13/25, Psych Therapist #2 indicated that Resident #72 is usually tearful and anxious in the morning before medication administration, and improved mood after. Further review failed to indicate a review of medications for efficacy prior to morning administration. Review of the psychotherapy note dated 1/24/25, Psych Therapist #2 indicated Resident #72 said that I know I feel better now but I feel so terrible in the morning. Further review failed to indicate a review of medications for efficacy prior to morning administration. On 1/28/25, at 8:07 A.M., the surveyor observed Resident #72 crying in bed, yelling out to call an ambulance because he/she was having extreme suicidal thoughts and was afraid he/she was going to snap. The surveyor observed several staff members in the hallway and 2 nurses sitting at the nurse's station, not responding to the distress calls from Resident #72. The surveyor also observed long call light cords and a bed adjustment cord hanging from the wall next to Resident #72's bed. The surveyor informed Nurse #10 of Resident #72's suicidal ideations. Nurse #10 said this is his/her normal behavior and brought Resident #72 to the dining room to eat. Nurse #10 neglected to address Resident #72's mental anguish. On 1/29/25 at 8:00 A.M. the surveyor observed Resident #72 standing in his/her room doorway crying out I don't feel good inside, I want to kill myself. Resident #72 was observed to be agitated and shaking, in acute psychosocial distress. There were several staff members in the hallway, however none responded to Resident #72. During an interview on 1/29/25 at 8:12 A.M. Nurse #11 said that he worked the 11 P.M.-7 A.M. shift last night. Nurse #11 said that it had not been reported to him that Resident #72 had verbalized SI the previous day and had requested a ambulance be called. Nurse #11 said that the physician should be notified if a resident verbalizes SI, and that a progress note should be in the clinical record indicating the physician's instructions. Review of the clinical record failed to indicate that the physician had been notified of Resident #72's verbalization of SI on 1/28/25 or that Psych Services had been notified or assessed the Resident's mood state to determine a plan to keep the Resident safe, resulting in continued mental anguish. During an interview on 1/29/25 at 8:02 A.M., with Resident #72's Certified nurse's Aide (CNA) #7, she said that Resident #72 wakes up around 6:00 A.M. and often says he/she doesn't feel good inside, but she has never heard Resident #72 claim to want to commit suicide. CNA #7 said that Resident #72 usually feels better by lunch. During an interview on 1/29/25 at 8:14 A.M., Nurse #4 said that Resident #72 just told her that he/she wanted to commit suicide. Nurse #4 then said that she would expect that a resident with active SI to have an active care plan in place. During an interview on 1/29/25 at 8:22 A.M., the Director of Nursing (DON) said that the physician and psych services should be notified immediately if a resident verbalizes SI, exhibits psychosocial distress and is requesting an ambulance be called. The DON also said that she would expect that a progress note would have been entered into the medical record. The DON said that said nursing should document in the clinical record the plan to keep the resident safe. The DON said all residents with a history of SI should have a care plan, with resident specific triggers and interventions, to address the SI. On 1/30/25 the surveyor observed the following: At 7:58 A.M. Resident #72 yelled out I am going to kill myself (three times), I feel like I am suicidal, I don't feel good, I am going to do it. Nurse #12 was in the hallway however walked away and neglecting to acknowledge the Resident's verbalizations of SI, resulting in continued mental anguish. Housekeeping was in the room at the time and also, did not intervene. At 8:01 A.M. Resident #72 yelled out I need help, I'm suicidal. I'm going to kill myself. Resident #72 was observed to be crying, and pleading with Nurse #12, who had briefly entered the room, not to leave him/her. Nurse #12 neglected to acknowledge the Resident's request and exited the room to resume working at his medication cart, resulting in his/her continued mental anguish. At 8:05 A.M. Resident #72 said I feel suicidal, I need help. Nurse #12 went into the Resident's room and said give me 5 min. Resident #72 responded; I don't feel good inside, I am going to kill myself. The Resident was crying out begging the Nurse #12 for help from the doorway as Nurse #12 neglected to address Resident #72's verbalizations, resulting in his/her continued mental anguish. At 8:07 A.M. Resident #72 was observed tearful and crying as he/she said I am suicidal I want to kill myself. Nurse #12 entered Resident #12's room with a breakfast tray, then walked out closing the door shut to 3-4 inches behind him and exited, neglecting to address Resident #72's verbalizations. Resident #72 was left alone in the room crying, resulting in his/her continued mental anguish. Between 8:08 and 8:41 A.M., the surveyor observed Resident #72 alone in his/her room, crying out feelings of SI and no staff intervened or checked on him/her. observed in bed moving, weeping, saying I am going to kill myself, I am suicidal please help me please. No staff responded, resulting in his/her continued mental anguish. During an interview on 1/30/25 at 8:38 A.M., Resident #72 told the surveyor 'I'm having anxiety attacks, I put the call light on because mornings are difficult, I want to kill myself, I need help. During an interview on 1/30/25 at 8:41 A.M., Nurse #12 said Resident #72 says I don't feel good inside all the time and explained it's a behavior thing, eventually he/she stops saying he/she wants to kill him/herself. During an interview on 1/30/25 at 8:46 A.M., the Administrator was updated on the observations of Resident #72 since 1/28/25. The Administrator said Resident #72 should not be left alone after making threats to harm him/herself and a plan should have been established immediately to ensure his/her safety. The Administrator said that staff should be intervening to address Resident #72's cries for help. During an interview on 1/30/25, at 10:20 A.M., the Medical Director said that she was. not notified of Resident #72's verbalizations of SI on 1/28/25 and his/her request for an ambulance to be called. The Medical Director said that it is her expectation that she be notified whenever a resident verbalizes SI so that she can make a determination of a treatment plan. In this case, the Medical Director said that the facility notified her of a verbalization of SI on 1/29/25 but they had ceased. She then said that if she had been made aware that the verbalizations began on 1/28/25 and continued on 1/29/25 she would have ordered Resident #72 be sent to the hospital for evaluation and treatment. During an interview on 1/30/25 at 11:10 A.M. the Director of Nursing said that no plan had been put in place since she was notified of the Resident's SI yesterday. She said that she thought that the Resident was put on 1:1 supervision but couldn't be sure. The DON said that a plan should have been implemented immediately when the Resident exhibited mental anguish and made the acute statements of suicidal ideation. The DON then said that staff should never just walk away from a resident exhibiting SI. During an interview on 1/30/25, at 11:18 A.M. Social Worker (SW) #1 said she was Informed on 1/29/25 that Resident #72 had verbalized SI and that she never heard him/her say this before. SW #1 said #72 should have immediately been offered behavioral health services. During an interview on 1/30/25 at 12:04 P.M., CNA #6, said she is Resident #72's regular CNA and that she was his CNA last night, 1/29/25 11 P.M.-7 A.M. CNA #6 said that she did not get a report that Resident #72 was having suicidal ideation's and that therefore no plan had been put in place to ensure his/her safety. CNA #6 said that Resident #72 always says he/she doesn't feel good inside and was very anxious last night and this morning. CNA #6 said that Resident #72 was more anxious last night and again this morning and just kept saying he/she doesn't feel good inside and needs his mother. he was not on 1:1 and was left alone in his room during the night. CNA #6 said she was upset that she was not told and said that that is not good if he/she was saying he/she was going to kill him/herself. During an interview on 1/31/25 at 7:27 A.M. Psych Therapist #1 said there was a care plan that got erased on his/her last admission and clearly there was a mistake. He then said that Resident #72 is upset and says that all the time; that he/she is going to kill him/herself and that he/she is suicidal. Psych Therapist #1 then said that If you go back at 11 A.M. he/she will be much better. Resident #72 needs to be left alone not bothered, yes he/she can be left alone because he/she says he/she is going to kill him/herself all the time. Psych Therapist #1 then said that it was not possible to change Resident #72's medication to earlier in the morning because this is a nursing home you know. Review of Nurse Practitioner (NP) #1's note dated 2/1/25, indicated that Resident #72 said he/she wanted to shoot him/herself with a gun. Resident #72 was transferred to the hospital for a psych evaluation. Resident #72 returned to the facility without changes to his/her plan of care. Review of Psych Therapist #2's note dated 2/3/25, indicated to change morning medication administration timing to 6:00 A.M. Review of the physician orders dated February 2025 indicated that all morning medications, including antipsychotic and antianxiety medication administration times were changed from 8:00 A.M. to 6:00 A.M. On 2/4/25, at 7:05 A.M. the surveyor observed Resident #72 resting quietly in bed without observed psychosocial distress. During an interview on 2/4/25, at 9:00 A.M., Nurse #10 said that Resident #72 is usually highly agitated in the mornings until around 10:00 A.M. (4 hours since waking up) when we are able to give him/her their medications, and today he/she is calm, not verbalizing anxiety or SI. Nurse #10 then said that he believes that changing the Resident's medication time to 6 A.M. has helped Resident #72 a lot as the Resident is no longer exhibiting signs of mental anguish in the morning. 48671 2. Resident #17 was admitted to the facility in August 2020 with diagnoses including major depressive disorder, bipolar disorder, and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/25, indicated Resident #17 had a Brief Interview for Mental Status exam score of 14 out of a possible 15, indicating intact cognition. On 1/31/25 at approximately 10:41 A.M., to 11:07 A.M., the surveyor was standing at the nurses station and Psych Therapist #1 and Resident #17 could be heard speaking to each other from the nurse's station. Resident #17 was calmly inquiring about lunch and could be heard asking Where is my lasagna? Is the lasagna here yet? As the discussion continued Psych Therapist #1 appeared to be irritated and in a harsh tone said Stop yelling or I will take it away again!. On 1/31/25 at approximately 11:10 A.M., Resident #17 observed the surveyor standing at the nurses station, and continued to ask, where is my lasagna?. Psych Therapist #1 observed the surveyor and the exchange, and in a much different tone from moments earlier said It's on it's way honey and then he exited the unit. On 1/31/25 at 11:49 A.M., the surveyor informed the Administrator of the interaction between Resident #17 and Psych Therapist #1. The Administrator said the Psych Therapist #1 should not have spoken that way to the Resident and said it could make him/her upset. While speaking with the Administrator the Medical Director introduced herself and said Psych Therapist #1 should not have threatened to withhold Resident #17's food. During an interview on 1/31/25 at 12:07 P.M., with the Administrator and Medical Director and Psych Therapist #1, Psych Therapist #1 said Resident #17 is care planned for yelling and taking away his/her food is part of the care plan and said If he/she yells, then yes, I will take his/her food away so he/she will stop yelling The Psych Therapist #1 said Resident #17 has behaviors and said he/she needs to know his/her food will be removed if the behaviors continue. The Psych Therapist #1 said I can see why this could be upsetting and I probably should have said it differently. Review of Resident #17 care plan failed to include documentation to support these Phych Therapist alleged behaviors During a follow-up interview on 1/31/25 at 12:57 P.M., the Administrator said the interaction between Resident #17 and the Psych Therapist was a form of verbal abuse and must be reported to the State Agency as well. He indicated he implemented the facility's abuse policy and asked Psych Therapist #1 to leave the facility pending investigation.

Based on observations, interviews and record review, the facility failed to notify the physician of a significant change in status for one Resident (#72) out of a total sample of 26 residents. Specifically, the facility failed to notify the physician when Resident #72 verbalized Suicidal Ideation (SI) and acute psychological distress. Findings include: Review of the facility policy titled Change in a Resident's Condition of Status, dated as revised February 2021 indicated the following: -The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility policy titled Suicide Threats, undated, indicated the following: -Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. -The nurse supervisor/charge nurse shall immediately assess the situation and shall notify Director of Nursing Services of such threats. -After assessing the situation in detail the nurse supervisor/charge nurse shall notify the resident's attending physician and shall seek further direction from the physician. Resident #72 was admitted to the facility in October 2023 and has diagnoses that include Suicidal Ideation, Major Depressive Disorder, Psychotic Disorder with Delusions, Anxiety Disorder, Bipolar disorder and Schizophrenia Review of the most recent Minimum Data Set (MDS) assessment, dated 12/15/24, indicated that Resident #72 has an active diagnosis of suicidal ideations. The MDS further indicated that Resident #72 scored a 6 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment and had expressed feelings of sadness/depression more than half of the time in the past week. Review of the psychotherapy note dated 12/20/24 indicated the following: has a life long history do (sic) Schizophrenia and multiple suicide attempts and multiple psych hospitalization s. On 1/28/25, at 8:07 A.M., the surveyor observed Resident #72 crying in bed, yelling out to call an ambulance because he/she was having extreme suicidal thoughts. Resident #72 said he/she was afraid he/she was going to snap. Resident #72 was observed to be agitated and shaking, in acute psychological distress. The surveyor observed several staff members in the hallway and 2 nurses sitting at the nurse's station not responding to the distress calls from Resident #72. The surveyor informed Nurse #10 of Resident #72's verbalizations. Nurse #10 then went into the Resident's room and said this is Resident #72's normal behavior and brought Resident #72 to the dining room to eat. On 1/29/25 at 8:00 A.M., the surveyor observed Resident #72 standing in his/her room doorway crying out I don't feel good inside, I want to kill myself. Resident #72 was observed to be agitated and shaking, in acute psychological distress. There were several staff members in the hallway however no one responded to Resident #72. During an interview on 1/29/25 at 8:12 A.M. Nurse #11 said that he worked the 11 P.M.-7 A.M., shift last night and it had not been reported to him that Resident #72 had verbalized SI the previous day and had requested an ambulance be called. Nurse #11 said a physician should be notified if a resident verbalizes SI, and that a progress note should be in the clinical record indicating the physician's instructions. Review of the clinical record failed to indicate that the physician had been notified of Resident #72's verbalization of SI on 1/28/25. During an interview on 1/29/25 at 8:22 A.M., the Director of Nursing (DON) said that the physician should be notified immediately if a resident verbalizes SI, exhibits psychosocial distress and is requesting an ambulance be called. The DON said nursing should document in the clinical record that the physician has been notified and what the physician's instructions are regarding the plan to keep the resident safe. During an interview on 1/30/25, at 10:20 A.M., the Medical Director said that she was not notified of Resident #72's verbalizations of SI on 1/28/25 and his/her request for an ambulance to be called. The Medical Director said that it is her expectation that she be notified whenever a resident verbalizes SI so that she can make a determination of a treatment plan that will ensure the resident's safety. In this case, the Medical Director said that the facility notified her of a verbalization of SI on 1/29/25, but that if she had been made aware that the verbalizations began on 1/28/25 and continued on 1/29/25 she would have ordered Resident #72 be sent to the hospital for evaluation and treatment.

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring for non-functioning call bell systems and Infection Control program related to COVID-19 vaccinations. Findings Include: During the survey period, multiple residents were identified as having signed consent to receive the COVID-19 vaccine however the facility failed to order the vaccine from the pharmacy or provide any monitoring of the vaccination status of Residents. During the survey period, two out of three nursing units were identified as having non-functioning call bell systems in place. Review of the QAPI program for the year 2024, failed to indicate that a QAPI was established and implemented for the ongoing non-functioning of the call bell system on two out of three units. Review of the QAPI program for the year 2024, failed to indicate that a QAPI was established and implemented for Infection Control program related to COVID-19 vaccinations. During an interview on 1/31/25, at 12:55 P.M., the Administrator said that he became aware of the issue with the call light system when he was hired a year ago. The Administrator then said that he should have completed a QAPI regarding the non-functioning of the call bells. The Administrator said he should have implemented a QAPI to track the progress of the vaccination status and monitoring of the infection control program to ensure the program is being followed.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program to promote and monitor the appropriate use of antibiotics. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: -The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. -Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. -The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. -Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of the facility policy titled Antibiotic Stewardship, dated as revised December 2016, indicated antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. As part of the facility antibiotic stewardship program. All clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. The Infection Preventionist or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. Review of the facility's antibiotic stewardship program failed to indicate a monitoring system was in place and failed to indicate that antibiotics prescribed to the residents in the facility had an antibiotic time out to reassess the need for the antibiotic therapy. During an interview on 1/29/25 at 9:30 A.M., Unit Manager #1 said she is not aware of the antibiotic stewardship program and said the Director of Nurses manages infections with the Infection Preventionist. Unit Manager #1 said she does not keep line listings or track of antibiotics. During an interview on 1/30/25 at 1:48 P.M., the Infection Preventionist (IP) said the facility has not conducted any antibiotic stewardship meetings and said she has not received any pharmacy reports regarding the use of antibiotic therapy because they have a new pharmacy. The IP said staff tell her when a resident is prescribed an antibiotic, but they do not contact the provider or review the need for antibiotic therapy. The IP said each month she reports infection to the Director of Nurses and Administrator but not information related to antibiotic stewardship. During an interview on 1/31/25 at 9:33 A.M., the Director of Nurses said there have been no meetings regarding the antibiotic stewardship program since she started in the facility in November 2024 and said the facility is lacking management right now. The DON said she is not aware of the antibiotic usage or infection control rates in the facility but would expect the Infection Preventionist to report and follow the antibiotic stewardship program. During an interview on 1/31/25 at 12:38 P.M., the Administrator said an antibiotic stewardship program is needed to monitor the usage and need for therapy and said staff should be aware of what the program is and how to initiate the program when a resident starts an antibiotic. The Administrator said he expects the Infection Preventionist and Director of Nurses to be implementing the Antibiotic program and tracking the usage monthly with the pharmacy and reporting data monthly.

Based on interview and record review, the facility failed to ensure that one Resident (#45) out of a total sample of 26 residents was free from significant medication errors. Specifically, the facility failed to ensure nursing held midodrine (medication used to raise blood pressure) in accordance with the physician's orders. Findings include: Review of the facility policy titled Administering Medications, dated as revised April 2022, indicated that medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 12. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary. Resident #45 was admitted to the facility in January 2025 with diagnoses including hypertension, orthostatic hypotension, syncope and collapse. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/25, indicated that Resident #45 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. Review of Resident #45's physician's order, dated 1/12/25, indicated: -Midodrine HCl oral tablet 10 milligrams (mg) (Midodrine HCl), give one tablet by mouth with meals for blood pressure. Hold if systolic blood pressure (SBP) is greater than 120. Review of Resident #45's Medication Administration Record (MAR), dated January 16, 2025, through January 27, 2025, indicated nursing administered Resident #45's midodrine on the following dates and times despite the physician's order to hold for a systolic blood pressure greater than 120: - 1/16/25 at 5:00 P.M., blood pressure 112/63. - 1/20/25 at 5:00 P.M., blood pressure 130/70. - 1/22/25 at 5:00 P.M., blood pressure 124/72. - 1/23/25 at 8:00 A.M., blood pressure 127/75. - 1/23/25 at 12:00 P.M., blood pressure 127/75. - 1/25/25 at 5:00 P.M., blood pressure 126/72. - 1/26/25 at 12:00 P.M., blood pressure 123/68. - 1/27/25 at 8:00 A.M., blood pressure 131/72. - 1/27/25 at 12:00 P.M., blood pressure 127/74. - 1/27/25 at 5:00 P.M., blood pressure 124/70 During an interview on 1/29/25 at 11:05 A.M., Nurse #5 said that Resident #45 receives midodrine. Nurse #5 said that midodrine is used to help raise his/her blood pressure. Nurse #5 said Resident #45's order has parameters and that the nurses should check his/her blood pressure prior to administrating the midodrine. Nurse #5 said if the blood pressure is greater than 120 the medication should be held. During an interview on 1/29/25 at 3:07 P.M., the Director of Nursing (DON) said nursing should implement the physician's order and hold the midodrine for a systolic blood pressure greater than 120. The DON reviewed the MAR with the surveyor and said the medication should have been held for a systolic blood pressure greater than 120 but the medication was not held.

Based on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMR) conducted by the consultant pharmacist were addressed by the facility in a timely manner for five Residents (#51, #52, #72, #7, and #86) out of a total sample of 26 Residents. Findings include: Review of the facility policy titled Pharmacy Consultant, dated as revised 2022, indicted that the facility works with the consultant pharmacist to establish a system whereby the consultant pharmacist observations and recommendations regarding resident's medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion. Further review indicated that all recommendations received from the pharmacy consultant should be addressed prior to the next medication regimen review. 1. Resident #51 was admitted to the facility in July 2021 with diagnoses including dementia, schizophrenia and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/14/24, indicated that Resident #51 was unable to complete the Brief interview for Mental Status exam and was assessed by staff to have moderately impaired cognition. Review of the pharmacy recommendation dated 11/20/24, indicated the following: -Please order daily blood sugars/Lantus (insulin) -Amantadine can make tremors worse . can get prior authorization for Vmat2 (from insurance). Review of the pharmacy recommendation dated 12/20/24, indicated the following: -Please order daily blood sugars/Lantus (insulin) -Amantadine can make tremors worse . can get prior authorization for Vmat2 (from insurance). Review of the medical record failed to indicate that the physician reviewed the 11/20/24 or 12/20/24 pharmacy recommendations. Review of the physician orders dated January 2025 failed to indicate an order for daily blood sugars or changes to the Amantadine order. 2. Resident #52 was admitted to the facility in April 2022 with diagnoses including Alzheimer's dementia, cancer and kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated that Resident #52 scored a 3 out of 15 on the Brief interview for Mental Status exam, indicating severe cognitive impairment. Review of the pharmacy recommendation dated 12/20/24 indicated the following: -Consider disc (discontinuing) multivitamin, Omeprazole, Pravastatin and aspirin/hospice. Review of the physician orders dated January 2025 indicated the following orders: -Aspirin EC low dose oral tablet delayed release 81 MG (milligrams) give 1 tablet by mouth one time a day. -Multivitamin-minerals tablet give 1 tablet by mouth one time a day. -Omeprazole Magnesium delayed release 20 MG give 20 mg by mouth one time a day. Review of the medical record failed to indicate that the physician reviewed the 12/20/24 pharmacy recommendations. 3. Resident #72 was admitted to the facility in October 2023 and had diagnoses that include Suicidal Ideation, Major Depressive Disorder, Psychotic Disorder with Delusions, Anxiety Disorder, Bipolar disorder and Schizophrenia. Review of the most recent Minimum Data Set assessment, dated 12/15/24, indicated that Resident #72 scored a 6 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the pharmacy recommendation dated 12/20/24 indicated the following: -Consider initiate a VMAT 2 inhibitor. Review of the January 2025 physician's orders for Resident #72 failed to indicate an order for a VMAT 2 inhibitor. Review of the medical record failed to indicate that the physician reviewed the 12/20/24 pharmacy recommendations. During an interview on 1/29/25 at 11:32 A.M., the Director of Nursing (DON) said that the month of November 2024 pharmacy recommendations were delayed. The DON then said that she could not remember why. 41105 4. Resident #7 was admitted to the facility in March 2014 and has diagnoses that include Hypothyroidism (is a condition where the thyroid gland does not produce enough hormones), Type II Diabetes (a condition results from insufficient production of insulin, causing high blood sugar) and obesity. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/31/24, indicated that on the Brief Interview for Mental Status exam Resident # 7 scored a 10 out of a possible 15, indicating moderately impaired cognition. Review of the January 2025 Physician orders for Resident # 7 included the following orders: 1. Lansoprazole 30 milligrams (mg) once a day at 6:00 A.M., Give 30 mg by mouth one time a day for Acid reflux Before breakfast. Dissolve on tongue before swallowing particles; do not chew, cut, break, or swallow whole. Start date 7/4/24 2. Levothyroxine tablet 50 mcg (micrograms) once a day at 6:00 A.M., Give 50 mcg by mouth one time a day for hypothyroidism. Start date 10/2/23. Review of the January 2025 Medication Administration Record (MAR) indicates that Resident # 7 was administered Lansoprazole and Levothyroxine daily at 6:00 A.M. Review of the monthly Pharmacist recommendations indicate the following: -11/22/24: Nurse rec: please separate the dose of Lansoprazole and Levothyroxine, currently both at 0600 -12/23/24: Nurse rec: please separate the dose of Lansoprazole and Levothyroxine, currently both at 0600 -1/27/25: Nurse rec: please separate the dose of Lansoprazole and Levothyroxine, currently both at 0600 Review of the clinical record failed to indicate the Physician or Nurse Practitioner were notified of the pharmacists recommendations. During an interview on 1/29/25 at 11:04 A.M., with the Unit Manager (#1) she said that she had not yet received the 1/27/25 pharmacy recommendations from the Director of Nursing (DON). Unit Manager #1 said that the expected process after the pharmacy conducts their monthly visit is that they provide their recommendations to the Director of Nursing (DON) who distributes them to each unit to get the recommendation reviewed by the Physician/Nurse Practitioner (MD/NP). She said that the MD/NP sign the recommendation and indicate if they agree or disagree with it. Unit Manager #1 searched Resident #7's record but was unable to locate the 12/23/24 and 11/22/24 recommendations. During an interview on 1/29/25 at 1:09 P.M., with the Director of Nursing she said that she is unable to find any of the recommendations for November 2024 and December 2024 and there is no indication that the recommendations were addressed. 44095 5. Resident #86 was admitted to the facility in August 2024 with diagnoses including morbid obesity, alcohol abuse, and infection of the joint prosthesis. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/20/24, indicated that Resident #86 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of a possible 15. Review of Resident #86's pharmacy noted, dated 11/20/24 and again on 1/27/25, indicated: - Nursing Recommendation: currently on Omeprazole at 8:00 A.M., and 5:00 P.M., changing administration times, should be given on empty stomach. - Physician Recommendation: evaluate concomitant use qvar and mometasone duplication of therapy. Review of Resident #86's medical record failed to indicate the Physician or Nurse Practitioner were notified of the pharmacist's recommendations as evidenced by the following orders: Review of Resident #86's physician's order, dated 8/20/24, indicated: - Omeprazole Oral Capsule Delayed Release 40 milligrams (Omeprazole), give 1 capsule by mouth two times a day for heartburn. Scheduled twice daily at 8:00 A.M. and 5:00 P.M. Review of Resident #86's physician's order, dated 9/20/24, indicated: - Mometasone Furoate Inhalation Aerosol Powder Breath Activated 220 micrograms, 1 puff inhale orally one time a day for asthma. Rinse mouth after use. Review of Resident #86's physician's order, dated 10/21/24, indicated: - Qvar RediHaler Inhalation Aerosol Breath Activated 80 micrograms, 1 puff inhale orally one time a day for asthma, rinse mouth after use with water. During an interview on 1/29/25 at 12:24 P.M., the Director of Nursing (DON) said she did not have access to pharmacy records for November 2024 and December 2024 and she said that pharmacy recommendations should be addressed monthly but were not. Further the DON said she had received the records for November 2024 and December 2024 a week or so ago and she sorted out the recommendations for the units and she said she had no idea where they went.

Based on employee training records reviewed and interview the facility failed to implement, and maintain an effective training program for staff, which includes, at a minimum, training on behavioral health care and services (consistent with S483.40) that is appropriate and effective, as determined by staff need and the facility assessment for 24 out of 24 direct care staff training records reviewed. Findings include: Review of the document titled Facility Assessment, dated 8/1/2024, indicated that on a daily average 40 plus residents with behavioral symptoms reside in the facility. Further review indicated that the facility provides behavioral health services for residents with mental health and behavioral health needs that require intervention. Further review indicated that all personnel are required to be trained in behavioral health including but not limited a review of the behavioral health program's written policies, review of competencies and skills necessary to provide person-centered care and services that promote mental and psychosocial well-being. Review of licensed staff training records, working in the facility on 1/28/25, 1/29/25 and 1/30/25, failed to indicate behavioral/mental health training was completed in 24 out of 24 employee training records reviewed. During an interview on 1/31/25 at 8:32 A.M., the Director of Nursing (DON) said that the facility had been without a Staff Development Coordinator (SDC) since September 2024. The DON said that it was the SDC that provided the staff with training on behavioral health. The DON said that without a SDC the training did not get completed. During an interview on 1/31/25 at 12:41 P.M., the Administrator said that all of the training records for the licensed staff working on 1/28/25, 1/29/25 and 1/30/25, were provided to the surveyors. The Administrator then said if the behavioral training is not in the employee training records provided to the surveyors then the training did not occur.

Based on observation and interviews, the facility failed to ensure it provided a means for residents to communicate to staff on two out of three nursing units. Findings included: On 1/30/25 at approximately 11:27 A.M., the surveyor observed that the call bell system was not functioning on the Solana Unit. The surveyor sampled the call bell system from several bedrooms and noted that the call bell did not sound, either in the hallway of the nursing station, and the call bell board at the nursing station continued to beep and displayed a list of room numbers but did not identify which bedroom requested help. The surveyor observed that in some of the sampled bedrooms the call light button illuminated the light outside the bedroom doorway. The surveyor observed that the call lights in the hallway located on each wing of the Solana unit, and the end of the hallway, were not visible from the nursing station. During an interview on 1/30/25 at 11:34 P.M., Nurse #1 said the call lights have been an ongoing issue on the Solana and [NAME] Units because the panel behind the nurse's station will continuously beep and show an error message. Nurse #1 said the panel is not reliable because the lights, bells and panel are not always accurate. Nurse #1 said she has notified management and said staff use an online reporting system called TELS (system used to track environmental issues), to report environmental issues like broken call bells to the maintenance department. On 1/30/25 at approximately 2:50 P.M., the surveyor along with the Director of Housekeeping tested the call bell system function in each of the following rooms by pressing the call bell button, observing the call light outside of the room, and checking the call bell panel at the nurse's station: room [ROOM NUMBER]-A Call bell system not working. No hand bell in the room. room [ROOM NUMBER]-A Call bell system not working. No hand bell in the room. room [ROOM NUMBER]-A Call bell system not working. No hand bell in the room. room [ROOM NUMBER]-B Call bell system not working. No hand bell in the room. The call bell cord was located behind the Residents bed and beyond the reach of the Resident. room [ROOM NUMBER]-A Call bell system not working. No hand bell in the room. room [ROOM NUMBER]-B Call bell system not working. No hand bell in the room. room [ROOM NUMBER]-A Call bell system not working. No hand bell in the room. room [ROOM NUMBER]-B Call bell system not working. No hand bell in the room. room [ROOM NUMBER]-C Call bell system not working. No hand bell in the room Review of the call bell panel located behind the nurse's station displayed the following data: 203W: TROUBLE 205W: TROUBLE 213W: TROUBLE 215W: TROUBLE The call bell panel was beeping throughout the observations. The surveyor and the Director of Housekeeping observed rooms 202, and 208 had call lights on in the hallways that did not display on the call bell panel. During an interview on 1/30/25 at 3:10 P.M., the Director of Housekeeping said when he presses the call bell the light outside of the Residents room should flash and the alarm should sound at the nurse's station indicating a call light is on. The Director of Housekeeping said the call bells are not working and not indicating that a resident needs help. On 1/31/25 at approximately 7:34 A.M., the surveyor observed that the call bell system was not functioning on the [NAME] Unit. The surveyor sampled the call bell system from several bedrooms and noted that the call bell did not sound, either in the hallway of the nursing station, and the call bell board at the nursing station did not illuminate to identify which bedroom requested help. The surveyor observed that in some of the sampled bedrooms the call light button illuminated the light outside the bedroom doorway. The surveyor observed that the call lights in the hallway located on each wing of the [NAME] unit, and the end of the hallway, were not visible from the nursing station. During an interview on 1/31/25 at 8:50 A.M., Certified Nursing Assistant (CNA) #8 said if residents need help the light might not go on outside the door or beep at the nurses station. CNA #8 said staff would notify maintenance if there are issues and said she would tell them verbally. On 1/31/25 at approximately 9:25 A.M., the surveyor along with the Director of Housekeeping tested the call bell system function in each of the following rooms by pressing the call bell button, observing the call light outside of the room, and checking the call bell panel at the nurses station: -room [ROOM NUMBER]E Call bell system not working. No hand bell in the room. The Director of Maintenance removed the call bell box from the wall and showed the surveyor wires that were not attached inside the wall. The Director of Maintenance said the cords need to be swapped out and said the call bell panel will say trouble when call bells do not work. Review of the call bell panel located behind the nurse's station displayed the following data: room [ROOM NUMBER]W TROUBLE room [ROOM NUMBER]W TROUBLE room [ROOM NUMBER]W TROUBLE room [ROOM NUMBER]E TROUBLE room [ROOM NUMBER]E TROUBLE The call bell panel was beeping throughout the observations. The surveyor observed call lights on in the hallways that did not display on the call bell panel. During an interview on 1/31/25 at 9:31 P.M., the Director of Maintenance said the facility had issues with the call bell system and said the facility has been replacing the broken units one by one and said he notified corporate that they need more supplies to change out the system. The Director of Maintenance said staff must enter maintenance issues in the online TELS system to be fixed and said the system does not indicate when a call light is pressed or if a light is on and not sounding at the display panel. Review of the open TELS Work Orders report dated 1/31/25, failed to indicate any notification of call bells not working. During an interview on 1/31/25 at 9:55 A.M., the Director of Nurses (DON) said if a call bell is not working, she would expect the staff to notify maintenance right away and give the resident a new room with a functioning call bell or a hand bell to ring for help. The DON said she was not aware of any call bell issues in the facility. During an interview on 1/23/25 at 12:51 P.M., the Administrator said he was aware of the technical issues with the call bell system when he started working in the facility and said the purchasing department sends units to the facility in regular intervals to replace broken call bells. The Administrator said he was not aware of how many units were not working in the facility and said Residents must have a way to call for help. The Administrator said the facility should have put a system in place to track the broken call bells and address the concerns during their QAPI (Quality Assurance Performance Improvement) program.

Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, 1. The facility failed to ensure that nursing performed hand hygiene and changed a wound dressing in accordance of professional standards to prevent infection. 2. The facility failed to sanitize shared resident equipment between resident uses. Findings include: 1. Review of the facility policy titled Handwashing/ Hand Hygiene, dated as revised October 2023, indicated this facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol - based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. 4. Personnel are educated regarding ways to prevent contact dermatitis and other skin irritation, and provided with supplies that support healthy hand skin. a. Facility-supplied lotions are compatible with antiseptics and gloves. b. ABHRs, soaps and lotions are free of allergenic surfactants, preservatives, fragrances and [NAME]. c. Triclosan-containing soaps are not recommended for use or supplied by the facility. Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. 5. The use of gloves does not replace hand washing/hand hygiene. Review of the facility policy titled Dressing, Dry/Clean, dated as revised September 2013, indicated the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the Procedure 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. 3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. 4. Position resident and adjust clothing to provide access to affected area. 5. Wash and dry your hands thoroughly. 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time and initials. Place on clean field. 11. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 12. Wash and dry your hands thoroughly. 13. Put on clean gloves. 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressing and secure with tape or bordered dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to top of dressing. 18. Discard disposable items into the designated container. 19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 20. Reposition the bed covers. Make the resident comfortable. 21. Place the call light within easy reach of the resident. 22. Clean the bedside stand. 23. Wash and dry your hands thoroughly. 24. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. On 1/29/25 at 11:20 A.M., the surveyor observed Nurse #3 perform Resident #86's wound care. The following observations were made: At 11:21 A.M., Nurse #3 applied gloves and entered the room (touching the door knob with the gloves, potentially contaminating the gloves), Nurse #3 placed wound care supplies directly onto an unclean bedside table. At 11:22 A.M., Nurse #3, wearing the same gloves, removed the dressing from the front of Resident #86's left thigh. Nurse #3 removed his gloves, he did not perform hand hygiene and he applied new gloves. At 11:23 A.M., Nurse #3 cleaned the right thigh wound with wound cleanser. Nurse #3 removed his gloves; he did not perform hand hygiene, and he applied new gloves. At 11:24 A.M., Nurse #3 used scissors that were not cleaned prior to use and he cut directly through a xeroform (sterile dressing) package, potentially contaminating the dressing supply. At 11:25 A.M., Nurse #3 applied the xeroform directly to the wound bed with his gloved hands and he covered the wound with a dressing. Nurse #3 removed his gloves; he did not perform hand hygiene. At 11:27 A.M., Nurse #3 applied new gloves and removed the dressing from Resident #86's posterior right thigh wound. There was a large amount of drainage to this wound. At 11:28 A.M., Nurse #3 removed his gloves, he did not perform hand hygiene, and he applied new gloves. At 11:29 A.M., Nurse #3 cleansed the wound, patted the wound dry, and he removed the gloves without performing hand hygiene. At 11:30 A.M., Nurse #3 applied new gloves, he touched xeroform directly with his hands and applied the xeroform directly to the posterior right thigh wound and covered the wound with a dressing. At 11:31 A.M., Nurse #3 removed his gloves, he did not perform hand hygiene, and he applied new gloves. At 11:34 A.M., Nurse #3 rolled Resident #86 over and applied barrier cream to his/her buttocks. Nurse #3 removed his gloves and he did not perform hand hygiene, and he gathered the supplies from the bedside table and placed them directly into the trash. During an interview on 1/29/25 at 4:04 P.M., Nurse #3 said he should have performed hand hygiene after glove removal, but he did not. During an interview on 1/29/25 at 3:13 P.M., the Director of Nursing said nursing should perform hand hygiene between changing gloves and complete dressing changes according to facility policy. 48671 2. Review of the CDC (Centers for Disease Control and Prevention) Recommendations for Disinfection and Sterilization in Healthcare Facilities indicated the following: 4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices 4.a. Process noncritical patient-care devices using a disinfectant and the concentration of germicide listed in Table 1. 4.b. Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. 4.c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). Review of the Micro-Kill Two manufacturer's instructions indicated: Contact time: Allow surface to remain visibly wet two minutes, let air dry. a. On 1/29/25 at 7:46 A.M., the surveyor made the following observations: Nurse #3 exited a resident room carrying a glucometer with his bare hand and placed the glucometer directly on top of the medication cart, potentially contaminating the top of the medication cart. Nurse #3 then cleaned the top of the glucometer with a Micro-kill two (germicidal wipe) and placed the glucometer directly back on top of the medication cart. The nurse did not allow the glucometer to air dry. Nurse #3 closed the lid to the germicidal wipe, picked up the glucometer with his bare hand, and placed the glucometer into the medication cart, potentially contaminating the contents of the drawer. During an interview on 1/29/25 at 7:48 A.M. Nurse #3 said he thinks the glucometer needs to be cleaned with germicidal wipes and left to dry for one minute. b. On 1/30/25 at 7:26 A.M., the surveyor made the following observations: Nurse #13 exited a resident room carrying a glucometer with his gloved hand and placed the glucometer directly on top of the medication cart, potentially contaminating the top of the medication cart. Nurse #13 then cleaned the glucometer with a Micro-kill two (germicidal wipe) and with his gloved hand, placed the glucometer into the medication cart, potentially contaminating the contents of the drawer. The nurse did not allow the glucometer to air dry. During an interview on 1/30/25 at 7:29 A.M., Unit Manager #1 said the glucometer needs to be cleaned before and after use for 10 seconds and said the directions on the container should be followed. During an interview on 1/30/25 at 11:49 A.M., Director of Nursing said the glucometer must be cleaned with alcohol for ten seconds before and after use and said if staff use a germicidal wipe, she expects staff to read the instructions first.

Based on observation, record review and interview the facility failed to ensure the facility developed and implemented plans of care for 6 Residents (#12, #34, #86, #70, #8 and #55) out of a total sample of 27 residents. Findings include: Review of facility policy titled 'Person- Centered Care plan', revised 10/24/22, indicated the following: *Policy: A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment (admission, annual, or significant change in status) and review and revise the care plan after each assessment. *Purpose: To attain or maintain the patient's highest practicable physical, mental and psychosocial well-being; to eliminate or mitigate triggers that may cause re-traumatization of the patient; to promote positive communication between patient, patient representative, and team to obtain the patient's and resident representative's input into the plan of care, ensure effective communication . -Care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals; 1a. For Resident #12, the facility failed to implement the Resident's care plan to keep him/her separated from another Resident (Resident #34) while in the dining room, resulting in a resident to resident altercation which resulted in a fractured fibula. Resident #12 was readmitted to the facility in March 2019 with diagnoses including dementia and unspecified mood disorder. Review of Resident #12's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status. The MDS further indicated the Resident had behavioral symptoms directed towards others 1 to 3 days out of the previous 7 days, verbal behavioral symptoms 4 to 6 days out of the previous 7 days, other behaviors 1 to 3 days out of the previous 7 days, did not reject care, requires extensive assistance with a one person physical assist for transfers and dressing, supervision with one person physical assistance for locomotion off the unit. Review of Resident #12's medical record indicated the following: -A SBAR (Situation, Background, Assessment and Recommendation) note for Resident #12 dated 5/1/22 which indicated Resident #12 swore, pushed his/her wheelchair into another resident and fell . -A resident to resident report for Resident #12 dated 5/1/22 which indicated that staff heard a loud noise in the hallway and quickly went and found two residents (#12 and #34) lying on the floor beside each other. The other Resident stated he/she needed to use the toilet and Resident #12 was sitting in the doorway. Resident #34 asked Resident #12 to move, then he/she swore at Resident #34 and backed up his/her wheelchair on the Resident and he/she fell . The report indicated the immediate actions taken were helping the two residents off the floor, removed them immediately from each other, incident reported to police. Continue to keep residents separated. -An undated altercation investigation summary signed by the Director of Nursing which indicated the following: Incident: On 5/1/22, staff responded to yelling and found Resident #34 tagging back and forth with Resident #12. Resident #34 stated he/she was walking in hallway when Resident #12 backed into him/her with his/her wheelchair. Resident #12 was unable to state exactly what happened. Staff separated residents. No apparent injuries to residents. Physician, responsible parties and police notified. Investigation: Staff and residents were interviewed. Staff stated that hey responded to the yelling and found residents tagging back and forth. Staff did not witness the beginning of the altercation and therefore did not know what triggered the incident. Resident #34 stated that Resident #12 backed into him/her with his/her wheelchair as Resident #34 was walking triggering the incident. Resident #12 denied backing into Resident #34 and was unable to state what happened. Conclusion: The residents got into an altercation due to some sort of misunderstanding. The minutes prior to the incident were unwitnessed. We are unable to verify Resident #34's account of events. Plan: Staff to keep residents separated. Social services to follow up with residents as needed. -An accident incident action team document dated as reviewed 5/2/22 which indicated a new intervention to keep Resident #12 and Resident #34 separated. -A care plan for Resident #12 revised 5/1/22 for risk for alteration in overall behavioral/psychosocial well-being with a new intervention added 5/1/22 to keep Resident #12 separated from Resident #34 in the dining room. Further review of Resident #12's medical record indicated the following: -A late entry note dated 8/8/22 at 9:02 P.M. effective for 8/8/22 at 8:30 A.M. which indicated Resident #12 was pulled out of his/her wheelchair and thrown to the ground. The Resident's Health Care Proxy (HCP) and Nurse Practitioner notified. notified. Seen by psych doctor, social services. Resident diagnosed with left distal fibula fracture. Seen by Nurse Practitioner. -A Nurse Practitioner (NP) encounter note dated 8/8/22: NP follow up resident to resident encounter, fracture. Resident was involved in the resident to resident encounter, he/she sustained a fall and was complaining of left ankle pain; X-ray shows acute oblique distal fibula (the outer bone between the knee and ankle joint) fracture (a fracture that occurs when the bone is broken at an angle); resident sent to ER (emergency room ) by this provider. -A radiology report dated 8/8/22 which indicated a left acute oblique distal fibula fracture. -A hospital after visit summary dated 8/8/22 which indicated the reason for the visit was a leg injury and the diagnosis was a broken leg. Review of facility provided investigations for Resident #12 indicated the following: -A Resident to Resident report dated 8/8/22 which indicated that staff heard a loud noise in the dining room and quickly ran and found Resident #12 and Resident #34 lying on the floor beside each other. Resident #12 said he/she was in his/her wheelchair by the dining room door. Resident #34 asked him/her to move and Resident #12 was about to do so then Resident #34 swore at Resident #12 and called him/her 'stupid idiot'. Resident #12 swore at Resident #34 and Resident #34 then hit Resident #12 in the face. Resident #12 threw a bottle of soda at Resident #34 and then Resident #34 pulled Resident #12 out of his/her wheelchair and threw him/her on the ground. -An unsigned summary document dated 8/8/22 which indicated the following: At approximately 8:30 A.M. on 8/8/22 staff on the mental health and recovery unit heard shouting from the dining room. Upon arrival to the dining room staff observed Resident #12 and Resident #34 on the floor entangled in one another. Upon initial interview, Resident #12 stated that Resident #34 told him/her to move, he/she began to try to move his/her chair to the side of the hallway when Resident #34 attempted to punch him/her in the face. Resident #12 explained that he/she splashed a cup of soda at Resident #34 and Resident #34 dragged him/her onto the ground. Upon initial interview, Resident #34 stated that he/she told Resident #12 to move, Resident #12 did not move and Resident #12 tried to punch Resident #34. The residents were immediately separated and assessed for injury. Resident #12 complained of left hip, left leg and left ankle pain. As needed Tylenol (a pain reliever) was administered and a stat x-ray was called in. Resident #34 had no injuries. Upon initial interview of the staff, no staff witnessed the altercation initiate .a Certified Nursing Assistant (CNA) observed Resident #34 pull Resident #12 out of his/her wheelchair onto the floor and responded to the incident and called for help. Upon arrival at the dining room, the resident was on the floor and staff separated them. Upon investigation of the incident the security footage was reviewed. Resident #34 is seen exiting the dining room past Resident #12 with no incident. The initiation of the altercation was not in clear view but Resident #34 is seen attempting to punch Resident #12, Resident #12 is seen putting his/her hands over his/her head. Resident #34 is seen wrapping his/her arms around Resident #12, pulling the Resident out of his/her wheelchair and both residents are seen on the ground. Resident #34 is seen attempting to kick Resident #12 as they are entangled on the ground. Staff come running into the room and separate the two residents. In conclusion, the center believes that Resident #34 initiated the resident to resident altercation. The center believes that the residents did have a verbal exchange where Resident #34 asked Resident #12 to move. The center believes that both residents swore at one another during the verbal exchange and Resident #34 initiated the physical altercation with Resident #12 .Resident #12 was sent to the ER for complaints of pain, x-rays were done and revealed a fracture of the left fibula. -A signed CNA statement dated 8/8/22 indicating the CNA was in the hallway and heard someone calling for help and the CNA ran to the dining room and saw the residents on the floor. -Two signed CNA statements dated 8/8/22 stating they heard one staff call for help, they ran and saw two residents on the floor. -A signed CNA statement dated 8/8/22 which indicated the CNA was in a resident's room and turned her head and saw Resident #34 grab Resident #12 and pull him/her on the floor and the CNA called for help. Further review of Resident #12 medical record failed to indicate staff had kept the Resident separated from Resident #34 in accordance with his/her care plan after a previous resident to resident altercation, resulting in an unwitnessed resident to resident altercation and a leg fracture for Resident #12. During an interview on 1/19/23 at 10:34 A.M., Unit Manager #1 said she is familiar with both residents. Unit Manager #1 said Resident #34 has a short fuse and doesn't always remember to get staff when he/she is frustrated. Unit Manager #1 said she was working the day of the resident to resident altercation in August and that it happened in the morning. Unit Manager #1 said she was sitting at the nurses station and she was alerted by another staff member saying there was an altercation between Resident #34 and Resident #12. Unit Manager #1 said the Residents had altercations prior to this. Unit Manager said there are many residents with behaviors on the unit and when in the dining room residents should be supervised and further said the Residents were not supervised when this occurred. Unit Manager #1 was unable to say why no staff were present to keep the Residents separated prior to the altercation, but said maybe staff was pulled from the dining room. Unit Manager #1 said the expectation is that care plan interventions will be adjusted and followed as written. Unit Manager #1 said in her opinion Resident #34 should be supervised when interacting with other residents because he/she is aggressive and can snap quickly without warning. During an interview on 1/19/23 at 4:05 P.M., Licensed Therapist #1 said staff was aware of Resident #34's behaviors and some interventions included staff staying in the dining room to be a buffer between Resident #34 and other residents and said that about 90% of time there is supervision plus cameras. Licensed Therapist #1 said supervision in the dining room is best for safety. During an interview on 1/19/23 at 4:54 P.M. with the Director of Nursing, Administrator and Corporate Consultant #2, the Director of Nursing said Resident #34 has had a few resident to resident incidents and has a lot of triggers. The Director of Nursing said Resident #34 is triggered by other residents and by people getting in his/her way and that the Resident ambulates independently with a cane. The Director of Nursing acknowledged that interventions were listed Resident #12's care plans to keep him/her separated from Resident #34 but said that the interventions were not meant to be permanent even though they were still listed as current interventions. The Director of Nursing said the care plan interventions were in place to keep the Residents separated and it wasn't done. 1b. For Resident #34, the facility failed to keep him/her separate from another Resident (#12) while in the dining room, resulting in a resident to resident altercation. Resident #34 was admitted to the facility in April 2021 with diagnoses including unspecified dementia with agitation and alcohol dependence. Review of Resident #34's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status Exam (BIMS). Further review of the MDS indicated the Resident had delusions, physical and verbal behaviors directed at others 1 to 3 days out of the previous 7 days, was independent with bed mobility, transfers, walking in his/her room and in the corridor and locomotion on and off the unit. Review of Resident #34's medical record indicated the following: -A SBAR note for Resident #34 dated 5/1/22 which indicated that residents were fighting on the floor due to stated issue, they were removed from each other and appropriate action taken. -A care plan for Resident #34 initiated 4/8/21 for potential to demonstrate verbal/physical behaviors related to cognitive loss/ dementia. He/she has gotten physical with other residents, history of punching another resident in the face, recently responded to resident attack with physical response with a new intervention added 5/1/22 to keep Resident #34 separated from Resident #12. Further review of Resident #34's medical record indicated the following: -A SBAR note dated 8/8/22 which indicated that staff heard loud noise from the dining room and quickly ran in to the dining room and found this Resident with another Resident laying on the floor kicking each other. When reviewing the camera they noticed this Resident was the aggressor. -A therapy note for service date 8/8/22 (the date of the altercation) which indicated the Resident started a fist fight with another resident who was in a wheelchair/ Resident #34 pulled the other Resident (Resident #12) out of his/her wheelchair, threw him/her on the ground, got on top of him/her and started punching him/her in the head and kicking him/her. Resident #34 denied having done all of these activities but everything was on video. Further review of the Resident's medical record failed to indicate staff had kept the Resident separated from Resident #12 in accordance with his/her care plan after a previous resident to resident altercation, resulting in an unwitnessed resident to resident altercation and a leg fracture for Resident #12. During an interview on 1/19/23 at 4:05 P.M., Licensed Therapist #1 said he has worked with Resident #34 since admission to the facility. Licensed Therapist #1 said Resident #34 will try to find someone he/she perceives as weaker than him/her and start a fight and that when asked about the Resident to Resident altercation in August Resident #34 said Resident #12 tried to fight him/her and that the surveillance video did not match with what Resident #34 had said happened. Licensed Therapist #1 said staff was aware of Resident #34's behaviors and some interventions included staff staying in the dining room to be a buffer between Resident #34 and other residents and said that about 90% of time there is supervision plus cameras. Licensed Therapist #1 said supervision in the dining room is best for safety. During an interview on 1/19/23 at 4:54 P.M. with the Director of Nursing, Administrator and Corporate Consultant #2, the Director of Nursing said Resident #34 has had a few resident to resident incidents and has a lot of triggers. The Director of Nursing said Resident #34 is triggered by other residents and by people getting in his/her way and that the Resident ambulates independently with a cane. The Director of Nursing acknowledged that interventions were listed in Resident #34 and Resident #12's care plans to keep them separated but said that the interventions were not meant to be permanent even though they were still listed as current interventions. The Director of Nursing said care plan interventions were in place to keep the Residents separated and it wasn't done. 41105 2. For Resident #86 the facility failed to ensure sleeves ordered by the physician were worn by the Resident to prevent further injury. Review of the facility policy titled Skin Integrity and Wound Management, dated as revised 9/1/22, indicated the following: * POLICY: A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. *6.7: Notify interdisciplinary team members for a comprehensive approach to care including prevention and wound treatments, as indicated. Resident #86 was admitted to the facility in August 2022, with diagnoses that include Alzheimer's disease and gout. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/16/22, indicated Resident #86 was assessed by staff to have had moderately impaired cognition. The MDS further indicated Resident #86 required extensive assistance from one to two staff with all aspects of his/her care, including dressing and hygiene care. During an observation on 1/17/23 at 8:29 A.M., Resident #86 was observed in bed. His/her skin was observed to be fragile with several scabs, and red marks on both arms. During a record review the following was indicated: *A physician's order, dated 12/22/22, Apply beige arm sleeves to bilateral arms. Remove for ADL care each shift. *An Activities of Daily Living (ADLs) care plan, dated as updated 10/14/22, with an intervention Assist too dependent with bathing, dressing and grooming. *A behavior care plan, updated 11/27/22, did not indicate Resident #86 refused to wear the bilateral arm sleeves. *The treatment Administration Record (TAR) indicated Resident #86 wore the arm sleeves every shift and failed to indicate he/she refused the application. During an observation on 1/18/23 at 7:08 A.M., Resident #86 was observed in bed and was not wearing bilateral arm sleeves, nor were they observed in the area. The TAR for this date indicated nursing staff had documented the sleeves were applied. During an observation on 1/18/23 at 8:19 A.M., Resident #86 was observed in bed and was not wearing bilateral arm sleeves, nor were they observed in the area. The TAR for this date indicated nursing staff had documented that the sleeves were applied. During an observation on 1/18/23 at 10:14 A.M., Resident #86 was observed in bed and was not wearing bilateral arm sleeves, nor were they observed in the area. Review of the TAR indicated nursing staff had documented the sleeves were applied. During an observation on 01/18/23 at 12:09 P.M., Resident #86 was observed in bed, dressed for the day, and was not wearing bilateral arm sleeves, nor were they observed in the area. Review of the TAR indicated nursing staff had documented that the sleeves were applied. During an interview with a Certified Nursing Assistant (CNA) #5 on 1/19/23 at 9:36 A.M., she said that Resident #86 required total care and wore bilateral sleeves because his/her skin was fragile. CNA #5 said Resident #86 did not refuse to wear the sleeves. During an interview with the Clinical Reimbursement Coordinator (CRC) Nurse and Director of Nursing (DON) on 1/19/23 at 9:48 A.M., the surveyor shared the daily observations of Resident #86 not wearing the bilateral arm sleeves. The DON said Resident #86 often refuses the sleeves and that it should be documented in the care plan and TAR. 3. For Resident #70 the facility failed to provide hand and nail hygiene during morning care, failed to ensure bilateral arm sleeves were worn as ordered and failed to ensure a padded tray table was provided. Resident #70 was admitted to the facility in March 2020 and had diagnoses that included dementia without behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/22, indicated Resident #70 was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #70 did not have behavior of rejecting care and required extensive two-person physical assistance with all Activities of Daily Living (ADLs), including dressing and personal hygiene care. During an observation on 1/17/23 at 8:17 A.M., Resident #70 was observed in his/her room, receiving morning care from 2 Certified Nursing Assistants (CNAs). The surveyor continued to make the following observations: * At 8:27 A.M., the 2 CNAs exited Resident #70's room, and Resident #70 was dressed for the day. Resident #70's fingernails were visibly soiled with thick dark brown substance under the fingernails and brown and yellow substance covering his/her cuticles. He/she had been placed in a wheelchair in the middle of room with an unpadded bedside table in front of him/her During a record review the following was indicated: * A physician's order initiated 9/22/22: Apply beige arm sleeves to bilateral arms. Remove for ADL care, every shift. * An ADL care plan, revised 8/27/22, with an intervention that Resident #70 is dependent with bathing, dressing, grooming. * A skin and bruising care plan, with an intervention bedside table padded. * An investigation for a bruise of unknown origin, dated 10/13/22, indicated Resident #70 was found to have a bruise on his/her right forearm. The intervention at the conclusion of this investigation was the center has padded his/her overbed table and seat in the dining room to avoid future incidents of the resident accidentally banging his/her arm. During an observation on 1/18/23 at 7:07 A.M., Resident #70 was observed asleep in bed and was not wearing bilateral arm sleeves, nor were they observed in the area. Nursing staff had documented in the TAR that the sleeves were applied. During an observation on 1/18/23 at 8:18 A.M., Resident #70 was observed seated in bed, not wearing bilateral arm sleeves, with his/her arms resting on top of the unpadded bedside table that had been placed directly in front of him/her. During an observation on 1/19/23 at 8:17 A.M., Resident #70 was observed in a chair in his/her room. He/she appeared anxious and was wringing his/her hands and arms on the unpadded bedside table that had been placed directly in front of him/her. During an interview with a Certified Nursing Assistant (CNA) #5 on 1/19/23 at 9:34 A.M., she said Resident #70 requires total care, including hygiene care, and that included nail care. CNA #5 said Resident #70 wore arm sleeves because his/her skin was very fragile, but that she had never seen a padded bedside table. During an interview with the Clinical Reimbursement Coordinator (CRC) Nurse and Director of Nursing (DON) on 1/19/23 at 9:48 A.M., they said that Resident #70 was supposed to have a padded bedside table and that someone must have moved it. The CRC Nurse said that nail care was an expected part of daily ADL care. 36876 4. For Resident #8 the facility failed to a. ensure the Resident wore a wander guard in accordance with the physician's orders, and b. failed to develop and implement a care plan for smoking. a. Resident #8 was admitted to the facility in October 2022 with diagnoses including dementia, schizophrenia, and a history of alcohol abuse. Review of the most recent minimum data set (MDS) completed in 1/10/2023 indicated a brief interview for mental status (BIMS) score of 9 out of a possible 15 indicating moderate impairment. On 1/8/23 at 11:14 A.M., and 1/19/23 at 8:45 A.M., Resident #8 was observed in his/her room without a wander guard on his/her left ankle. Review of Resident #8's January 2023 physician's orders indicated the following: *Wander guard left ankle, check placement qs, (each shift) check function with wand on 11-7 daily, exp 7/25. Review of the care plan dated October 2022 indicated Resident #8 is at risk for elopement related to exit seeking in the hospital. Review of the behavior flow sheets dated December 2022 and January 2023 indicated Resident #8 attempted to elope/exit seek on 12/3/22 (day shift), 12/11/22 (day shift), and 1/3/23 (night shift). During an interview with the Unit Manager (UM #1) on 1/18/23 at 12:49 P.M., she said the Resident should have a wander guard on his left leg as ordered by the physician. During an interview with the Regional Nurse (RN#1) on 1/18/23 at 3:09 P.M., he said staff should follow physician's orders and care plans in the medical record. b. The facility failed to develop and implement a smoking care plan for Resident #8. Review of the facility's Smoking Policy dated 11/4/19, indicated the following: *The admitting nurse will perform a smoking evaluation on each patient who chooses to smoke. *A patient's smoking status - independent, supervised, or not permitted to smoke - will be documented in the care plan *The care plan will be updated, as necessary. Review of the facility's grievance log indicated a grievance alleging that Resident #8 was smoking in his/her room on 12/12/22. Review of Resident #8's Smoking Evaluation dated 10/17/22 indicated that Resident #8 has a history of selling/sharing cigarettes and is unable to locate the smoking area and required supervision while smoking. Review of Resident #8's care plans failed to indicate a care plan for smoking. During an interview with UM #1 on 1/19/23 at 11:00 A.M., she said that Residents who smoke should have a care plan and acknowledged that Resident #8 did not have a smoking care plan. 43807 5.) For Resident #55 the facility failed to implement a physician's order for right elbow brace and a right palm protector. Review of the facility policy titled, Person- Center Care Plan, dated as revised 10/24/22, indicated the Center must development and implement a care plan that will be communicated to appropriate staff. Resident #55 was admitted to the facility in December 2016 with diagnosis including persistent vegetative state, non-traumatic subdural hemorrhage and quadriplegia. Review of Resident #55's Annual Minimum Data Set Assessment, dated 12/17/22, indicated he/she was comatose (persistent vegetative state), he/she required total dependence of one for dressing and had functional limitation in range of motion impairments on both upper extremities. Review of the physician's order dated 6/15/21 indicated: Apply Right elbow brace daily as tolerated. Apply after morning care and remove before bedtime care. Monitor skin for redness/irritation daily. If brace unavailable, place rolled towel to right elbow Review of the Treatment Administration Record, dated January 2023, indicated the right elbow brace was applied as ordered on 1/17/23. Review of the physician's order dated 3/2/22 indicated: Apply palm protector to right hand as tolerated. May remove for daily hygiene and skin inspection to ensure no redness/skin breakdown. May use rolled towel as alternate if palm protector is not available. Review of the Treatment Administration Record, dated January 2023, indicated the palm protector was applied to right hand on 1/17/23 and 1/18/23. During observation's on 1/17/23 at 8:03 A.M., 1/17/23 at 1:42 P.M., 1/18/23 at 7:20 A.M., 1/18/23 at 11:30 A.M., and on 1/18/23 at 4:30 P.M., there was no brace or rolled towel to his/her right elbow and there was no palm protector or rolled towel to his/her right hand. During an interview on 1/18/23 at 11:07 A.M., Certified Nurse Aide (CNA) #1 said she was not aware that Resident #55 required a brace or rolled towel to his/her right elbow or a palm protector or rolled towel to his/her right hand. CNA #1 said that the nurse will apply them. During an interview on 1/18/23 at 11:23 A.M., CNA #2 she was not aware that Resident #55 required a brace or rolled towel to his/her right elbow or a palm protector or rolled towel to his/her right hand. CNA #2 said that the nurse will apply them. During an interview on 1/18/23 at 11:30 A.M., Nurse #1 said CNA's will apply braces and palm protectors during care. Nurse #1 she has not seen a brace or a palm protector for Resident #55. Nurse #1 accompanied the surveyor to Resident #55's room. Resident #55 was not wearing anything in his/her right hand or anything on his/her right elbow. Nurse #1 and the surveyor were able to locate a brace in a box in his/her room and Nurse #1 said she had never seen this brace. During an interview and observation on 1/18/23 at 4:30 P.M., CNA #3 and CNA #4 had just completed providing care to Resident #55. There was no brace or rolled towel to his/her right elbow or a palm protector or rolled towel to his/her right hand. During an interview on 1/18/23 at 4:34 P.M., Nurse #1 said she was going to apply a face cloth to Resident #55's right hand. During an observation on 1/18/23 at 4:44 P.M., the surveyor with the Director of Nursing and the Regional Nurse made observations of Resident #55. Resident was not wearing a right arm brace. During an interview on 1/18/23 at 4:08 P.M., the Director of Nursing said nursing should be applying the brace and right palm protector as ordered. During an interview and observation on 1/19/23 at 8:08 A.M., the Director of Nursing and Occupational Therapist #2 were in Resident #55's room observing his/her right elbow. The Director of Nursing said that the brace was on hold until further evaluation. During an interview on 1/19/23 at 3:11 P.M., Occupational Therapist #1 said that she made the recommendations for the brace and the palm protector. OT #1 said she implemented a functional maintenance plan and said that Resident #55 was able to tolerate these devices. OT #1 said that if Resident #55 was unable to tolerate his/her brace and palm protector, nursing should have made a referral for a revision to his/her plan of care. 44095

Based on interview, record review and policy review, the facility failed to protect 1 Resident (#12) out of a total sample of 27 residents from physical abuse from Resident (#34), who had known and well-documented aggressive tendencies, resulting in a fracture. Findings include: Review of facility policy titled OPS300 Abuse Prohibition, revised 5/1/22, indicated the following: *Policy: Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property and exploitation for all residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish .Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. *Process: Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of patient property, will include: -Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur -If the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. -The Center will provide adequate supervision when the risk of patient to patient altercation is suspected. -The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. Resident #12 was readmitted to the facility in March 2019 with diagnoses including dementia and unspecified mood disorder. Review of Resident #12's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status. The MDS further indicated the Resident had behavioral symptoms directed towards others 1 to 3 days out of the previous 7 days, verbal behavioral symptoms 4 to 6 days out of the previous 7 days, other behaviors 1 to 3 days out of the previous 7 days, did not reject care, and requires extensive assistance with a one person physical assist for transfers and dressing as well as supervision with one person physical assistance for locomotion off the unit. Resident #34 was admitted to the facility in April 2021 with diagnoses including unspecified dementia with agitation and alcohol dependence. Review of Resident #34's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status Exam (BIMS). Further review of the MDS indicated the Resident had delusions, physical and verbal behaviors directed at others 1 to 3 days out of the previous 7 days, and was independent with bed mobility, transfers, walking in his/her room and in the corridor and locomotion on and off the unit. Review of Resident #12's medical record indicated the following: -An undated altercation investigation summary signed by the Director of Nursing which indicated the following: Incident: On 5/1/22, staff responded to yelling and found Resident #34 tagging back and forth with Resident #12. Resident #34 stated he/she was walking in hallway when Resident #12 backed into him/her with his/her wheelchair. Resident #12 was unable to state exactly what happened. Staff separated residents. No apparent injuries to residents. Physician, responsible parties and police notified. Investigation: Staff and residents were interviewed. Staff stated that they responded to the yelling and found residents tagging back and forth. Staff did not witness the beginning of the altercation and therefore did not know what triggered the incident. Resident #34 stated that Resident #12 backed into him/her with his/her wheelchair as Resident #34 was walking triggering the incident. Resident #12 denied backing into Resident #34 and was unable to state what happened. Conclusion: The residents got into an altercation due to some sort of misunderstanding. The minutes prior to the incident were unwitnessed. We are unable to verify Resident #34's account of events. Plan: Staff to keep residents separated. Social services to follow up with residents as needed. Review of an accident incident action team document dated as reviewed 5/2/22 indicated a new intervention to keep Resident #12 and Resident #34 separated. Review of Resident #12 risk for alteration in overall behavioral/psychosocial well-being care plan, revised 5/1/22, indicated a new intervention added 5/1/22 to keep Resident #12 separated from Resident #34 in the dining room. Review of Resident #34's medical record indicated the following: -A SBAR note for Resident #34 dated 5/1/22 which indicated that residents were fighting on the floor due to stated issue, they were removed from each other and appropriate action taken. -A care plan for Resident #34 initiated 4/8/21 for potential to demonstrate verbal/physical behaviors related to cognitive loss/ dementia. He/she has gotten physical with other residents, history of punching another resident in the face, recently responded to resident attack with physical response with a new intervention added 5/1/22 to keep Resident #34 separated from Resident #12. Further review of Resident #12's medical record indicated the following: -A late entry note dated 8/8/22 at 9:02 P.M. effective for 8/8/22 at 8:30 A.M. which indicated Resident #12 was pulled out of his/her wheelchair and thrown to the ground. The Resident's Health Care Proxy (HCP) and Nurse Practitioner notified. Seen by psych doctor, social services. Resident diagnosed with left distal fibula fracture. Seen by Nurse Practitioner. -A Nurse Practitioner (NP) encounter note dated 8/8/22: NP follow up resident to resident encounter, fracture. Resident was involved in the resident to resident encounter, he/she sustained a fall and was complaining of left ankle pain; X-ray shows acute oblique distal fibula (the outer bone between the knee and ankle joint) fracture (a fracture that occurs when the bone is broken at an angle); resident sent to ER (emergency room ) by this provider. -A radiology report dated 8/8/22 which indicated a left acute oblique distal fibula fracture. -A hospital after visit summary dated 8/8/22 which indicated the reason for the visit was a leg injury and the diagnosis was a broken leg. Review of facility provided investigations for Resident #12 indicated the following: -A Resident to Resident report dated 8/8/22 which indicated that staff heard a loud noise in the dining room and quickly ran and found Resident #12 and Resident #34 lying on the floor beside each other. Resident #12 said he/she was in his/her wheelchair by the dining room door. Resident #34 asked him/her to move and Resident #12 was about to do so then Resident #34 swore at Resident #12 and called him/her 'stupid idiot'. Resident #12 swore at Resident #34 and Resident #34 then hit Resident #12 in the face. Resident #12 threw a bottle of soda at Resident #34 and then Resident #34 pulled Resident #12 out of his/her wheelchair and threw him/her on the ground. -An unsigned summary document dated 8/8/22 which indicated the following: At approximately 8:30 A.M. on 8/8/22 staff on the mental health and recovery unit heard shouting from the dining room. Upon arrival to the dining room staff observed Resident #12 and Resident #34 on the floor entangled in one another. Upon initial interview, Resident #12 stated that Resident #34 told him/her to move, he/she began to try to move his/her chair to the side of the hallway when Resident #34 attempted to punch him/her in the face. Resident #12 explained that he/she splashed a cup of soda at Resident #34 and Resident #34 dragged him/her onto the ground. Upon initial interview, Resident #34 stated that he/she told Resident #12 to move, Resident #12 did not move and Resident #12 tried to punch Resident #34. The residents were immediately separated and assessed for injury. Resident #12 complained of left hip, left leg and left ankle pain. As needed Tylenol (a pain reliever) was administered and a stat x-ray was called in. Resident #34 had no injuries. Upon initial interview of the staff, no staff witnessed the altercation initiate. The interviews revealed CNA was in room [ROOM NUMBER] W, which has a clear siteline into the dining room. Certified Nursing Assistant (CNA) observed Resident #34 pull Resident #12 out of his/her wheelchair onto the floor and responded to the incident and called for help. Upon arrival at the dining room, the resident was on the floor and staff separated them. Upon investigation of the incident the security footage was reviewed. Resident #34 is seen exiting the dining room past Resident #12 with no incident. The initiation of the altercation was not in clear view but Resident #34 is seen attempting to punch Resident #12, Resident #12 is seen putting his/her hands over his/her head. Resident #34 is seen wrapping his/her arms around Resident #12, pulling the Resident out of his/her wheelchair and both residents are seen on the ground. Resident #34 is seen attempting to kick Resident #12 as they are entangled on the ground. Staff come running into the room and separate the two residents. In conclusion, the center believes that Resident #34 initiated the resident to resident altercation. The center believes that the residents did have a verbal exchange where Resident #34 asked Resident #12 to move. The center believes that both residents swore at one another during the verbal exchange and Resident #34 initiated the physical altercation with Resident #12 .Resident #12 was sent to the ER for complaints of pain, x-rays were done and revealed a fracture of the left fibula. -A signed CNA statement dated 8/8/22 indicating the CNA was in the hallway and heard someone calling for help and the CNA ran to the dining room and saw the residents on the floor. -Two signed CNA statements dated 8/8/22 stating they heard one staff call for help, they ran and saw two residents on the floor. -A signed CNA statement dated 8/8/22 which indicated the CNA was in a resident's room and turned her head and saw Resident #34 grab Resident #12 and pull him/her on the floor and the CNA called for help. Further review of Resident #12 and Resident #34's records failed to indicate staff had kept the residents separated in accordance with their care plans after a previous resident to resident altercation, resulting in aresident to resident altercation and a leg fracture for Resident #12. During an interview on 1/19/23 at 10:34 A.M., Unit Manager #1 said she is familiar with both residents. Unit Manager #1 said Resident #34 has been in the facility for about 2 years and used to be on the dementia unit but was fighting with the vulnerable residents on that unit so he/she moved to the current unit. Unit Manager #1 said Resident #34 has a short fuse and doesn't always remember to get staff when he/she is frustrated. Unit Manager #1 said she was working the day of the resident to resident altercation in August and that it happened in the morning. Unit Manager #1 said she was sitting at the nurses station and she was alerted by another staff member saying there was an altercation between Resident #34 and Resident #12. Unit Manager #1 said when she arrived both residents were on the floor and she and a CNA separated them. Unit Manager #1 said that Resident #34 told her he/she wanted to use the bathroom and asked Resident #12 to move out of the way and he/she said the other resident tried to grab him/her so he/she had to defend him/herself. Unit Manager #1 said Resident #12 initially said he/she was fine but she could tell he/she wasn't. Unit Manager #1 said she checked on Resident #12 a bit after the altercation and he/she reported pain in his/her leg, and an x-ray was ordered which showed a fracture in the leg. Unit Manager #1 said the Residents had altercations prior to this. Unit Manager said there are many residents with behaviors on the unit and when in the dining room residents should be supervised and further said the Residents were not supervised when this occurred. Unit Manager #1 was unable to say why no staff were present to keep the Residents separated prior to the altercation, but said maybe staff was pulled from the dining room. Unit Manager #1 said the expectation is that care plan interventions will be adjusted and followed as written. Unit Manager #1 said in her opinion Resident #34 should be supervised when interacting with other residents because he/she is aggressive and can snap quickly without warning. During an interview on 1/19/23 at 11:33 A.M., Nurse #3 said she is familiar with Resident #34 and is explosive and hot tempered. Review of Resident #34's medical record indicated the following: -A therapy note for service date 7/8/22 (one month before the altercation in which Resident #12's leg was broken) which indicated that the Resident continues to bully other residents in the facility. -A therapy note for service date 7/22/22 (17 days before the altercation) which indicated the Resident continued his/her bullying activities within the larger group and that the Resident said he/she was not going to be a bully. -A therapy note for service date 7/29/22 (10 days before the altercation) which indicated the Resident was confronted about his/her bullying behavior within the unit and how he/she treats other residents. -A therapy note for service date 8/8/22 (the date of the altercation) which indicated the Resident started a fist fight with another resident who was in a wheelchair/ Resident #34 pulled the other Resident (Resident #12) out of his/her wheelchair, threw him/her on the ground, got on top of him/her and started punching him/her in the head and kicking him/her. Resident #34 denied having done all of these activities but everything was on video. During an interview on 1/19/23 at 4:05 P.M., Licensed Therapist #1 said he has worked with Resident #34 since admission to the facility. Licensed Therapist #1 said he worked with Resident #34 on the dementia unit briefly and said the Resident was violent and would antagonize other residents and try to start fights or get other residents riled up. Licensed Therapist #1 said Resident #34 was transferred down to the mental health unit. Licensed Therapist #1 said Resident #34 is far too violent and that when he/she gets violent he/she gets violent. Licensed Therapist #1 said that on 8/8/22 Resident #34 pulled Resident #12 out of his/her wheelchair and beat him/her 'like you would in a street fight'. Licensed Therapist #1 said Resident #34 will try to find someone he/she perceives as weaker than him/her and start a fight and that when asked about the Resident to Resident altercation in August Resident #34 said Resident #12 tried to fight him/her and that the surveillance video did not match with what Resident #34 had said happened. Licensed Therapist #1 said he couldn't remember details about the Resident to Resident altercation in May between Resident #34 and Resident #12 but said would check his notes. Licensed Therapist #1 said Resident #34 is a tough person to have in the facility and that Resident #34 would try to be tough around other residents and posturing, and acknowledged his notes indicated Resident #34 was observed with bullying behaviors prior to the altercation on 8/8/22. Licensed Therapist #1 said staff was aware of Resident #34's behaviors and some interventions included staff staying in the dining room to be a buffer between Resident #34 and other residents and said that about 90% of time there is supervision plus cameras. Licensed Therapist #1 said supervision in the dining room is best for safety. During an interview on 1/19/23 at 4:54 P.M. with the Director of Nursing, Administrator and Corporate Consultant #2, the Director of Nursing said Resident #34 has had a few resident to resident incidents and has a lot of triggers. The Director of Nursing said Resident #34 is triggered by other residents and by people getting in his/her way and that the Resident ambulates independently with a cane. The Director of Nursing acknowledged that interventions were listed in Resident #34 and Resident #12's care plans to keep them separated but said that the interventions were not meant to be permanent even though they were still listed as current interventions. The Director of Nursing said care plan interventions were in place to keep the Residents separated and it wasn't done. The Director of Nursing and the Administrator said they didn't recall Resident #34 being documented as a bully or that information being communicated to them by Licensed Therapist #1. During a follow up interview on 1/20/23 at 10:16 A.M., the Director of Nursing said Resident #34's most recent roommate was moved after getting feedback from the nursing staff about Resident #34 and his/her behaviors. The Director of Nursing said she was unaware of bully phrase being used in psych notes and said care plan interventions should be reviewed and updated if there is a change or a new issue or concern. The Director of Nursing acknowledged no interventions were added after Resident #34's return from hospitalization and Licensed Therapist #1 assessing the Resident as being a threat to other residents still. During an interview on 1/20/23 at 11:44 A.M., Licensed Therapist #1 said he met with Resident #34 this morning and there was a behavioral health round session with staff to try to identify potential triggers for the Resident and that the facility revised his/her care plan today with new interventions based on the identified triggers including: people going into his/her bathroom, placing a stop sign in front of his/her door, and managing the TV in the dining room. Licensed Therapist #1 said he was unaware of any care plan updates after Resident #34 was readmitted to the facility in August and he identified that Resident #34 was still a threat. Licensed Therapist #1 said the expectation would be that his/her care plan would have interventions based on identified triggers.

Based on policy review, record review, observation and interview, the facility failed to 1) provide adequate supervision to prevent accidents for three of 36 sampled residents (#4, #5 and #64). 1. (A.) Resident #4 was not supervised while eating breakfast and placed a small plastic butter container in his/her mouth. The small plastic butter container had to be extricated (removed), by a nurse, from Resident #4's mouth. Despite, the risk of choking or possible death, the staff continued to provide non-edible items, including sugar packets on Resident #4's meal trays and leave Resident #4 unsupervised at mealtimes, after the initial observation. 1. (B.) Resident #5 was not supervised while eating breakfast and placed a plastic hair curler in his/her mouth. The plastic hair curler needed to be removed from the Resident's meal tray by the Administrator. Despite, the risk of choking or possible death, the staff continued to provide non-edible items, including sugar packets on Resident #5's meal tray at a subsequent meal, and 1. (C.) Resident #64 was not directly supervised in an activity and had placed a strap from a hoyer pad (a sling used to lift a resident in a mechanical lift) into his/her mouth and was audibly gagging on it; 2) the facility failed to ensure the environment remains free of accident hazards by utilizing space heaters in resident rooms, and 3) the facility failed to provide adequate supervision to residents to prevent elopements for 3 Residents (#65, #87, and #2) out of total sample of 36 residents. 2. The facility failed to have the environment remain free from accident hazards by placing space heaters in resident rooms. 3. The facility failed to provide adequate supervision to residents to prevent elopements. Findings include: 1. The facility failed to provide adequate supervision during meal time to prevent accidents. Review of the facility document titled, Meal Service, dated 6/1/21, indicated the following: *If a patient requires assistance with eating, do not deliver the tray until assistance can be provided. A. Resident #4 was admitted to the facility in March 2020 with diagnoses that included dementia. Review of Resident #4's most recent Minimum Data Set (MDS) dated [DATE], revealed Resident #4 was unable to complete the Brief Interview for Mental Status (BIMS) and the nursing staff has assessed the Resident to have moderate cognitive impairment. The MDS indicated that Resident #4 had adequate vision for functional tasks without corrective lenses and required extensive assistance from staff for self-feeding tasks. Review of the Speech Therapy evaluation dated 12/15/21 indicated Resident #4 had a diagnosis of dementia and was having increased difficulty with swallowing due to advancing dementia. Review of the Occupational Therapy (OT) discharge summery dated 12/30/21, indicated Resident #4 was referred to OT secondary to an increased need for assistance during activities of daily living. The discharge summary indicated Resident #4 required supervision for self-feeding tasks and recommended the Resident be out of bed and in the dining room for all meals. On 2/16/22 at 8:32 A.M., Resident #4 was observed eating breakfast in bed without supervision or assistance from staff. Resident #4 was observed to be chewing on a white, plastic object. Nurse #1 entered the room and removed the item from the Resident's mouth and identified the object as a butter packet that was left on the Resident's meal tray. Nurse #1 then left the room, leaving Resident #4 to continue eating unsupervised and with no assistance. Resident #4 then picked up his/her empty juice glass and attempted to drink from the bottom of the glass. Resident #4 was observed licking the bottom of the glass for the next 4 minutes. Review of Resident #4's physician orders indicated the following order: *Regular/liberalized diet: Dysphagia advanced texture, written 8/14/2020. Review of Resident #4's Activity of Daily Living (ADL) care plan last revised 12/2/21 indicated the following interventions: *Resident #4 is independent to assist with meals. Review of the document titled, Licensed Nursing Summary (Mass) - V2, dated 1/21/22, indicated Resident #4 requires total assistance from staff throughout entire meal due to the diagnosis of dementia. During an interview on 2/16/22 at 8:49 A.M., the Director of Nursing (DON) said she had been told about Resident #4 attempting to eat an inedible object. The DON said that Resident #4 is able to start a meal independently but often needs help from staff to stay on task and finish the meal. The DON said that she was not aware that the nursing summary assessed Resident #4 to need total assistance during meals. The following care plan intervention was added to Resident #4's ADL care plan on 2/16/22: *Education provided to staff members to remove any inedible items such as sugar/salt/pepper packets, plastic wraps, butter containers, etc. after setting up the trays. During an interview on 2/16/22 at 1:30 P.M., Nurse #1 said that the staff on the unit were educated to remove any inedible objects from resident's trays after meal setup. Nurse #1 said that this education occurred prior to the lunch meal. On 2/16/22 at 5:30 P.M., Resident #4 was observed eating in the dining room. Resident #4's tray was prepared by the nursing staff. A napkin and a meal ticket (piece of paper) were observed left on the meal tray. This observation occurred after the unit staff received education to remove all inedible objects from the meal tray On 2/17/22 at 8:25 A.M., a nurse brought Resident #4 his/her breakfast into the Resident's room and prepared the meal tray. The nurse then left the room. Resident #4 then attempted to eat his/her meal without supervision or assistance from staff. The meal tray had 2 sugar packets, a napkin, and the meal ticket on the tray. For the next 8 minutes, Resident #4 was observed scooping the plastic handle of his/her built-up utensil into his/her oatmeal and then placing the handle into his/her mouth and biting down. At 8:38 A.M., a nurse entered the room and fed the Resident for the entire meal. This observation occurred after the unit staff received education to remove all inedible objects from the meal tray. B. Resident #5 was admitted to the facility in January 2017 with diagnoses that included dementia. Review of Resident #5's most recent Minimum Data Set (MDS) dated [DATE], revealed Resident #5 was unable to complete the Brief Interview for Mental Status (BIMS) and staff assessed him/her to have moderate cognitive impairment. The MDS indicated that Resident #5 had adequate vision for functional tasks without corrective lenses and required supervision from staff for self-feeding tasks. On 2/16/22 at 12:20 P.M., Resident #5 was observed eating lunch in his/her room without staff present to provide supervision. A plastic hair curler, approximately 3 inches in length, was present on his/her meal tray. Resident #5 picked up the curler, dipped the curler into his/her food and then placed the curler in his/her mouth. Resident #5 did this three more times. The Administrator entered the room and was made aware Resident #5 had placed the curler in his/her mouth several times and she removed the hair curler. When asked, the Administrator did not know the level of assist Resident #5 required for meals. Review of Resident #5's Activity of Daily Living (ADL) care plan, last revised on 12/20/21, indicated Resident #5 required continual supervision/assist for meals. Review of the document titled, Licensed Nursing Summary (Mass) - V2, dated 1/26/22, indicated Resident #5 requires continual supervision (1:8) throughout the entire meal due to the diagnosis of dementia. During an interview on 2/16/22 at 1:30 P.M., Nurse #1 said that Resident #5 requires continual supervision for all meals. Nurse #1 said the Resident requires supervision because he/she is unable to stay on task and needs cueing to manage the items on his/her meal tray. Nurse #1 said Resident #5 will eat anything, so the staff have to be careful and supervise him/her. Nurse #1 said the staff on the unit were educated to remove any inedible objects from resident's trays after meal setup. On 2/17/22 at 8:29 A.M., Resident #5 was observed eating breakfast in the dining room. A staff member prepared Resident #5's tray and left 2 sugar packets, a napkin and a meal ticket (piece of paper) on the tray and then walked away to attend to another resident. This observation occurred despite the unit staff receiving education to remove all inedible objects from the meal tray. C. Resident #64 was admitted to the facility in April 2018, with diagnoses that included Alzheimer's disease. Review of the most recent Minimum Data Set (MDS), dated [DATE], revealed Resident #64 was unable to complete the Brief Interview for Mental Status (BIMS) and staff was assessed by staff to have moderately impaired cognition. During an observation in the dementia unit on 2/16/22 at 3:49 P.M., the surveyor observed 7 residents seated in the unit large dining room with two staff members present. The two staff that were present were engaged in a conversation and were not supervising Resident #64 and the other residents in the room. Resident #64 was sitting in his/her wheelchair with a hoyer pad (a sling used to lift a resident in a mechanical lift) underneath him/her. Resident #64 had the strap of the hoyer pad in his/her mouth. Resident #64 was sucking on the strap and pushing it further in his/her mouth, making gagging noises on and off. After approximately 2 minutes, one of the two staff persons left the room and the other resumed an activity of offering the residents in the room drinks. On 2/16/22 at 3:53 P.M., the staff member saw the Resident that had the strap in his/her mouth and was able to remove approximately 4 inches of strap from Resident #64's mouth. During an observation on 2/16/22 at 4:48 P.M., the surveyor observed Resident #64 in his/her room placing his/her johnny (medical gown) into his/her mouth and chewing on it. Certified Nursing Assistant (CNA) #1 was standing in the hallway with her back to the door. CNA #1 and the surveyor then observed Resident #64 together and CNA #1 pulled the johnny out of the Resident's mouth. CNA #1 said that this was a regular behavior and that Resident #1 put anything he/she can get his/her hands on in his/her mouth. Review of Resident #64's care plans failed to indicate a care plan to address placing non-edible items in his/her mouth. During an interview on 2/17/22 07:58 A.M., Nurse #3 said that if a resident has a history of putting inedible items in their mouth, a care plan should be implemented for this behavior. Nurse #3 said she was aware of Resident #64 chewing on his/her johnny but was not told of the incident where he/she had the hoyer strap in his/her mouth. Nurse #3 said that these behaviors should be documented on the Resident's behavior sheets. Nurse #3 reviewed Resident #64's behavior sheets and found there was no documentation of this behavior. After the facility had submitted an abatement plan to remove the immediacy of jeopardy by educating the staff to remove all non-edible items off the resident food trays, the following additional observations of dining on the Solana Unit were observed: During an observation on 2/22/22 between 5:39 P.M., and 5:46 P.M. Resident #56 was observed seated in the unit dining room chewing and biting on his/her shirt. Nurse #7 was present and facing the Resident, however at no time intervened or removed the non-edible item from his/her mouth. During an interview on 2/22/22 at 5:47 P.M., Nurse #7 said he had not been in-serviced to remove non-edible items from Residents mouths. During an interview on 2/22/22 at 5:59 P.M., the Director of Nursing (DON) said Nurse #7 came in late for his shift and she had not given him education regarding the removal of any non-edible items from resident meal trays. During an observation on 2/23/22 at 5:14 P.M., the following was observed by the surveyors during the meal service in the large dining room: *Two residents were seated at a table with meal trays and had rolled cellophane wrappers in front of them. *A third resident at the table was given his meal tray by the Dietitian and the cellophane wrapped cookies were left on the tray. During an interview, right after serving the meal tray, the Dietitian said he was helping with supper and does not usually deliver trays. He said he knew there was a concern about residents on the unit having inedible items on the meal trays, however, did not receive any education about residents who are at risk of ingesting non-food items *A fourth resident sitting at a different table had 2 butter containers, 2 salt packets and cellophane wrapped cookies. Corporate Nurse #1 went with the surveyor and saw the non-edible items on the fourth resident's tray. During an observation on 2/24/22 at 8:23 A.M., the surveyors observed Resident #36 seated alone in his room with his/her breakfast tray with 2 sugar packets and a butter container left on the tray. During an interview on 2/24/22 at 8:24 A.M., the Director of Nursing (DON) was informed of the surveyor's observation. The DON educated the nurse who had passed out the tray and ask the nurse to remove all inedible items from Resident #36's tray. The surveyor re-entered Resident #36's room on 2/24/22 at 8:29 A.M. Resident #36 was observed seated in his/her room with his/her breakfast tray and the two sugar packets were still on the tray, despite the nurse being educated and instructed moments earlier to remove those items. On 2/24/22 at 12:35 P.M., staff was observed delivering a tray to a resident in her room. Once the staff left the room, the surveyor observed the resident's tray to have a plastic lid on the coffee mug and plastic wrap over the food items. On 2/24/22 at 12:45 P.M., Corporate Nurse #1 observed the inedible items on the resident's meal tray and removed them. 2.) During a tour of the facility's 3 resident units on 2/16/22, beginning at 7:46 A.M., the surveyors observed that 11 rooms had portable space heater units. During an interview with the Facility Maintenance Director (FMD) #1 and Corporate Administrator on 2/16/22 at 9:47 A.M., FMD #1 said: * He had placed several space heaters in resident rooms due to complaints of the rooms being cold; * That the facility had heat control issues because (1.) It was an old building and (2.) There was a broken circulating pump. FMD #1 said that the circulating pump had been repaired 10 days prior; * He did not plan to remove the space heaters until it was warmer weather outside; * He did not keep a log of which rooms had space heaters; * He did not have a system to monitor the space heaters for safe functioning. 3.) A. For Resident #65 the facility failed to prevent him/her from eloping from a locked Dementia care unit twice. The facility policy titled Elopement of Patient, revised 2/28/21, indicated the following: * Patients will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as a part of the clinical assessment process. Resident #65 was admitted to the facility in November 2019, and had diagnoses that included dementia with behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/12/22, revealed Resident #65 was unable to complete the Brief Interview for Mental (BIMS) Status Exam and had behavior of wandering 4-6 days per week in the previous week. During a record review on 2/23/22 at 3:20 P.M., two incident reports were reviewed and indicated that on 9/8/21 and 11/20/21 Resident #65 was able to elope from the facility. A.) Elopement #1: A report dated 9/8/21, indicated Resident #65 had left unit via East side stair case and exited the building. The report further indicated that Resident #65 was not witnessed leaving the building and was found outside by the maintenance director, when another resident alerted him that there was a Resident outside. * Review of the Medication Administration Record, for September 2021, indicated that 9 days after the actual elopement, Resident #65 was placed on 15 minute checks on 9/17/21 through 9/20/21; During an interview on 2/24/22 at 2:32 P.M., the Director of Nursing she said she could not recall why there was a delay in the facility learning about the elopement but that once she was aware, 9 days later, she initiated an investigation. * Review of the incident report indicated the Physician (MD) and Resident #65's responsible party were not notified of the elopement until 9/17/21. * Review of the clinical progress notes in the months preceding the incident indicated wandering occurs daily and poses significant risk and/or is intruding on others (2/8/21, 3/31/21, 5/29/21, 7/23/21). * A care plan, initiated 11/25/19 and revised 9/17/21, with a focus area Resident #65 is at risk for elopement related to dementia and wandering, no sense of direction/destination/follows others, pushes on exit doors until door opens, Interventions included: as appropriate redirect Resident if near exits or doorways. * A quarterly elopement assessment dated [DATE]: the facility coded yes, that Resident #65 had a history of actual or attempted elopement. Despite knowledge that Resident #65 was at high risk for elopement, wandered on a regular basis and wore a wanderguard bracelet, he/she was still able to elope from a locked dementia unit and from the facility on 9/8/21. B.) Elopement #2: A report, dated 11/20/21, indicated Resident #65 had exited the unit/facility onto facility grounds. The report further indicated that Resident #65 was not witnessed leaving the building, and that it was not until visitors alerted facility staff that Resident #65 was found outside, having fallen on the ground, that staff were aware Resident #65 was missing. * Review of the section of the report titled Elopement Investigation was blank, and failed to indicate that Resident #65's wanderguard had activated the door alarm. * The report further indicated that Resident #65 sustained a left forearm skin tear when he/she eloped and fell . Further clinical progress notes indicated that Resident #65, developed an infection to the skin tear, resulting in the need for hospitalization , Intravenous (IV) and oral antibiotics and the wound area drained with a wick then placed in it for 48 hours. * Care plan evaluation, dated 10/9/21, indicated Resident #65 remained at risk of elopement related to dementia and wandering, no sense of direction/destination/follows others, pushes on exit doors until door open. * A physician's order, started 4/27/21, remained in effect, for a wanderguard to right ankle (a device utilized to alert staff that Resident #65 was attempting to exit the unit.) Despite knowledge that Resident #65 was at high risk for elopement, had previously eloped on 9/8/21, wandered on a regular basis and wore a wanderguard bracelet, he/she was still able to elope from a locked dementia unit and from the facility on 11/20/21. As well, Resident #65 required a hospitalization , IV and oral antibiotic and a surgical procedure on 12/8/21 due to an injury sustained during the elopement. C. For Resident #87, whose Health Care Proxy was activated due to not being capable of making informed decisions, the facility failed to provide supervision to prevent an elopement during an out of facility doctor's appointment. This resulted in Resident #87 sleeping outside overnight and going to the emergency room being diagnosed with hypothermia (low body temperature), [CONDITION(S)] (low blood sugar) and alcohol ingestion. Resident #87 was admitted to the facility in 10/2020 with diagnoses including chronic obstructive pulmonary disease and alcohol abuse. Review of Resident #87's record indicated on 11/2/20, Resident #87's health care proxy was activated indicating Resident #87 was incapable of making informed decisions due to altered mental status related to alcohol use disorder. A quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #87 scored an 11 out of a possible 15 on the Brief Interview for Mental Status indicating Resident #87 had moderately impaired cognition. In addition, Resident #87 was independent with activities of daily living. Review of a facility investigation report indicated on 12/9/21, Resident #87 left the facility unescorted via a transportation service at 7:15 A.M. for a doctor's appointment in [NAME]. Resident #87 was dropped off at the appointment at 7:34 A.M. Between 3:00 P.M. - 3:30 P.M., Unit Manager #2 noticed Resident #87 was not on the nursing unit and did not see Resident #87 return from the appointment. Unit Manager #2 called the doctor's office and spoke to the receptionist. The receptionist told Unit Manager #2 that Resident #87 left the clinic at 8:30 A.M. when his appointment was over and returned to the clinic at 10:00 A.M. and was waiting for a ride. Unit Manager #2 asked the receptionist why clinic staff did not call transportation to pick up Resident #87. The receptionist stated Resident #87 stated he/she would call for transportation himself/herself. At 3:30 P.M., Unit Manager #2 called the [NAME] police to report Resident #87 was missing. Unit Manager #2 stated the police reported they received a call from a store employee earlier about an elderly person who seemed upset. The police recognized Resident #87's name and stated they had been looking for Resident #87. At 3:30 P.M., the social worker called the [NAME] police to report Resident #87 was missing. Between 3:30 P.M. - 3:40 P.M., Unit Manager #2 called Resident #87's cell phone. Resident #87 answered but hung up before Unit Manager #2 could talk to him/her. Unit Manager #2 made several attempts to call Resident #87's cell phone, but Resident #87 did not answer. 3:45 P.M. - 4:00 P.M., staff called the local hospital to check if Resident #87 was in the emergency room with no result. Between 5:00 P.M. - 12:00 A.M., Unit Manager #2 drove around [NAME] looking for Resident #87 but could not find him/her. At 9:30 P.M., the [NAME] police were called for an update. They had not located Resident #87, but the search was continuing. Resident #87 was not located until the following morning, 12/10/21. Review of a police report from [NAME] police indicated they had received a call from the [NAME] police on the morning of 12/10/22 advising they had found Resident #87 at around 6:00 A.M. in [NAME]. Resident #87 was transported to the hospital via [NAME] Emergency Medical System (EMS). Review of the hospital emergency room report dated 12/10/21 indicated Resident #87 stated he/she was out drinking and unable to get home so decided to sleep on the street. Resident #87's vital signs in the emergency room were: Temperature: 92 degrees (normal 97 - 99 degrees), Oxygen saturation 92% (normal 96% or higher), pulse 118 (normal 60 - 100), blood pressure 141/52 (normal 120/80). Resident #87's history and presentation at the hospital were: alcohol intoxication and sleeping on the street resulting in hypothermia. A [NAME] (a warming blanket) was applied. Resident #87's initial accucheck (blood sugar) was 37 (normal range 80 - 130). 1 ampoule of dextrose (used to treat low blood sugar) was administered. After 5 hours of intravenous hydration, Resident #87's blood sugar improved and temperature was 98 degrees. The following were the discharge diagnoses: 1. Acute alcohol ingestion 2. Acute nausea and vomiting 3. Acute hypothermia 4. Acute [CONDITION(S)] 5. Acute alcohol induced transaminitis (high levels of liver enzymes) 6. Acute leukocytosis (elevated white blood count) Resident #87 was discharged back to the facility on [DATE]. The Administrator interviewed Resident #87 on 12/12/21 at 1:00 P.M. Resident #87 stated while he/she was waiting for his/her ride, Resident #87 went to a store that was a short walk from the doctor's office. Resident #87 returned to the doctor's office and sat and waited. Resident #87 said he/she asked the man in the booth twice what happened to his/her ride and the man in the booth told Resident #87 that it was not his responsibility to get Resident #87 a ride. Resident #87 told the man he/she would take care of it himself/herself. Resident #87 said he/she tried to call the facility but his/her phone was dead and he/she did not have enough money for a cab. Resident #87 stated he/she walked to [NAME] Donuts and stayed inside for an hour. Resident #87 then went to a liquor store and bought nips, drank 1 and put 2 in his/her pocket. Resident #87 said he/she went to a residential house where he/she used to stay, went into the yard and slept near a red bike. During an interview on 2/24/22 at 12:00 P.M.,Unit Manager #2 said if a resident has an activated Health Care Proxy, a staff member is to accompany the resident to appointments. An interview was conducted on 2/24/22 at 2:30 P.M. with the Administrator, Director of Nursing and Corporate Nurse #1. The Administrator said the receptionist at the doctor's office is supposed to call the transportation company when the resident is ready to return to the facility. The Administrator said the transportation company was called and the driver did return to the doctor's office, but Resident #87 was no longer there. Corporate Nurse #1 said Resident #87 had been out to appointments alone before and always returned to the facility and that Resident #87 will now have a staff member go with him/her to appointments.

Based on observation, record review and interview, for 1 Resident (#80), in a total sample of 36 residents, the facility failed to ensure he/she was free from abuse, when the surveyor witnessed Certified Nurse Aide (CNA) #6 force feed Resident #80. Findings include: Review of the facility policy titled OPS300 Abuse Prohibition and dated as revised 4/9/21, indicated that mistreatment, as defined as inappropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #80 was admitted to the facility in Oct. 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan on 2/16/22, at 5:52 P.M., failed to indicate that Resident #80 refused to eat. Review of the nurse's notes dated 1/1/22, through 2/16/22, failed to indicate that Resident #80 refused to eat. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #80 requires extensive assistance for eating. Further review indicated that Resident #80 was not able to complete a Brief Interview for Mental Status and is considered to have moderately impaired cognitive deficits with poor decision making, requiring cues and supervision. Further review indicated that Resident #80 did not have behaviors that included physically hitting or pushing others. On 2/17/22, at 5:28 P.M., the surveyor observed CNA #6 feeding Resident #80 in her/his room while the Resident was in bed. The surveyor observed Resident #80 repeatedly screaming the word no when CNA #6 would put food into Resident #80's mouth. The surveyor also observed Resident #80 telling CNA #6 to get the f*** out of her/his room as he/she was repeatedly slapping and pushing the hand of CNA #6 away from her/his mouth as CNA #6 was feeding him/her. The surveyor also observed Resident #80 repeatedly turn her/his head away from the direction the spoonful of food that CNA #6 was feeding him/her. Although the Resident was objecting to being fed, the CNA continued to push food into his/her mouth. Review of Resident #80's medical record failed to indicate any nursing notes prior to 2/17/22 that indicated this was typical behavior during meals for Resident #80. During an interview on 2/17/22, at 5:35 P.M., CNA #6 said that staff encourage Resident #80 to eat and continue to feed her/him even when the Resident says no because the Resident is confused, and staff are afraid he/she will lose weight. CNA #6 said Resident #80 does not spit the food out, so CNA #6 feels the Resident is able to eat this way. CNA #6 then said that staff is supposed to stop feeding a resident when the resident says no. During an interview on 2/17/22, at 5:37 P.M., the Director of Nursing said that staff are to stop feeding a resident when the resident says no.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure the staff notified Family Member #1 when they learned Resident #1 did not receive [MEDICATION NAME] in error from 9/1/14 to 9/16/14, and the 9/2/14 international normalized ratio (INR: a blood test to measure blood clotting time), was not completed. This resulted in Resident #1 not receiving the anti-coagulant medication [MEDICATION NAME] between 9/1/14 and 9/16/14. Findings include: The Annual Minimum Data Set (MDS), completed on 6/9/14, indicated Resident #1 was alert and oriented and had no cognitive impairment. The physician order, dated 8/29/14, included: [MEDICATION NAME] 4 mg on Monday, Wednesday, and Friday, [MEDICATION NAME] 3.5 milligrams (mg) on Tuesday, Thursday, Saturday, and Sunday, and staff were to obtain an INR level on 9/2/14. The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M., on 11/3/14. The DON said on 9/17/14, the Facility noted the nurse did not complete the laboratory slip for Resident #1's 9/2/14 INR level; the laboratory did not obtain the INR and [MEDICATION NAME] time (PT), and therefore, Resident #1 did not have a [MEDICATION NAME] order, and did not receive [MEDICATION NAME] between 9/1/14 and 9/16/14 in error. This placed Resident #1 at risk for a blood clot The laboratory study, completed on 9/17/14, at 11:00 A.M., indicated Resident #1 had a subtherapeutic INR level of 0.9 (therapeutic range between 2-3). [MEDICATION NAME] has a narrow therapeutic index (defined as a small range at which a medication dose is beneficial without causing serious complications, which meant that careful monitoring was necessary to ensure medication was effective to prevent a blood clot but not cause bleeding). The laboratory slip did not indicate the time the INR level was reported to the Facility. The physician order, dated 9/17/14, included [MEDICATION NAME] 5 mg for two days and staff were to obtain an INR level on 9/19/14. The Surveyor interviewed Unit Manager #1 at 1:15 P.M., on 11/3/14. Unit Manager #1 said that on 9/17/14, she told Resident #1 the laboratory study was not completed a few weeks ago and the nurses had not given Resident #1 [MEDICATION NAME] for several weeks. Unit Manager #1 said she told Resident #1 the laboratory would obtain blood work today; the nurse would notify the Physician of the laboratory results, and the nurse would contact the Physician or the Nurse Practitioner (NP) for further orders. Unit Manager #1 said she told Resident #1 she would notify Family Member #1 of the incident. Unit Manager #1 said at the end of his/her shift, the 9/17/14 INR and PT results were not reported to the Facility. The Surveyor interviewed Family Member #1 at 3:00 P.M., on 10/30/14. Family Member #1 said Resident #1 discussed all changes in his/her status and treatment plan with her. Family Member #1 said due to Resident #1's history of a stroke after being taken off [MEDICATION NAME] in the past, Resident #1 was cognizant of the importance of receiving daily [MEDICATION NAME] and would have immediately notified her if told he/she had not received [MEDICATION NAME]. Family Member #1 said Resident #1 never told her she did not have laboratory studies completed on 9/2/14 and had not received [MEDICATION NAME] for a few weeks. Family Member #1 said on 9/17/14, Resident #1 told her he/she had diarrhea and did not feel well Family Member #1 said on 9/17/14, in the afternoon, the Facility staff left her a message that Resident #1 was fine and to call the Facility at her convenience. Family Member #1 said in the afternoon, Resident #1 told her he/she had blood in his/her stools. Family Member #1 said Resident #1 did not tell her he/she had not received [MEDICATION NAME] for a few weeks. Unit Manager #1 said that on 9/17/14, she left a message on Family Member #1's telephone to call her regarding Resident #1. Unit Manager #1 said Family Member #1 did not call her during her shift. Unit Manager #1 said she told Nurse #5, who was assigned to Resident #1 during the evening shift to disclose the incident to Family Member #1 when Family Member #1 called the Facility. Unit Manager #1 said the nurses were responsible for notifying a resident and/or family member regarding significant changes in a resident's status or treatment plan. Unit Manager said the expectation was the nurses would notify Resident #1 and Family Member #1 regarding the need to change Resident #1's treatment plan in response to the missed [MEDICATION NAME] doses. Unit Manager #1 said the following morning, 9/18/14, there was no report regarding Family Member #1 and she assumed Nurse #5 disclosed the incident to Family Member #1. Unit Manager #1 said she assumed Nurse #5 notified Resident #1 and Family Member #1 regarding the Physician's plan for Resident #1 to receive [MEDICATION NAME] and have an INR and PT level on 9/19/14. The Surveyor interviewed Nurse #5 at 2:45 P.M. on 11/3/14. Nurse #5 said on 9/17/14, Unit Manager #1 did not tell her she was awaiting a call from Family Member #1 and she was to disclose the incident to Family Member #1. Nurse #5 said she assumed Unit Manager #1 disclosed the incident, the INR and PT results, and the plan for [MEDICATION NAME] and a follow-up INR and PT level on 9/19/14 to Resident #1 and Family Member #1. Nurse #5 said she did not tell Resident #1 she gave him/her [MEDICATION NAME] on 9/19/14 and did not notify Family Member #1 regarding changes in the treatment plan. Unit Manager #1 said Nurse #5 did not notify Family Member #1 and Resident #1, which was not consistent with the Facility's Policy, regarding the 9/17/14 laboratory results; the plan for Resident #1 to receive [MEDICATION NAME] for the next two days (9/17/14 and 9/18/14), and for INR and PT laboratory studies to be done on 9/19/14. Unit Manager #1 that said on 9/18/14, the night nurse did not tell her Family Member #1 did not call the Facility and she assumed the evening nurse spoke with Family Family Member #1 said on 9/18/14, the nurse notified her the staff were transferring Resident #1 to the Emergency Department (ED) related to Resident #1's diarrhea. Family Member #1 said she asked the nurse why they couldn't treat Resident #1's diarrhea at the Facility and the nurse said Resident #1 had diarrhea five times between 3:00 P.M. and 5:45 P.M. Family Member #1 said the nurse did not notify her of the laboratory omission or that Resident #1 did not receive [MEDICATION NAME] for weeks, and the two doses of [MEDICATION NAME] and one dose of [MEDICATION NAME] since the incident was discovered. The nurse's note, dated 9/18/14, indicated Resident #1 complained of loose stools and per Resident #1 and shift report, Resident #1 had 4 to 5 loose stools during the day shift. The nurse's note indicated Resident #1 complained of rectal bleeding and had a small amount of blood on a piece of toilet paper. The nurse's note indicated the nurses notified the Physician, who gave an order for [REDACTED].#1 had a moderate amount of bleeding in the toilet. The nurse's note indicated Resident #1 was alert, had a heart rate of 90, and a blood pressure of 163/78. The nurse's note indicated the staff transferred Resident #1 to the ED. The Surveyor interviewed Nurse #7 at 4:30 P.M., on 11/3/14. Nurse #7 said on 9/18/14, she told Resident #1 the Physician wanted him/her to receive [MEDICATION NAME]. Nurse #7 said on 9/18/14, she told Family Member #1 that Resident #1 had a loose stool with a small amount of blood and then had a loose stool with blood. Nurse #7 said she did not tell Family Member #1 she gave Resident #1 [MEDICATION NAME] per the physician order. Nurse #7 said she told Family Member #1 the staff were transferring Resident #1 to the Hospital for an evaluation of the bleeding, which could be from hemorrhoids or from administration of [MEDICATION NAME]. Nurse #7 said she assumed Family Member #1 was aware of the laboratory and [MEDICATION NAME] incident and therefore, did not discuss the incident with her. Unit Manager #1 said Nurse #7 did not discuss Resident #1's treatment plan related to the incident per the Facility Policy. Family Member #1 said the ED staff told her the Facility notified them Resident #1 had not received [MEDICATION NAME] for several weeks, had an INR level of 0.9, and was given 2 doses of [MEDICATION NAME] and 100 mg of [MEDICATION NAME]. Family Member #1 said she and Resident #1 were not aware of the incident, prior to speaking to the ED staff. Family Member #1 said the Hospital staff admitted Resident #1 to the medical intensive care unit (MICU). Family Member #1 said on 9/20/14, a CT (computed tomography) Scan of the intestines indicated Resident #1 had a large blood clot in his/her small intestine. The DON said the Facility used Federal regulation F 157 as their notification policy and said the nurses did not follow the Facility Policy.

Based on record review and interviews, for one of three sampled residents (Resident #1), regarding the completion of laboratory studies, the Facility failed to ensure the laboratory studies were obtained as ordered by the physician, which resulted in Resident #1, whose [DIAGNOSES REDACTED]. On 9/18/14, Resident #1 had blood in his/her stool; the staff transferred Resident #1 to the Emergency Department (ED), and Resident #1 was admitted to the hospital with [REDACTED]. Findings include: Resident #1 had a history of [REDACTED]. The physician order, dated 8/29/14, included: [MEDICATION NAME] 4 milligrams (mg) on Monday, Wednesday, and Friday, [MEDICATION NAME] 3.5 milligrams (mg) on Tuesday, Thursday, Saturday, and Sunday, and INR level on 9/2/14. The Surveyor interviewed Nurse #7 at 4:30 P.M., on 11/3/14. Nurse #7 said in error, she did not complete laboratory paperwork for Resident #1's 9/2/14 INR and [MEDICATION NAME] time (PT). The "Nursing 2014 Drug Handbook indicated INR determinations were essential for proper control and the recommended INR range was usually 2 to 3." [MEDICATION NAME] has a narrow therapeutic index (defined as a small range at which a medication dose is beneficial without causing serious complications, and which necessitates careful monitoring of INR). The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M., on 11/3/14. The DON said Nurse #7 did not complete a laboratory slip for the 9/2/14 INR and PT, and therefore the laboratory did not obtain the 9/2/14 INR and PT. The DON said the Physician/Nurse Practitioner (NP) gave [MEDICATION NAME] orders based on Resident #1's INR; the nurse did not call the Physician/NP, and therefore, there were no further [MEDICATION NAME] orders after 9/1/14. The DON said Resident #1 did not receive [MEDICATION NAME] between 9/1/14 and 9/16/14. The DON said the staff discovered the error on 9/17/14 and notified the Physician. The evening shift nurse's note, dated 9/18/14, indicated Resident #1 had 4 loose stools between 3:00 P.M. and 6:00 P.M. The nurse's note indicated Resident #1 complained of rectal bleeding and had a small amount of blood on a piece of toilet paper. The nurse's note indicated when the nurse checked on the Resident, Resident #1 had a moderate amount of bleeding in the toilet. The nurse's note indicated the staff transferred Resident #1 to the ED. The Hospital Computed Tomography (CT) Scan of the Abdomen and Pelvis with intravenous and oral contrast, dated 9/20/14, indicated Resident #1 had suspicion of a near but not completely occluding thrombus (blood clot), likely an [MEDICAL CONDITION] (piece of a thrombus that has broken free) in the superior [MEDICATION NAME] artery approximately 3.5 centimeters (cm). The CT Scan of the Abdomen and Pelvis indicated Resident #1 had ischemic (dead) bowel changes.

Based on record review and interviews, for one of three sampled residents (Resident #1), who required anticoagulant therapy, the Facility failed to ensure that Resident #1's international normalized ratio (INR) was obtained on 9/2/14 as ordered. Resident #1, who had a history of [REDACTED]. On 9/17/14, the staff identified the error, and Resident #1's 9/17/14 INR was 0.9 (therapeutic range 2 to 3). Resident #1 received [MEDICATION NAME] 5 milligrams (mg) on 9/17/14 and 9/18/14, and the anti-coagulant medication, [MEDICATION NAME] 100 mg by injection on 9/18/14. Resident #1 had rectal bleeding; was admitted to the Hospital and diagnosed with [REDACTED]. Findings include: The Admission record indicated the staff admitted Resident #1 to the Facility in June 2013 and his/her [DIAGNOSES REDACTED]. The March 2014 physician orders, included: [MEDICATION NAME], a medication with a narrow therapeutic index (a small range at which a medication dose is beneficial without causing serious complications), and would be adjusted per Resident #1's INR/[MEDICATION NAME] (PT) levels for [MEDICAL CONDITION] and aspirin 81 mg daily (side effect bleeding). The plan of care, dated 3/18/14, related to Resident #1's use of anticoagulation therapy for management of [MEDICAL CONDITION], included: anticoagulant and laboratory studies as ordered and monitor for active bleeding. The Annual Minimum Data Set (MDS), completed on 6/9/14, indicated Resident #1 was alert and oriented and had no cognitive impairment. The Surveyor interviewed Family Member #1 at 3:00 P.M., on 10/30/14. Family Member #1 said Resident #1 was alert and oriented, had a history of [REDACTED]. Family Member #1 said Resident #1 had weekly international normalized ratio (INR) levels at the Facility. Family Member #1 said although the nurses gave Resident #1's medications whole in applesauce, Resident #1 asked the nurses if they gave him/her [MEDICATION NAME]. The Surveyor interviewed Unit Manager #1 at 1:15 P.M. on 11/3/14. The Surveyor interviewed Nurse #1 at 10:10 A.M. on 11/3/14. The Surveyor interviewed Nurse #2 at 2:05 P.M. on 11/3/14. The Surveyor interviewed Nurse #3 at 3:25 P.M. on 11/3/14. The Surveyor Nurse #4 at 2:25 P.M. on 11/3/14. The Surveyor interviewed Nurse #5 at 2:45 P.M. on 11/3/14. The Surveyor interviewed Nurse #6 at 5:00 P.M. on 11/3/14. The Surveyor interviewed Nurse #7 at 4:30 P.M. on 11/2/14. The Surveyor interviewed Nurse #8 at 10:50 A.M. on 11/3/14. Unit Manager #1, Nurse #2, Nurse #3, Nurse #5, Nurse #6, and Nurse #8 said they were aware Resident #1 had a history of [REDACTED].#8 said she was often assigned to Resident #1. Nurse #8 said Resident #1 often asked if he/she received [MEDICATION NAME] during the evening medication pass. The physician order, dated 8/22/14, included [MEDICATION NAME] 4.0 mg alternate daily with [MEDICATION NAME] 3.5 mg until 8/29/14 and staff were to arrange for Resident #1 to have an INR on 9/2/14. The laboratory studies, dated 7/8/14 to 8/29/14, indicated Resident #1 had weekly PT and INR levels; the nurses notified the Physician/Nurse Practitioner (NP), and new orders for [MEDICATION NAME] were obtained. The Surveyor interviewed the Minimum Data Set (MDS) Coordinator at 8:10 A.M. on 11/3/14. The MDS Coordinator said late in the afternoon, on the last day of each month, she printed the physician orders [REDACTED]. The MDS Coordinator said once the monthly printing was completed, the nurses had to add new changes in physician orders [REDACTED]. The MDS Coordinator said on Friday, 8/29/14, there were computer issues and to avoid printing issues on the weekend, the Corporation instructed the Facility to print the September physician orders [REDACTED]. This would necessitate staff writing any medication and treatment changes ordered by the MD/NP from 8/29/14 to 8/31/14, onto both the August 2014 and September 2014 medication administration records. Unit Manager #1 said on 8/29/14, she told the day nurses, the September 2014 physician orders/MARs were printed and to add physician orders [REDACTED]. Unit Manager #1 said she told the day nurses to tell the evening nurses during shift report and continue passing on the information during shift reports. The laboratory study, dated 8/29/14, included: an INR level of 2.89 (therapeutic range 2 to 3). The physician order, dated 8/29/14, included: [MEDICATION NAME] 4 mg on Monday, Wednesday, and Friday and [MEDICATION NAME] 3.5 mg on Tuesday, Thursday, Saturday, and Sunday and INR level on 9/2/14. The Surveyor interviewed Nurse #9 at 2:30 P.M. on 11/5/14. Nurse #3, Nurse #4, Nurse #7, and Nurse #9 said they were assigned to work between 8/29/14 and 8/31/4. Nurse #3, Nurse #4, Nurse #7, and Nurse #9 said they were not aware the September 2014 physician orders/MARs were printed on 8/29/14 and not on the last day of the month per the usual practice. Nurse #7 and Nurse #9 said they were never educated regarding transcribing orders at the end of the month on the next month's MAR. Nurse #7 said although she placed the 8/29/14 [MEDICATION NAME] order on Resident #1's August 2014 MAR, she did not place the order on the September 2014 physician order [REDACTED].#7 said in error, she did not complete a laboratory slip for Resident #1's 9/2/14 INR/PT. The MDS Coordinator said each night, the night nurses reviewed the orders from the previous 24 hours to ensure the orders were posted accurately. Nurse #3 said during her review of the past 24 physician orders [REDACTED]. Nurse #3 said sometimes when she came back to the computer, the computer had timed out, and she had to reboot the computer. Nurse #3 said she was assigned on Resident #1's unit during the night shift between 8/29/14 and 8/30/14. Nurse #3 said if she had to reboot the computer, in error, she may have not reviewed Resident #1's 24 hour orders. Nurse #3 did not identify the order for [MEDICATION NAME] doses for 9/1/14 and 9/2/14 or the order for Resident #1's INR to be obtained on 9/2/14 and therefore, the orders were not transcribed onto the September MAR and the laboratory slip was not completed. The nurse's note, dated 8/30/14, indicated Resident #1 complained of right sided abdominal pain, which felt skin deep and not visceral, and the nurse notified the Nurse Practitioner (NP). The nurse's note, dated 8/31/14, indicated Resident #1 had no abdominal pain. The physician progress notes [REDACTED].#1 had a history of [REDACTED]. The Physician note indicated the staff closely monitored Resident #1's INRs and his/her most recent INR, dated 8/29/14 was 2.89. The Surveyor interviewed the Physician at 12:00 P.M. on 11/5/14. The Physician said on 9/5/14, he evaluated Resident #1 for an ear issue. The Physician said the NP usually ordered the [MEDICATION NAME] dose and follow up INR and PT laboratory studies for Resident #1. The Physician said he and the NP did not track resident's laboratory schedules and results. The Physician said the Facility was responsible for tracking laboratory work and physician notification. The Physician said he was not aware the 9/2/14 INR level was not completed and was not aware Resident #1 had no order for [MEDICATION NAME] between 9/2/14 and 9/16/14. There was no documentation to indicate in Resident #1's MAR that Resident #1 received [MEDICATION NAME] after 8/31/14. Unit Manager #1 said the Physician and Nurse Practitioner (NP) did not contact the Facility regarding Resident #1's 9/2/14 INR/PT. The [MEDICATION NAME] ([MEDICATION NAME]) Monitoring Policy, dated 4/22/13, indicated the nurses were to use the [MEDICATION NAME] Therapy Medication Administration Record (MAR) or the [MEDICATION NAME] Flow sheet instead of the monthly MAR. The [MEDICATION NAME] Monitoring Policy indicated the nurse was to document the [MEDICATION NAME] time (PT)/international nationalized ratio (INR) laboratory results and new orders for [MEDICATION NAME] on the [MEDICATION NAME] Therapy MAR or Flow Sheet. The [MEDICATION NAME] Monitoring Policy indicated that residents on [MEDICATION NAME] therapy were to have a [MEDICATION NAME] Alert notice placed in the front of their MAR. The Surveyor interviewed the Director of Nurses (DON) at 8:00 A.M., on 11/3/14. The DON provided the Surveyor with the names of the nurses assigned to Resident #1 during the evening shift between 9/1/14 and 9/16/14, which included Nurse #1, Nurse #2, Nurse #3, Nurse #4, Nurse #5, and Nurse #6. The DON said Nurse #5 was the nurse, who usually was assigned to Resident #1 and Nurse #2 was the usual weekend nurse. Nurse #1, Nurse #2, Nurse #4, Nurse #5, and Nurse #6 said they were aware there was a [MEDICATION NAME] alert sheet placed in the front of a resident's MAR, if the resident received [MEDICATION NAME]. Nurse #2 said not all residents who received [MEDICATION NAME] had a [MEDICATION NAME] alert. Nurse #1, Nurse #2, Nurse #4, Nurse #5, and Nurse #6 said between 9/1/14 and 9/16/14, there was no notation in the MAR that Resident #1 had an order to receive [MEDICATION NAME]. Nurse #1 said she did not usually work on Resident #1's unit and was not aware Resident #1 received [MEDICATION NAME] or had a history of [REDACTED].#1 and Nurse #2 said the only way they would have known Resident #1 was on [MEDICATION NAME] was by a [MEDICATION NAME] order in the MAR and the [MEDICATION NAME] alert sheet. Nurse #4 said she rarely was assigned on Resident #1's unit. Nurse #4 and Nurse #5 they did not recall seeing a [MEDICATION NAME] alert sheet in Resident #1's MAR. Nurse #5 said she could not be expected to remember all the medications each resident received. Nurse #5 said she gave medications to residents based on the medication orders written on the MARs. Nurse #6 said she did not consistently check the alerts kept in the residents' MARs. Nurse #1, Nurse #2, Nurse #4, Nurse #5, and Nurse #6 said they did not question why Resident #1's [MEDICATION NAME] abruptly stopped on 9/1/14, did not question why Resident #1 did not receive [MEDICATION NAME]. Nurse #1, Nurse #2, Nurse #4, Nurse #5, and Nurse #6 said they were not aware Resident #1 had an order for [REDACTED]. The DON said on 9/17/14, the MDS Coordinator noted the error; the Physician was notified, and an INR/PT was ordered. The DON said the nurse did not notify the laboratory regarding the 9/2/14 INR level; the 9/2/14 INR was not completed, Resident #1 did not have a [MEDICATION NAME] order, and once new September 2014 medication administration records were implemented, Resident #1 did not receive [MEDICATION NAME] between 9/1/14 and 9/16/14. The DON said at the front of Resident #1's MAR, there was a [MEDICATION NAME] alert sheet. The DON said the nurses did not look at the [MEDICATION NAME] alert sheet, prior to giving Resident #1 his/her medications. The DON said on 9/17/14, when the error was noted, she and Unit Manager #1 reviewed Resident #1's MAR and the [MEDICATION NAME] alert was in front of the medication sheets per the protocol. The DON said prior to the incident, there was a [MEDICATION NAME] Log on each unit. The DON said the [MEDICATION NAME] Log contained the names of all residents, who received [MEDICATION NAME]. The DON said the nurses added a resident's name to the log after each anticoagulant medication change and/or when they received INR and PT reports. The DON said the [MEDICATION NAME] Log did not contain the date of a resident's next INR/PT laboratory study. The DON said the last notation for Resident #1 in the [MEDICATION NAME] Log was on 8/29/14 and contained the 8/29/14 INR and PT results and the current [MEDICATION NAME] order, and did not contain the date of the next INR and PT laboratory study for 9/2/14. The DON said the [MEDICATION NAME] Log was not kept and was shredded due to the log containing all names of residents, who received [MEDICATION NAME] and was not available for the Surveyor to review on the day of the survey visit. The "Nursing 2014 Drug Handbook" indicated INR determinations were essential for proper control and the recommended INR range was usually 2 to 3. The physician order, dated 9/17/14, included [MEDICATION NAME] 5 mg daily for two days and recheck INR on 9/19/14. The laboratory study, dated 9/17/14, included: a subtherapeutic INR of 0.9 (therapeutic range 2 - 3, and a low level can place Resident #1 at an increased risk for a blood clot due to his/her [MEDICAL CONDITION]). The Surveyor interviewed Family Member #1 at 3:00 P.M., on 10/30/14. Family Member #1 said on 9/18/14, at approximately 10:30 A.M., Resident #1 told Family Member #1, he/she had nausea, stomach pain, and diarrhea with blood, and Resident #1 informed his/her assigned certified nurse aide (CNA). The physician progress notes [REDACTED].#1 did not receive [MEDICATION NAME] for the first 17 days of September 2014. The Physician note indicated Resident #1 received [MEDICATION NAME] 5 mg on 9/17/14 and 9/18/14. The Physician note indicated the plan was to give Resident #1 a dose of [MEDICATION NAME] as a "bridge" to the [MEDICATION NAME] anticoagulation with daily INRs and subsequent [MEDICATION NAME] per the laboratory studies. The physician order, dated 9/18/14, included the anticoagulant medication, [MEDICATION NAME] 100 mg by injection. The Physician said [MEDICATION NAME] would take approximately five days to significantly increase Resident #1's INR level. The Physician said he consulted with another physician and the plan was to give [MEDICATION NAME] daily based on daily INR and PT labs until the INR was at a therapeutic level. The Physician said he discussed the incident with the DON. The Physician said the nurses, who routinely gave [MEDICATION NAME] to Resident #1 did not question why Resident #1 did not receive [MEDICATION NAME]. The Physician said Resident #1's admission INR level at the Hospital was subtherapeutic at 1.1 and Resident #1's hematocrit was at a normal level. The Physician said a blood clot in the intestine can formulate quickly. The Physician said not receiving [MEDICATION NAME] placed Resident #1 at a greater risk for a blood clot. The evening shift nurse's note, dated 9/18/14, indicated Resident #1 complained of loose stools and per Resident #1 and shift report, Resident #1 had 4 to 5 loose stools during the day shift with some blood visible on the toilet tissue. The note indicated the nurses notified the Physician, who gave an order for [REDACTED]. The nurse's note indicated when the nurse checked on the Resident, Resident #1 had a moderate amount of bleeding in the toilet. The nurse's note indicated Resident #1 was alert, had a heart rate of 90, and a blood pressure of 163/78. The nurse's note indicated the staff transferred Resident #1 to the ED. The ED Physician note, dated 9/18/14, indicated Resident #1 passed a small amount of bright red blood from the rectum. The Computed Tomography (CT) Scan of the Abdomen and Pelvis without contrast, dated 9/19/14, indicated there was no acute abnormality. The CT Scan of the Abdomen and Pelvis with intravenous and oral contrast, dated 9/20/14, indicated Resident #1 had suspicion of a near but not completely occluding thrombus (blood clot), likely an [MEDICAL CONDITION](piece of a thrombus that has broken free) in the superior [MEDICATION NAME] artery approximately 3.5 centimeters (cm). The CT Scan of the Abdomen and Pelvis indicated Resident #1 had ischemic bowel (defined as a condition in which inflammation and injury occurs to the large intestine as a result from inadequate blood supply. changes).

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1, who had a history of [REDACTED]. The Director of Nurses (DON) said Resident #1 had five falls in about 2 months because Resident #1 fell when he/she got out of bed while not wearing non skid slipper socks and before staff responded to the safety alarms. Physician #1 said Resident #1 sustained a fractured left fibular due to the fall on 4/16/13 and sustained a laceration due to the fall on 6/30/13 that required 25 sutures. Findings include: The Admission Record indicated that Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The updated plan of care, dated 3/15/13, indicated that Resident #1 was at risk for falls due to a cerebrovascular accident that resulted in left sided weakness and impulsiveness. The plan of care interventions included: call light and personal items within reach, keep area free of clutter, remind him/her to request assistance for toileting, care needs, and ambulation, a bed alarm, and non skid socks or proper footwear at all times. The quarterly resident fall evaluation, dated 3/19/13, indicated that Resident #1 had fallen in the last thirty days, had no change in mobility, and required physical assistance with bed mobility, transfer or ambulation. The Surveyor interviewed the Director of Nurses (DON) at 8:15 A.M. and 3:30 P.M. on 7/22/13. The DON said Resident #1 had a history of [REDACTED].M. on 4/16/13 while getting out of bed unassisted, and while not wearing non skid slipper socks per the plan of care. The day shift nurse's note, dated 4/16/13, indicated that Physician Assistant #1 was notified that Resident #1 had a fall, was seated with his/her left leg beneath him/her, and complained of left leg pain. The nurse's note indicated that new orders were obtained from Physician Assistant #1 to transfer Resident #1 to the Hospital for an evaluation. The incident report, dated 4/16/13, indicated that Resident #1 was seated in bed, and then he/she got out of bed without assistance to use the toilet, and fell due to weakness. The incident report indicated that at the time of the fall Resident #1 had no footwear on. The Surveyor interviewed Nurse #1 at 12:45 P.M. on 7/22/13. Nurse #1 said she was assigned to Resident #1's nursing care needs during the day shift on 4/16/13. Nurse #1 said she had last entered Resident #1's bedroom at approximately 12:00 P.M. on 4/16/13 to do a treatment, but did not notice if Resident #1 had his/her non skid slipper socks on because his/her feet were covered by linen. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 at 1:15 P.M. on 7/22/13. CNA #1 said she was assigned to Resident #1's personal care needs during the day shift on 4/16/13. CNA #1 said she had assisted Resident #1 with personal morning care and assisted him/her with toileting when he/she requested assistance. CNA #1 said she could not recall if she had put Resident #1's slipper socks on. The Facility's (4/16/13) internal investigation report, indicated that Resident #1's bed alarm was activated (sounding), and he/she was found seated by his/her bathroom door. The report indicated that Resident #1 transferred out of bed without assistance, and landed on the floor next to his/her bathroom door at 12:20 P.M. on 4/16/13. The report indicated that Physician Assistant #1 was notified that Resident #1 had left leg pain after the fall and Physician Assistant #1 gave new orders to transfer Resident #1 to the Hospital for evaluation. The Hospital x-ray report, dated 4/16/13, indicated Resident #1 had a left fibular fracture. The Hospital Emergency Department (ED) report, dated 4/16/13, indicated that Resident #1, returned to the facility on the same day with recommendations to wear a left leg splint and maintain a non weight bearing status until a follow up appointment in 2 days (4/18/13). The DON said an alarmed floor mat on the right side of the bed was added to Resident #1's plan of care following his/her fall on 4/16/13. The physician orders, dated 4/18/13, indicated Resident #1 had a weight bearing as tolerated status while wearing the left leg immobilizer. The DON said Resident #1 fell at 4:00 P.M. on 5/5/13 when he/she got out of bed unassisted to use the toilet while not wearing non skid slipper socks per the plan of care and sustained no injury. The DON said the bed alarm was in the off position and had not sounded but was in good working order when tested . The DON said staff believed Resident #1 shut off the bed alarm because it was on and functioning when checked during shift change. The Surveyor interviewed Nurse #2 at 1:00 P.M. on 7/22/13. Nurse #2 said she was assigned to Resident #1's nursing care needs during the evening shift on 5/5/13. The Surveyor interviewed CNA #2 at 1:30 P.M. on 7/22/13. CNA #2 said he was assigned to Resident #1's personal care needs during the evening shift on 5/5/13. CNA #2 said he routinely assisted Resident #1 with toileting when she requested assistance. Nurse #2 and CNA #2 said they had last entered Resident #1's bedroom during shift rounds at approximately 3:00 P.M. on 5/5/13, but did not notice if Resident #1 wore his/her non skid slipper socks because his/her feet were covered by linen. The Facility's (5/28/13) internal investigation report, indicated that Resident #1's safety alarms were sounding, and he/she was seated on the floor on the right side of his/her bed. The report indicated that Resident #1 slid off the side of the bed while not wearing non skid slipper socks, landed on the floor next to his/her bed at 3:45 A.M. on 5/28/13. The report indicated that Physician #1 was notified that Resident #1 had fallen with no apparent injury and recommendations included a wider bed. The DON said a wider bed was added to Resident #1's plan of care following his/her fall out of bed on 5/28/13. The DON said Resident #1 fell at 6:45 P.M. on 6/7/13 when he/she got out of bed unassisted to use the toilet while not wearing non skid slipper socks per the plan of care, and sustained no injury. The Surveyor interviewed Nurse #4 at 4:45 P.M. on 7/23/13. Nurse #4 said she was assigned to Resident #1's nursing care needs during the evening shift on 6/7/13. Nurse #4 said Resident #1 routinely used the call light for assistance with toileting. The Assigned CNA was not interviewed because he was on vacation. Nurse #4 said she entered Resident #1's bedroom shortly before supper time on 6/7/13 to do a treatment. Nurse #4 said she left Resident #1 lying in bed with the call light within reach and safety alarms functioning, Nurse #4 said she did not notice if Resident #1 had his/her slipper socks on because his/her feet were covered by linen. The Facility's (6/7/13) internal investigation report, indicated that Resident #1's safety alarms were sounding, and he/she was found lying on the floor in front of the bathroom door. The report indicated that Resident #1 transferred out of bed without assistance, while not wearing any footwear, landed on the floor next to his/her bathroom door at 6:45 P.M. on 6/7/13. The report indicated that Nurse Practitioner #1 was notified that Resident #1 had fallen, had no apparent injury and received no new orders. Nurse #4 said Resident #1 was toileted when he/she requested because he/she was able to communicate his/her needs. The DON said Resident #1 required physical assistance during ambulation. The DON said Resident #1 was encouraged not to ambulate unassisted or with barefeet. The DON said Resident #1 fell at 9:30 P.M. on 6/30/13 when he/she got out of bed unassisted to use the toilet while not wearing non skid slipper socks per the plan of care. The DON said Resident #1 fell before staff responded to the floor mat alarm and sustained a 5 centimeter (cm) by 1 cm laceration on the forehead that required sutures. CNA #2 said he was assigned to Resident #1's personal care needs during the evening shift from 3:00 P.M. to 7:00 P.M. on 6/30/13. CNA #2 said he was unable to recall if Resident #1 had on non skid slipper socks prior to the fall on 6/30/13 because his/her feet were beneath the bed linen. CNA #2 said he could not recall if Resident #1 had requested assistance prior to him leaving duty at 7:00 P.M. on 6/30/13. The Surveyor interviewed CNA #4 at 7:45 A.M. on 7/23/13. CNA #4 said he was assigned to Resident #1's personal care needs during the evening shift from 7:00 P.M. to 11:00 P.M. on 6/30/13. CNA #4 said Resident #1 requested assistance with toileting and evening personal care when he/she wanted care. CNA #4 said he did not check Resident #1's safety alarms or to see if he/she had on his/her non skid slipper socks. CNA #4 said Resident #1 had not requested toileting or personal care prior to his/her fall at 9:30 P.M. on 6/30/13. CNA #4 said he thought Resident #1 was provided personal care earlier in the shift by CNA #2. CNA #4 said the floor mat alarm sounded, but the bed alarm did not sound when he/she fell because the bed alarm was turned off. The Facility's (6/30/13) internal investigation report, indicated that Resident #1's bed alarm was in the off position, the floor mat alarm sounded, and he/she was found lying on the floor next to his/her bed. The report indicated that Resident #1 transferred out of bed without assistance or proper footwear, landed on the floor next to his/her bed at 9:30 P.M. on 6/30/13. The report indicated that Physician #1 was notified that Resident #1 had sustained a laceration when he/she fell and gave new orders to transfer Resident #1 to the Hospital for treatment. The DON said a sensor motion detector was added to Resident #1's plan of care following his/her fall out of bed on 6/30/13. The Hospital Discharge Summary, dated 7/1/13, indicated that Resident #1 required 25 sutures by a plastic surgeon due to a large forehead laceration that occurred due to a fall at the Facility. The Surveyor interviewed Physician #1 at 12:15 P.M. on 7/22/13. Physician #1 said Resident #1 required hospitalization s for treatment of [REDACTED].

Based on observation, record review and staff interview, the facility failed to ensure that 2 Residents (#14 and #16) in a sample of 24 were provided adequate supervision and effective interventions to prevent accidents. In addition, the facility failed to follow their smoking policy for 16 smoking residents including 5 of 7 Non-Sampled Residents (NS #3, NS #4, NS #5, NS #6 and NS #7). Findings include: 1. For resident# 14, the facility failed to ensure that the resident, who has a history of falls with injuries, was properly supervised and that identified care plan interventions were in place to prevent further injuries. Resident #14 was admitted to the facility in 1/13. The resident's [DIAGNOSES REDACTED]. The Initial Minimum Data Set ((MDS) dated [DATE] identified the resident as having short and long-term memory loss, requiring extensive assistance in transfers and ambulation and having fallen in the previous month. The care plan identified falls as a problem area and indicated it was related to weakness, decreased mobility, impaired cognition and decreased safety awareness secondary to a TBI/dementia. Interventions included: *2 person assist for transfer as needed due to increased weakness or behaviors. *Bed and chair alarms as ordered. *Assist resident getting in and out of bed with assistance and rolling walker. The resident was noted to have an infection and was on antibiotics when he/she fell on [DATE]. Specifically, review of an Accident/Incident report dated 1/11/13 indicated the resident was found on the floor in the dining room at 9:15 A.M. with the alarm sounding. Prior to the fall, the resident was restless and agitated. At the time of the fall, it was unknown what the resident as doing. Further review indicated staff was called into the room by another resident's family member notifying them that this resident had fallen on the floor and the alarm was on. In addition, the report noted it was the third time in five minutes the resident's alarm had sounded. No injury was noted. The resident's care plan was updated to include a medication review. The resident sustained [REDACTED]. Review of the facility report sent to the Department of Public Health indicated the following: The resident was toileted on 1/27/13 at 6:30 P.M. and then put to bed. Information in the report indicated a few hours passed when staff heard an alarm. The resident's door was opened and the resident was found on the floor holding the area above his/her left eyebrow. There was no evidence indicating the resident was observed by staff between the hours of 6:30 P.M. and 8:30 P.M., a 2 hour time span. The report indicated the resident transferred himself/herself out of bed alone. He/she was unable to participate in an interview due to his/her cognitive status. He/she sustained a 3 centimeter laceration above his/her left eyelid and was sent to the emergency room for treatment. He/she returned with 6 sutures in place. The resident's care plan was updated to include the following interventions: *Bed in low position. *Mats next to bed. *Bed against the wall. However, the care plan did not address the resident's inability to call for assistance due to his/her cognitive deficits. Furthermore, the care plan did not include effective interventions that would alert staff that he/she needed assistance. On 2/7/13 at 11:05 A.M., the resident was observed lying in a low bed next to the wall with a mat on the floor. Nurse #3 was in the room with the resident and she stated she had just put the resident in bed. The surveyor left the room and returned 5 minutes later after Nurse #3 left the room. The resident was observed asleep in bed with a mat on the floor. The bed alarm was attached to the resident's side rail, however there were no wires attached to the alarm box thereby rendering the alarm inoperable. On 2/7/13, the resident was observed at 1:45 P.M. and at 2:15 P.M. asleep in a low bed next to the wall. Once again the bed alarm was attached to the resident's side rail but there were no wires attached to the alarm box, thereby rendering the alarm inoperable. In addition, the mat was not on the floor next to the resident's bed but was standing up against the wall beside the resident's bed. On 2/7/13, at 2:20 P.M. the surveyor requested Nurse #2 to observe the resident with the surveyor. Upon observation, she stated she was unaware the bed alarm wiring was not attached to the resident's bed alarm and that the resident's mat was not on the floor while he was in bed. The surveyor informed her of an earlier observation made at 11:05 A.M. whereby nursing staff did not properly attach the resident's bed alarm to the resident. She stated that she would follow-up with nursing staff. The facility failed to properly supervise this resident as he/she sustained 2 falls within a 16 day period, one with injury. In addition, the facility failed to implement effective interventions that were developed to keep the resident safe. 2. For Resident #16, the facility failed to ensure a bed alarm was in put in place for a resident who had a history of [REDACTED]. Resident #16 was admitted to the facility in 4/11. The resident's [DIAGNOSES REDACTED]. Review of a Risk Management Report dated 12/2/12 indicated the resident was sitting in the main Dining Room when he/she fell to the floor and vomited. The resident was sent to the hospital and admitted for aspiration pneumonia. Review of a Risk Management Report dated 12/10/12, indicated the resident returned from the hospital on [DATE] at 3:30 P.M. The resident was evaluated by the Speech Therapist between 3:30-4:00 P.M. It was noted that when she left, the resident was lying in bed. A thump was heard at 4:20 P.M. He/She was sent to the hospital and returned with 6 sutures on his/her forehead. A bed alarm was instituted by nursing at that time and a physician's orders [REDACTED]. The significant Change MDS dated [DATE], identified the resident as having short and long-term memory loss and moderately impaired cognition. He/she required extensive assistance in transfers and ambulation and had sustained a fall in the previous 3 months with major injury. Review of a Risk Management Report dated 1/31/13 indicated the resident was found that evening at 7 P.M. in a sitting position on the floor beside his/her bed fixing his/her shoelaces. The report further indicated an alarm was not being used for the resident at the time. On 2/11/13, the surveyor reviewed the 12/12 Treatment Administration Record (TAR) and found there was no written documentation regarding the use of a bed alarm for the entire 12/12 time period. The resident was observed out of bed on 3 separate occasions on 2/11/13: * At 8:30 A.M. he/she was observed ambulating independently in the Day Room with staff nearby. * At 10:45 A.M., he/she was observed seated in the Day Room with his/her head down on the table. * At 1:20 P.M., he/she was observed ambulating independently in the hallway. Interview with the Speech Therapist at that time revealed the resident is able to ambulate safely independently. * At 2:35 P.M., the resident was observed ambulating independently in the hallway with staff nearby. On 2/11/13 at 2:40 P.M., an interview was held with Nurse #2. She stated that when a bed alarm is being used for a resident, it is identified on the resident's TAR. She confirmed this physician ordered intervention was not written on the 12/12 TAR and she could not confirm if it was in place at that time. 3. The facility's Smoking Policy, dated 1/08, indicated that the Administrator/designee was to provide a method of storage for smoking materials (matches, lighters, and cigarettes). During an interview with the Administrator on 2/12/13 at 1:30 P.M., he said that residents were not to have cigarettes and/or matches/lighters on their person. He said, however, cigarettes had been found on some of the residents in the past. However, no lighters and/or matches were found on a resident. On 2/12/13 at 8:10 A.M., NS #3 was observed by a surveyor to exit the front door and light a cigarette in front of the building to smoke. The surveyor told Unit Manager #2 who instructed the resident to return inside the facility. The surveyor observed NS #3 throw the lit cigarette into the snowbank prior to re-entering the building, when Unit Manager #2 approached him/her. On 2/12/13 at 9:45 A.M., the surveyor observed NS #4 in a common area holding an unlit cigarette and NS #5 and NS #6 sitting in his/her wheelchair in the hallway holding an unlit cigarette. The residents were waiting either beside or across from the supervised smoking area on the Whitemore unit for the 10:00 A.M. smoking time to begin. The Activity Assistant assisted the residents (16 residents) outside for the scheduled smoking time at approximately 10:00 A.M.. Once all the residents were outside on the porch, she gave a cigarette to each resident without a cigarette from a storage container labeled with the resident's name and lit that cigarette. She also lit the cigarettes of those residents who had brought a cigarette out with them. NS #3 was observed taking a package of cigarettes from his/her pocket and withdrew 2 cigarettes to smoke. No lighter and/or matches were observed on NS #3. During the smoking period, NS #3, NS #5, and NS #7 were observed dropping ashes from their lit cigarette onto the rubberized mat which was covering on the porch. The Activity Assistant tried to provide ash trays to the residents to prevent ashes from landing on the rubberized mat, but she was unable to reach each resident before ashes dropped from the lit cigarette. No cigarettes were observed being crushed on the porch floor. On 2/12/13 at 10:30 A.M., the Administrator said that residents were not to have cigarettes on their person and more ashtrays will be provided.

Based on observation and record review, the facility failed to ensure that one resident, who had an unrepaired right [MEDICAL CONDITION] (Resident #1 ), out of a total sample of 3 residents, received the necessary care and services to minimize pain with repositioning. The findings are as follows: The facility failed to implement a care plan to minimize pain, and ensure comfort and proper positioning for Resident #1, who was receiving end of life care. Although interviews with the Director of Nursing Services (DNS) and hospice nurse on 9/23/10 indicated that Resident #1 was on an air mattress for comfort and was to be positioned minimally, the DPH surveyor observed that Resident #1, who experienced pain with minimal movement, was not on a low air loss mattress (though clinically indicated by the facility and hospice care) and was being turned totally from side to side every few hours causing undue pain to this Resident, who was at end of life. Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's admission MDS (minimum data set) Assessment, dated 5/21/10, revealed that Resident #1 was moderately impaired in decision making with short and long term memory loss, required extensive assistance of one staff for bed mobility, transfer, walking and locomotion and toilet use, was continent of bowel and bladder, and had mild pain daily. The record revealed that on 9/12/10, Resident #1 was hospitalized for [REDACTED]. Resident #1 returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. The hospital Discharge Summary of 9/15/10 documented:(Resident #1 was in distress due to the fracture and the pain. The health care proxy (patient's daughter) did not want Resident #1 to undergo any intervention given Resident 1's overall extremely poor prognosis with a metastatic [MEDICAL CONDITION]. After extensive discussion with (Resident #1) and health care proxy, they would like Resident #1 to be kept comfortable and enroll in hospice. They would not like any intervention. They would like pain control. Subsequently hospice was consulted. At this point, the plan is to send Resident #1 back to the skilled nursing facility and a hospice counsel would be requested.) Although, Resident #1 had an unrepaired fractured right hip, the above Discharge Summary documented: "Discharge Activity: Frequent positioning for comfortable, bed to chair, non- weight bearing right leg." (This summary nor Resident #1's record specify how to reposition Resident #1 for comfort, other than to say pillow between the knees.) The facility Interdisciplinary Progress Notes documented: "On 9/15/10 at 12:10 pm Resident #1 returned via stretcher and 2 attendants to room. Upon nursing assessment, Resident #1 is in acute pain with movement to right hip secondary to family and resident choosing to do no surgical interventions. Comfort measure to be maintained thru pain management, Skin check reveals remarkable at bony prominences with area open under left breast with small drainage with dressing in place. Pillows between legs for positioning. Resident #1 somewhat alert but moaning with movement." The Long Term Care Fax Report dated 9/17/10, which was sent by the facility to the Department of Public Health, documented, "Resident #1 remains in bed for comfort and an air mattress has been ordered for comfort. Resident #1's care plan has been updated." A Multidisciplinary Screening Form on 9/16/10 documented: "Patient with new [DIAGNOSES REDACTED]. Currently bed rest on [MEDICATION NAME] (narcotic pain medication) every hour as needed for breakthrough." The following care plan was initiated by the facility for pain for Resident #1 on 9/16/10. "Focus - Orthopedic aftercare secondary to status [REDACTED]." "Resident will be free from discomfort related to [MEDICAL CONDITION]." "Interventions: Pain management program in place. Monitor effectiveness and side effects. Encourage Resident to be out of bed as tolerated. Encourage Resident to perform a much self-care as able. Orthopedic follow up as indicated. Provide assist for ambulation as tolerated. Position for comfort." (There was no further directions regarding positioning for this resident who had an unrepaired [MEDICAL CONDITION].) The facility Interdisciplinary Progress Note on 9/17/10 documented that Resident #1 received religious services and that Hospice was in to start hospice services with Resident #1. On 9/18/10 there was a physician's orders [REDACTED]." The following care plan was initiated for Resident #1 on 9/18/10. "Focus Needs hospice care due to terminal condition of : cancer of end [MEDICAL CONDITION]." "Goals: Will be kept comfortable and cares will be coordinated between Hospice agency and nursing center." "Interventions: Communicate changes in physician orders [REDACTED]. Encourage visitors. Evaluate for pain (0 - 5 scale) and medicate as ordered. Hospice agency will offer social work and chaplain services per their plan of treatment. Maintain quality of life as possible. Observe Resident's comfort measure preferences as applicable.(Again, this was not detailed.)" On 9/23/10 at 10:00 am, during interview with the DPH Surveyor, the DNS reported that Resident #1 was on a low air loss mattress which was initiated for comfort measures (to reduce the need for drastic positioning changes for this Resident with an unrepaired [MEDICAL CONDITION]) and to prevent skin breakdown. The DNS further reported that Resident #1 was now totally dependent on staff for bed mobility and was placed on Hospice care for care and comfort measures only. On 9/23/10 at 10:50 am, the DPH Surveyor observed Resident #1 in bed lying on the right side with eyes closed and both legs bent at the knees. Resident #1's right orbital area was bruised as well as the right cheek. Resident #1 was not on a low air loss mattress. At this time, Resident #1 was observed to cry out in pain when slightly turned to the side by the CNA and nurse, who were checking the sensor alarm in the bed that Resident #1 was lying on. On 9/23/10 at 1:40 pm, interview with the Hospice Agency Nurse #3 revealed that based on her assessment of Resident #1 that morning, Resident #1's pain was a 7 to 8 with any major repositioning (the pain scale used was 1 to 10 with 10 being the worst pain.) Hospice Nurse #3 stated that it was a challenge to manage pain in a Resident with an unrepaired [MEDICAL CONDITION]. Hospice Nurse #4 further commented that Resident #1 should not be fully repositioned side to side, rather there should be only "minute changes" made in positioning Resident #1. Hospice Nurse #3 further indicated that Resident #1 was on a low air loss mattress, in order to minimize the amount of repositioning needed for Resident #1. In addition, Hospice Nurse #3 reported that lying on the right side was Resident #1's position of comfort and "you don't want to go against that if that's where the hip is naturally sitting." When the DPH surveyor informed Hospice Nurse #3 that Resident #1 was not on a low air loss mattress on 9/23/10, Hospice Nurse #3 indicated that this was the first time Hospice Nurse #3 saw Resident #1 (as another hospice nurse saw Resident #1 last week) and Hospice Nurse #3 may have been getting Resident #1 mixed up with another Resident. On 9/23/10, further interview with the DNS, at approximately 2:00 pm confirmed that Resident #1 was suppose to be on a low air loss mattress that the Hospice Agency was responsible to provide this mattress. The DNS further confirmed that the nursing home had some loss air loss beds available at the nursing home that could be used for Resident #1, however, this bed had not been provided as it was the Hospice Agency's responsibility to provide this specialty bed. The DNS also confirmed that the CNAs should only be making small shifts when positioning Resident #1 and should avoid fully turning Resident #1 side to side every two hours. This was not what was observed by the surveyor on 9/23/10 as the DPH surveyor observed Resident #1 in bed lying on the right side at 10:00 am, and at 12:35 pm and 1:14 pm was lying fully turned to and on the left side in bed. At 1:14 pm on 9/23/10, CNA #2 was interviewed and reported that Resident #1 was turned every two hours side to side and that Resident #1 was in pain when turned. On 9/23/10 at 2:45 pm Resident #1 was observed lying in the bed and was now totally turned on the right side. At this time, CNA #1 was interviewed and reported that Resident #1 moans when turned. This CNA confirmed that Resident #1 was turned side to side every two hours Although Resident #1 had pain with movement as documented on admission and observed by the Surveyor on 9/23/10 at 10:50 am, and reported by facility staff above, the facility failed to develop a positioning plan that minimized movement based on Resident #1's pain level and position of comfort, and failed to ensure that a specialty bed that minimized the need for major positioning changes was obtained for Resident #1 though clinically indicated.

Based on observation, record review, staff interview and family interview, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 resident (#1) out of 3 sampled residents, who were at risk for falls, in a total sample of 3 residents. Findings included: For Resident #1, although the facility had identified that Resident #1's sensor alarm was not turned on when Resident #1 fell on [DATE], the facility failed to further investigate the circumstances surrounding the fall, including the alarm being off. The facility failed to revise Resident #1's care plan to address the cause(s) of the fall, and Resident #1 sustained a second fall on 9/12/10 in which the facility once again identified Resident #1's alarm being off as a factor in the fall. Resident #1 sustained a fracture hip during this second fall on 9/12/10 that was not repaired due to Resident #1's terminal prognosis. In addition, during the survey on 9/23/10 Resident #1's falls care plan was not followed (see below) as the bed was not always in the lowest position, there were no mats on the floor at Resident #1's bedside, the call bell was not always accessible, the strip sensor alarm was positioned under Resident #1's buttocks and not under Resident #1's shoulders, and the alarm box was within reach of Resident #1. Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission MDS (minimum data set) Assessment, dated 5/21/10, revealed that Resident #1 was moderately impaired in decision making with short and long term memory loss, required extensive assistance of one staff for bed mobility, transfer, walking and locomotion and toilet use and was continent of bowel and bladder. The Resident Assessment Protocol Summary (RAPS) dated 5/21/10 noted, "Resident has difficulty with following complex commands, exhibits poor safety awareness, sequencing and following through with tasks and impulsivity due to her mild - moderately impaired memory deficits." Record review revealed that Resident #1 started going out for radiation treatments on 6/14/10 for treatment of [REDACTED].#1 exhibited increased: depression, anxiety, weepiness, lethargy, confusion, shortness of breath requiring oxygen, and nausea, vomiting and loose stool, required two assists two ambulate to the bathroom and spent most time in bed and in bedroom. Resident #1 stopped going to Radiation Therapy on 6/23/10. In addition, Resident #1's rehabilitative services provided by Physical Therapy, Occupational Therapy and Speech Therapy were discontinued at the end of 6/10 due to Resident #1's decline in medical condition. Resident #1's care plan for falls revealed that on 6/24/10 the following intervention was initiated: "Bed and chair pressure alarms in place. Check function and placement every shift." The record reflected that on 6/29/02 there was a new physician's orders [REDACTED]. On 6/30/10, the Interdisciplinary Progress Notes documented: Increased agitation of this Resident. "New order for Ativan starting tonight, continues on fall precautions." The facility's Risk Management Report documented: "On 7/2/10 at 11 pm Resident #1 was found sitting on the floor beside the bed. Stated Resident #1 had fallen but could not be more specific. Complained of pain in hip and sacral area. Transferred to hospital secondary to evaluation of new pain. CT scan and xrays done negative for injury. Is on pain management plan for cancer at this time. Has had some mental status changes." This report further documented that the alarm for Resident #1 was not turned on, and was not functioning. In addition, the report indicated that the Clinical Management Team determined that the fall, was unwitnessed, was related to decreased cognition and the recommendation was "Check frequently at night." The above facility incident documentation contained inconsistent information as it documented that the fall was unwitnessed and in another section documented that Resident #1 was standing before the fall. Also the hospital Department of Emergency Medicine note, on 7/3/10, documented that the "Patient was standing next to a bench, fell backwards onto buttocks and then bumped the back of her head." (Note: Resident #1 returned to the facility on [DATE] with hospital discharge [DIAGNOSES REDACTED]. After the 7/2/10 fall, there was no evidence that the facility followed up with staff to gather further information on the circumstances surrounding the fall and why the alarm was turned off. Review of Resident #1's care plan revealed that the following general intervention was added to the falls care plan on 7/2/10: "Monitor frequently at night for increased restlessness or increased pain." Although Resident #1 experienced a medical, behavioral, mood, cognitive and functional decline, Resident #1's MDS Quarterly Review, conducted by the facility on 8/25/10, documented "No change in the Resident's overall care needs." Resident #1's care plan to prevent falls was not revised to include specific interventions to address Resident #1's decline and need for increased supervision and monitoring round the clock as evidence by the following care plan. This care plan, other than the use of the alarm, includes all general interventions, some of which were no longer appropriate for this confused, dependent Resident (see below items: c, h, and i.) On 9/23/10, Resident #1's current care plan for falls, which had an initiation date of 8/24/10, documented the following: "Focus: Resident is at risk for falls related to weakness, psychotropic medication use and chronic pain." "Goals: No significant injury related to a fall." "Interventions: a. Bed and chair pressure alarms in place. Check function and placement every shift. b. Assist resident with ambulation as tolerated. c. Encourage resident to communicate needs/ask for assistance. d. Ensure environment is free of clutter. e. Evaluate effectiveness and monitor for side effects of psychotropic drugs. Gradual dose reduction as indicated. f. Have commonly used articles within easy reach. g. Resident to wear proper and non slip footwear. h. Verbal cues and reminders as needed for safety. i. Keep call bell within reach of resident. Remind resident to call for assist. j. Monitor frequently at night for increased restlessness or increased pain. Review of Resident #1's record and the facility Long Term Fax Report Form to the Department of Public Health (DPH), date 9/17/10, revealed that on 9/12/10 Resident #1 turned off the alarm, ambulated unassisted to the bathroom and fell sustaining a fractured right hip, facial bruises and arm pain. The Long Term Fax Report Form report read: "On 9/12/10 at 1:20 pm Resident #1 was heard calling for help from her room. Staff (Nurse #4) immediately responded and observed Resident #1 lying on the floor on her right side with right side forehead leaning against the wall. At this time Nurse #4 observed that Resident #1's alarm had been turned off. Resident #1 was noted to have a large lump on the forehead and complained of right arm pain but was able to move all extremities. However, at the time of the transfer, Resident #1's right leg was noted to be short and externally rotated. Resident #1 was transferred to the hospital and admitted to the hospital with [REDACTED]. On 9/23/10 at 11:05 am, CNA #1 was interviewed by the DPH surveyor regarding what happened on 9/12/10 when Resident #1 fell . CNA #1 reported the following: I was assigned to Resident #1. After lunch, I toileted and changed Resident #1 in Resident #1's room. I placed the sensor alarm pad on the seat of chair beside the bed in Resident #1's room and attached the alarm box with a strap to the wooden arm of the chair. I left Resident #1 sitting on this chair eating lunch, and I left the unit to go on my lunch break. At times, Resident #1 would turn the alarm off. The nurses knew this. At times I would put the alarm box under Resident #1's pillow to prevent Resident #1 from putting it off. I did not do this on 9/12/10. On 9/23/10 at 5:55 pm Nurse #4, who was the first responder to Resident #1's fall on 9/12/10, was interviewed by the DPH surveyor and reported the following: As Nurse #4 was walking down the corridor on 9/12/10 at 1:20 pm, this Nurse happened to glance into Resident #1's room and saw Resident #1 lying on the right side on the bathroom floor and Resident #1's head was pressed up against the wall near the threshold of the door. Resident #1 was unable to tell Nurse #4 what happened. Nurse #4 observed the sensor alarm pad on the bed and the alarm box lying on the floor beside the bed. The alarm was usually clipped to the siderail when Resident #1 was in bed but was not at this time. The alarm was not sounding. Resident #1 is notorious for turning the alarm off. Resident #1 has done it in the past and just starts walking. Resident #1 would say that the alarm was too noisy and the noise was bothersome. I never saw Resident #1 turn it off myself. Resident #1 had fine dexterity to use the phone. I have heard other staff say Resident #1 could turn the alarm off." The statement by Nurse #4 that upon responding to the fall Nurse #4 found the sensor pad on the bed and the alarm box lying on the floor does not support the statement made by CNA #1, during interview, that CNA #1 put the sensor pad on the chair and attached the alarm box to the arm of the chair. The facility's (undated) Summary of Investigation, documented the following regarding the 9/12/10 fall: - At 12:30 pm CNA #1 assisted Resident #1 back to bed and turned the bed alarm on. - The LPN stated that she gave Resident #1 meds at 1 pm and at that time Resident #1 was sitting quietly on bed eating lunch. - Nurse #4, when was in charge of Resident #1 that day, stated she heard Resident #1 calling for help entered the room and found Resident #1 in the bathroom laying on her right side. Nurse #4 stated the alarm did not sound and when she checked the alarm it was turned off. - Per Unit Manager and other staff on unit, Resident #1 on occasion does turn the alarm off.. The Summary of Investigation above further documented: - "Care plan interventions at the time of the fall were grippy socks, call bell within reach, no restlessness, received pain meds at 9 am per schedule. Alarm was in place but off. Resident #1 was toileted 50 minutes prior to fall. " - "Interventions had been effective, however, since Resident #1 turns alarm off and sensor pad under buttocks, upon return will tape/secure sensor pad under shoulders and keep alarm box out of reach. " The investigation did not include a review of Resident #1's ability to shut off the alarm, nor was there evidence of consideration of the possibility that it was never turned on. On 9/12/10, the facility added the intervention to Resident #1's falls care plan: " Tape alarm pad to bed under shoulders. Keep alarm pad out of reach. " On 9/23/10 at 10:00 am, during interview with the DPH Surveyor, the Director of Nurses (DNS) reported the following : Prior to the fall, Resident #1 was pretty mobile and was a stand by assist for ambulation. Resident #1 had some confusion but Resident #1 was able to make decisions. The facility used a bed sensor alarm for Resident #1 in the bed and chair and the box to the alarm was placed on the bed siderail when Resident #1 was in bed. Staff reported that once in awhile Resident #1 would turn the alarm off. Nurse #4 said the alarm was turned off when Nurse #4 found Resident #1 on the bathroom floor. Resident #1 was sent out to the hospital and returned to the facility for care and comfort on 9/15/10, with an unrepaired right fractured hip (health care proxy and Resident #1 declined surgery). Upon return to the facility, Resident #1 was bedbound, totally dependent on staff for bed mobility and was placed on Hospice care on 9/17/10 . According to record review and interview with the DNS on 9/23/10, the facility implemented the following new care plan interventions on 9/15/10: a low bed and mats on either side of the bed. In addition, according to the DNS, and interview with the Hospice Nurse on 9/23/10 an air mattress was in place for comfort. On 9/23/10 at 10:50 am, the DPH Surveyor observed Resident #1 in bed lying on the right side with eyes closed and both legs bent at the knees. Resident #1's right orbital area was bruised as well as the right cheek. There were two padded siderails, approximately 18 inches long on either side of the bed, positioned at the level of Resident #1's shoulders and the head of the bed was slightly elevated. The sensor pad was positioned under Resident #1's buttocks and not under the shoulders as called for in Resident #1's care plan. The alarm box was strapped to the arm of a chair which was adjacent to the bed. This alarm box was potentially within reach of Resident #1 if Resident #1 were to regain some bed mobility. Resident #1 was not on a special air mattress, but on a regular mattress that had some pressure relieving capabilities. On 9/23/10 at 10:50 am, the DPH Surveyor observed that Resident #1's care plan for falls was not followed as evidenced by the following: - The bed was not in the lowest position and there were no mats on the floor - The call bell was not accessible as it was hanging off the bed and out of Resident #1's reach. - The sensor pad to the bed alarm was positioned under the Resident's buttocks and not under Resident #1's shoulders. - The alarm box was within reach of Resident #1. On 9/23/10 further interview with CNA #1 and Nurse #1 revealed that neither were aware that mats on the floor beside the bed were suppose to be used for Resident #1. The alarm that was observed in use on 9/23/10 was the Attendant Economy Alarm which according to the Director of Nurses and Unit Manager #2 was the same type of alarm that was in place at the time of the 7/2/10 and 9/12/10 fall. The manufacturer's placement instructions for this alarm state: "Alarm monitors. Alarms must be mounted out of the resident's reach. Examples of suitable mounting locations include the back of the headboard, back of wheelchair, wall, or under the bed. Be sure that the resident cannot tamper with monitor or reach the " Reset " button. Pressure pads. Place pad under shoulder to be alerted when resident sits up in bed. The (alarm manufacturer) highly recommends the use of a monitor with a safety automatic reset which uses always on technology, eliminating the need for an on/off switch." The alarm that the facility used for Resident #1 did not have an automatic reset. The alarm box being used, had a very small on off switch on the side of the box which slid one way for off and the other way for on. This switch was recessed on the side of the alarm box, was very small (appeared to be less than ? of an inch) and not noticeable. It was hard to see and was not clearly identified as an on/off switch and it required fine dexterity to operate. In addition, the manufacturer's instructions called for testing of the system, prior to use, by applying pressure to the pad at which time two beeps would be heard to show that it was activated. Interview with CNA #1 on 9/23/10 revealed that CNA #1 did not know about testing the device before it's use. CNA #1 reported that when applying the device the sensor strip was put in place and turned on. When asked if there was anything else that had to be done to test the device to ensure that it was operating properly, CNA #1 indicated that there was nothing done to check it's operation other than switching the switch to on. On 9/23/10 at 12:35 pm, 1:14 pm, and 2:45 pm Resident #1 was still observed lying in the same bed. The sensor alarm was still in place. At these times, the bed was low to the ground and the call bell was accessible. However, there were still no mats on each side of the bed and the sensor pad was positioned under Resident #1's buttocks. On 9/23/10 at 6:12 pm, Resident #1's daughter and health care proxy was interviewed and reported that Resident #1's cognitive ambulation ability started to go down hill cognitively around July of this year. The daughter said that the last time that she saw her mother walk was in July. Since then it had been very difficult to get her mother to walk and Resident #1 refused to walk anytime the daughter was visiting. The daughter further reported that the facility told her that her mother had turned the alarm off, however, the daughter did not believe that Resident #1 had the dexterity to turn the alarm off or the cognitive ability to understand the connection between the on/off switch and the alarm.