Every finding on record at Royal Wayland Rehabilitation and Nursing Center

Based on observations, record reviews, interviews and policy review, the facility failed to provide a dignified dining experience in the facility's main dining room. Specifically, the facility failed to ensure residents seated at the same table were served/assisted with meals at the same time as their table mates. Findings include:Review of the facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes Policy, revised February 2025, indicated:-It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life.-All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. During an interview on 5/17/26 at 12:01 P.M., a resident's family member told the surveyor there is often not enough staff in the dining room to assist the residents with their meals. The family member said many residents who require assistance often have to wait a long time to be assisted. The family member said the staff put their food in front of them while they wait and it gets cold by the time assistance is provided. On 5/17/26 the surveyor made the following observations during lunch in the main dining room:-Two residents were sitting at a table. At 12:28 P.M. one resident was observed with a covered meal and two covered drinks sitting in from of her, while his/her neighbor was eating breakfast. At 12:40 P.M., twelve minutes later, a certified nurse assistant (CNA) began to assist the resident with his/her meal, which was still sitting covered in front of them, and he/she said, can I have something to eat and drink. His/her neighbor had completed eating their meal.-Three residents were sitting at a table. At 12:25 P.M, one resident was served his/her lunch. The last resident at the table was not served until 12:38 P.M., 13 minutes later.-A resident was sitting at a table with his/her meal placed in front of him/her at 12:28 P.M. Staff did not assist the resident with his/her meal until 12:40 P.M., 12 minutes later. -A resident was sitting at a table with his/her meal placed in front of him/her at 12:28 P.M. Staff did not assist the resident with his/her meal until 12:48 P.M., 20 minutes later. -A resident was sitting at a table with his/her meal placed in front of him/her at 12:28 P.M. Staff did not assist the resident with his/her meal until 12:58 P.M., 30 minutes later. While the resident was waiting for his/her meal, he/she was observed licking an empty spoon.-A resident was sitting alone in a broda chair, which would not fit under the dining tables. At 12:28 P.M., there was a covered meal and a covered juice on a rolling overbed table next to him/her. At 12:52 P.M., 24 minutes later, a CNA began to assist the resident with the meal.-Another resident was sitting alone in a broda chair, which would not fit under the dining tables. At 12:28 P.M., there was a covered meal and a covered juice on a rolling overbed table next to him/her. At 12:47 P.M., 21 minutes later, a CNA began to assist the resident with the meal. On 5/18/26 the surveyor made the following observations during breakfast in the main dining room:-Two residents were sitting at a table. Both residents were served their meals at 8:21 A.M., however staff did not assist one of the residents until 8:31 A.M., 10 minutes later. -Three residents were sitting at another table. At 8:23 A.M., all three residents were served their meals. One resident who needed assist with his/her meal did not have staff assist until 8:36 A.M., 14 minutes later.-A resident was sitting alone in a broda chair, which would not fit under the dining table. At 8:22 A.M., the resident was observed with an uncovered puree meal on a rolling overbed table next to him/her. At 8:33 A.M., 11 minutes later, the Administrator began to assist the resident with his/her meal. During the observation of breakfast in the main dining room, on 5/18/26 from approximately 8:21 A.M. to 8:33 A.M., the surveyors attempted to interview the residents, however, they were unable to participate. During an interview on 5/18/26 at 12:54 P.M., CNA #2 said everyone at a table should be served at the same time, and if assist is needed it should be provided at that time. CNA #2 said this is for dignity purposes, and also to ensure acceptable food temperature. CNA #2 said food should be reheated if it's sitting for too long before assistance is provided. During an interview on 5/18/26 at 12:57 P.M., Nurse #2 said everyone at a table should be served at the same time, and if assist is needed it should be provided at that time. Nurse #2 said this is to ensure a dignified dining experience. During an interview on 5/18/26 at 12:47 P.M., the Administrator said meals should be served at the same time to all residents seated at the same table. The Administrator said that if a resident requires assistance, that resident should be assisted at the same time that the table mates are eating. The Administrator further said a resident should be assisted promptly at the time the meal is served. The Administrator said this to ensure a dignified dining experience.

Based on observations and two test trays, the facility failed to provide food that was palatable to taste based on temperature. Findings include:Review of the facility policy titled Record of Food Temperatures, revised May 2025, indicated:-Hot foods will be held at 135 degrees Fahrenheit or greater. -Potentially hazardous cold food temperature will be kept at or below 41 degrees Fahrenheit.-No food will be served that does not meet the food code standard temperatures. During an interview on 5/17/26 at 12:01 P.M., a resident's family member told the surveyor that food often sits in front of residents for a long time before getting assistance with meals and food is often cold. On 5/17/26 the surveyor observed meal delivered to the main dining room at 12:28 P.M. The last resident was assisted with his/her meal at 12:58 and at this time a test tray was completed with the following findings:-Steamed spinach was 80 degrees Fahrenheit, and tasted cold.-Sweet potato was 82 degrees Fahrenheit, and tasted cold.-Ham was 78 degrees Fahrenheit, and tasted cold. A second test tray was completed on 5/18/26 at 8:36 A.M., in the main dining room with the following findings:-Cream of wheat was 94 degrees Fahrenheit, and tasted warm not hot.-Orange juice was 56 degrees Fahrenheit, and tasted cold.-Milk cool was 58 degrees Fahrenheit, and tasted cool, not cold.-French toast was 88 degrees Fahrenheit, and tasted cold. -Sausage was 86 degrees Fahrenheit, and tasted cool. During an observation of breakfast in the main dining room, on 5/18/26 from approximately 8:21 A.M. to 8:33 A.M., the surveyors attempted to interview the residents, however, they were unable to participate. During an interview on 5/18/26 at 12:47 P.M., the Administrator said she was unsure what the temperatures of food should be held at and would refer to the facility policy. During an interview on 5/18/26 at approximately 12:50 P.M., the [NAME] said he was unsure what the temperatures of food should be held at and would refer to the facility policy.

Based on record review and interview, the facility failed to ensure one Resident (#17), out of a total sample of 16 residents, received care and treatment to prevent worsening of a pressure injury. Specifically, the facility failed to implement a wound treatment timely resulting in a delay in treatment and deterioration of the wound to a stage 3 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the Resident's sacrum (an area at the base of the spine). Findings include: Resident #17 was admitted to the facility in December 2023 with diagnoses including dementia and a history of a traumatic brain injury. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #17 could not participate in the Brief Interview for Mental Status due to severe cognitive impairment. Review of the MDS indicated Resident #17 was dependent for mobility and care. Review of the policy titled Skin Integrity Management, dated December 2023, indicated the following: - Resident's skin integrity status and need for prevention intervention or treatment modalities is identified through review of assessment information. * care plan for residents at high risk for skin breakdown * perform and document skin inspection on admission and weekly * perform wound assessment upon initial identification or altered skin integrity and weekly thereafter - Comprehensive care plan developed to include prevention and wound treatments as indicated * evaluate need for support surfaces * Refer to wound MD/wound clinic as appropriate. Implement wound care modalities - Products for skin and wound care will be selected based on RHG guidelines - Document all treatments per facility policy Review of the skin integrity care plan for Resident #17 indicated the following interventions: -Impaired Skin Integrity Risk: I have the potential for pressure ulcer development r/t impaired mobility, double incontinence, and comorbidities (initiated 12/29/23) Interventions: -Air Mattress (initiated 4/25/24) -Monitor/document/report to MD (doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size, stage (initiated 12/29/23) -Educate the resident/family/caregivers as to cause of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning (initiated 12/29/23) Review of the skin check, dated 4/18/24, indicated Resident #17 presented with a pressure ulcer on the coccyx. Further review of the skin check failed to indicate a description of the wound. Review of the Medication Administration Record for April 2024 indicated, on 4/18/24, Resident #17 had an alteration in skin integrity, which was warm and dry. Review of the clinical record failed to indicate that the physician or nurse practitioner (NP) was notified of the change in skin condition on 4/18/24. Review of the progress note, dated 4/22/24, indicated Resident #17's wound had opened and needed a protective dressing. Review of the skin check, dated 4/22/24, indicated the following Pressure ulcer to the sacrum is open to a stage II. awaiting appropriate dressing. Review of the clinical record did not indicate that any treatment measures had been put in place for the open wound on 4/22/24 and failed to indicate that the physician or NP was notified of the open wound. Review of the progress note, dated 4/25/24, indicated the following: Note Text: NP reported to this writer on 4/24/24 that resident had area on sacrum. Wound MD in on 4/24/24 and was able to see resident. New Dx of stage 3 pressure wound (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue) on sacrum. New order to apply Silver Sulfadiazine (a medication cream used to treat open wounds) daily followed with a silicone bordered foam dressing. New order for Vit C bid (twice a day), Zinc for 14 days. Review of the wound physician note, dated 4/24/24, indicated Resident #17 had a stage 3 pressure wound to the sacrum that measured 1.4 centimeters in length, 0.5 centimeters in width, and 0.1 centimeters in depth. Review of the physician orders indicated that the Silver Sulfadiazine was ordered on 4/24/24, 6 days after the initial change in condition of Resident #17's skin. During an interview on 7/24/24 at 8:18 A.M., the Director of Nursing said that if a nurse identifies a new area on a Resident then it needs to be reported to the doctor and a treatment would be put in place right away. The Director of Nursing said that barrier cream was being used per house protocol when the skin alteration was first identified and that it is put on bony prominences to prevent skin breakdown and a dressing was put in place, but that the Silvadene was ordered on 4/24/24. The Director of Nursing said that the barrier cream had been in place prior to the skin alteration discovered on 4/18/24 since that was standard protocol.

Based on record reviews and interviews, the facility failed to follow the physician order to obtain weekly weights for 1 Resident (#35) out of a total sample of 16 residents. Findings include: Resident #35 was admitted to the facility in March 2024 with diagnoses including dementia and unspecified severe protein-calorie malnutrition. Review of Resident #35's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status exam and staff had assessed him/her to have severe cognition. The MDS also indicated Resident #35 required substantial assistance from staff for functional daily tasks. Review of Resident #35's physician orders indicated the following order: -Weekly Weights, initiated on 4/25/24. Review of Resident #35's weight log indicated the Resident had not been weighed weekly since 5/31/24. Review of the nutritional assessments dated 3/12/24 and 6/4/24 indicated the recommendation to weigh the Resident as ordered. During an interview on 7/23/24 at 11:41 A.M., Nurse #1 said Resident #35 has an order to have weights taken weekly. Nurse #1 reviewed Resident #35's weight log and said this order has not been followed in the past two months. During an interview on 7/23/24 at 12:07 P.M., the Director of Nursing said orders should be followed as written.

Based on observations, record reviews and interviews, the facility failed to ensure quality of care was provided according to facility protocols and professional standards of practice for one Resident (#6) , out of a total sample of 16 residents. Specifically, the facility failed to identify a skin alteration on Resident #6's foot and document accordingly. Findings include: Review of the facility's policy titled 'Skin Integrity Management' indicated the following but not limited to: -Resident's skin integrity status and need for prevention intervention or treatment modalities is identified through review of assessment information. -Perform and document skin inspection on admission and weekly. Resident #6 was admitted to the facility in October 2017 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy and dementia. Review of Resident #6's Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated that the Resident was dependent on staff for activities of daily living (ADL) care. On 7/23/24 at 9:43 A.M., the surveyor observed Resident #6 lying in his/her bed with feet not covered. The surveyor observed a dark calloused area on the Resident's right foot 3rd toe. Review of the medical record indicated the following physician orders: -Diabetic foot care every evening shift -Complete weekly skin check every day shift every Monday note skin alteration. Review of the care plan titled Resident has diabetes mellitus with the following interventions: -Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. -Check all of body for breaks in skin and treat promptly as ordered by doctor -Wash feet daily with mild soap and water, dry thoroughly, may use a light dusting powder or lotion. Review of the Treatment Administration Record (TAR) for July indicated a weekly skin check and daily diabetic foot care had been completed and no skin alteration had been documented. During an interview on 7/24/24 at 7:59 A.M., Nurse #1 said she would describe the area on Resident #6's right foot 3rd toe as black dark toe, she said that area should be noted on the weekly skin check or during the diabetic foot care. During an interview on 7/24/24 at 10:23 A.M., the Director of Nursing (DON) said that she and the physician assistant went and observed the area on Resident #6's right foot 3rd toe and the physician assistant said it's not a soft tissue concern and to follow up with podiatry. The DON further said it was her expectation that any skin alteration noted on the Residents skin would have been documented.

Based on observations, record review and interview the facility failed to implement a physician's order for the use of a bed alarm for one Resident (#1) out of a total sample of 16 residents. Findings include: Review of the facility's policy titled 'Managing Falls and Fall Risk, dated December 2023 indicated; Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk, 8. Position-change alarms will not be used as the primary or sole interventions to prevent falls, but rather will be used to assist staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Resident #1 was admitted to the facility in September 2018 with diagnoses that include but are not limited to unspecified dementia, neuropathy, pain, and depression. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #1 was assessed by staff as having severely impaired cognitive skills and is dependent on staff for bathing and bed mobility. Review of a facility reported incident report dated 2/8/24 indicating Resident #1 had a fall out of bed on 2/7/24, resulting in a displaced condyle fracture of the lower right femur and a displaced fracture of the medial condyle of left tibia. Review of Resident #1's medical record indicated the following: -Fall risk assessments dated 7/31/23, 2/11/24 and 6/11/24 indicate Resident #1 is 'At risk' for falls. -A current physician's order dated 2/12/24 alarms: bed-check function and placement every shift for safety/fall risk. -A fall risk care plan dated as initiated 9/28/2018, revised 8/19/2021, I am at high risk for fall and injury r/t (related to) decreased mobility, impaired safety awareness, use of antidepressant medications, chronic pain, and comorbidities, history of fall. Interventions * bed alarm at all times in bed date initiated 2/19/2024. -A Kardex (a guide for resident care and interventions used by staff) report, dated as of 7/24/24 Safety: bed alarm at all times in bed. During the survey the following observations were made: On 7/23/24 at 4:55 P.M., Resident #1 was resting in bed with the head of the bed elevated. The bed alarm box was affixed to his/her left side of the bed, a light on the box was blinking red and the alarm box was not attached to anything. The sensor pad was behind the bed resting on top of the bed frame and not attached to the bed alarm box. On 7/24/24 at 8:08 A.M. Resident #1 was in bed, eating is/her breakfast. The bed alarm box was affixed to the left side of his/her bed, was blinking red and was not attached to anything. The sensor pad was behind the bed resting on top of the bed frame. On 7/24/24 at 8:47 A.M., staff exited Resident #1's room with his/her breakfast tray. Resident #1's bed was in a lower position and the bed alarm box was affixed to the left side of the bed, blinking red, and was not attached to the sensor pad. The sensor pad was behind the bed on top of the bed frame. During an interview and observation on 7/24/24 at 9:26 A.M., Nurse #1 said the nurses are responsible for documenting on the Treatment Administration Record the use of a bed alarm to ensure it is in place and functioning. Nurse #1 said Resident #1 makes her needs known and chooses to stay in bed most of the time. Nurse #1 said Resident #1 did have a fall a few months back and has a bed alarm to alert staff. Nurse #1 went to Resident #1's room, said the blinking light means it (the bed alarm) is not working and needs to be attached to the sensor pad. Nurse #1 located the sensor pad behind the bed and attempted to attach the cord to the alarm box but was unable to do so and said the part that plugs into the box is broken. Nurse #1 said the bed alarm should be plugged in and always working. Nurse #1 said she was not made aware that the bed alarm was not in place and working and that staff have been in and out of the room.

Based on record review and interview, the facility failed to prevent unnecessary medication after the recommendation of a gradual dose reduction for one Resident (#30) out of a total sample of 16 residents. Findings include: Resident #30 was admitted in February 2023 with diagnoses including dementia with agitation and major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #30 is severely cognitively impaired and could not participate in the Brief Interview for Mental Status (BIMS). Review of the physician's orders indicated Resident #30 was taking 150 milligrams of Seroquel at night in June 2023. Review of the Psychiatric Evaluation and Consultation, dated 6/27/23, indicated Resident #30 had had increased lethargy (a feeling of fatigue) and a recommendation was made to decrease Resident #30's Seroquel (a medication used to treat mood disorders) dose to 125 milligrams at night in an attempt to reduce the lethargy. Review of the Medication Administration Record failed to indicate the change in medication until 8/30/23, over a month after the initial recommendation. Review of the physician notes did not indicate that the recommendation was reviewed or addressed after 6/27/23. During an interview on 7/24/24 at 10:23 A.M., the Director of Nursing said that it is facility protocol to present the recommendation to the doctor and it would get approved or denied. The Director of Nursing could not say why the medication reduction was put in on 8/30/23 and not when the recommendation was made.

Based on observations and interviews, the facility failed to maintain a homelike environment on 1 of 1 resident units. Findings include: *In room [ROOM NUMBER], the radiator was broken and significantly rusty. Wallpaper was missing on the wall below the window. There was wallpaper peeling on the wall by the television. The ceiling tiles had yellow stain marks near the window. *In room [ROOM NUMBER], the radiator was bent and had a broken piece. On the wall next to the closet, there was wallpaper peeling. The bathroom had a dirty towel on the floor surrounding the toilet. The wall across from the toilet had missing paint on a large rectangular piece of the wall. There was also a tile missing on the wall above the paper towel holder. *In room [ROOM NUMBER], the window blinds were broken in numerous places. On the wall next to Bed A and Bed D's closet there was wallpaper peeling. *In room [ROOM NUMBER], there was peeling wallpaper next to the bathroom door and next to the window. *In room [ROOM NUMBER], the window blinds were broken. *In room [ROOM NUMBER], the leather of the armrest for a chair for Bed A was peeling off. There was wallpaper peeling next to Bed A and next to the window. The window blinds were bent and broken. A ceiling tile next to the window had yellow stain marks. *In room [ROOM NUMBER], there was scraped paint next to the closet. The window blinds were broken. A ceiling tile in the bathroom had yellow stain marks and had spider webs hanging from it. During an interview on 6/29/23 at 1:28 P.M., the Maintenance Director and his trainee said when something is broken and needs to be fixed, the staff will leave a note on his desk. He also said he completes daily rounds for broken things. He further said that some blinds need to be replaced and wallpaper needs to be repaired and they are ongoing issues.

Based on observation, interview and record review, the facility failed to 1) properly store food items to prevent the risk of foodborne illness in accordance with professional standards for food service safety and 2) failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness. Findings include: 1. Review of the facility policy titled, Food Storage: Cold Foods, dated ,d+[DATE], indicated the following: *All foods will be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. During the initial walk through of the kitchen on [DATE] at 7:00 A.M., the surveyor made the following observations in refrigerator: *Bin containing multiple peppers visible with black and white mold spots sitting in wet juice. Peppers were mushy and soft. *Sliced watermelon dated [DATE] sitting in juice with discoloration. *Bin of tomatoes undated sitting in juice, visible mold spots, mushy and wet. *Container of chicken salad dated [DATE]. *Breakfast tray of pre-poured skim milk with an expiration date of [DATE] on the container of skim milk. *Pre-Frozen ham covered in frost and not dated. During an interview on [DATE] at 07:28 A.M., the cook said food is stored for up to 3 days before it gets thrown out and all food items should be labeled with the date the item was opened. He also said he did not check the expiration date prior to pouring the milk into cups for breakfast. He then observed the skim milk expired on [DATE] and stated that staff must check expiration dates prior to use. During a follow-up visit to the kitchen on [DATE] at 07:48 A.M., the surveyor made the following observations: *A container labeled as beef paste dated [DATE] in the walk-in refrigerator. *A container labeled potato salad dated [DATE] in the walk-in refrigerator. *A container labeled Caesar salad dressing dated [DATE] with a manufacturer's expiration date of [DATE]. *A bottle of sweet and sour dressing dated [DATE]. *A jar of chopped garlic in oil dated [DATE] * A bottle of lemon pepper seasoning dated [DATE]. * A bottle of ground ginger dated ,d+[DATE]. *A box of Raisin Bran cereal dated [DATE]. *A container of potato salad dated [DATE]. *Pre-Frozen Ham defrosted, soft, undated in refrigerator. The surveyor observed personal food items of the kitchen staff stored in the resident refrigerator. During an interview on [DATE] at 08:01 A.M., Regional Food Service Director said all opened items must be used within 3 days and then discarded. Food items should be labeled with the date the item was opened. Previously frozen foods must be dated and discarded within three days if not used. He continued to say staff's personal food items should not be stored with resident food and should be stored in the staff break room in a designated refrigerator. He then proceeded to remove the staff items from the Resident refrigerator. 2. Review of the facility polity titled, Food: Preparation, dated ,d+[DATE], indicated the following: *All staff will practice proper hand washing techniques and glove use. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. On [DATE] at 7:38 A.M., the following was observed in the facility kitchen during the breakfast meal line: *The cook put on a pair of gloves without first washing his hands. He then opened a package of bread and touched the outside bag and twist tie with his gloved hands, potentially contaminating his gloves. The cook then touched the bread with his gloved hands and placed bread into the toaster with his hands. He then served the toast onto the plates using his gloved hands. The cook then picked up an oven mitt with his gloved hand and opened the oven door. He then used his gloved hand to pick up the food thermometer to check food temps. The cook then picked up bowls placing his thumb and fingers on the inside of the bowls. The cook picked up omelets with his gloved hands and placed them on plates. He proceeded to touch plates, serving utensils, trays, and bowls, with his gloved hands. The cook touched bread, toast, omelets and corn bread and placed items on a plate to be served to residents. The cook did not remove his gloves or perform hand hygiene during the breakfast meal line. During an interview on [DATE] at 9:37 A.M., the cook said all staff need to wash hands prior to putting on gloves and then if gloves become contaminated by touching items other than food, the gloves must be changed, and hands washed again. Gloves should not be worn when touching utensils and then touching food. During an interview on [DATE] at 1:35 P.M., the cook said all staff need to wash hands prior to putting on gloves and then if gloves become contaminated by touching items other than food, the gloves must be changed, and hands washed again. The cook said he must use utensils when picking up food items and not his contaminated hands.

Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for 3 Residents (#3, #21 and #13) out of a total sample of 13 residents. Findings include: 1. Resident #3 was admitted to the facility in October 2022 with diagnoses including Alzheimer's Disease. Review of Resident #3's most recent Minimum Data Set (MDS) dated [DATE] indicates Resident #3 is unable to complete the Brief Interview for Mental Status (BIMS) exam and the staff assessed him/her to have severely impaired cognition. The MDS also indicates Resident #3 is dependent on staff for all functional daily tasks. On 6/29/23 at 9:00 A.M., Resident #3 was observed lying in bed. The Resident was lying on an air mattress set all the way to the firmest setting. In addition, the Resident's bed did not have a bed alarm in place. Review of Resident #3's physician orders indicated the following orders: *Alarms: bed - check function and placement every shift. *Air Mattress - check placement and function every shift - set for optimal comfort setting is 1/2 on setting dial line indication on dial, intermittent, normal pressure light on, every shift. *Bed alarm while in bed. Every shift for falls risk. Review of Resident #3's Treatment Administration Report (TAR) indicated the nurse had marked the above orders as completed. During an interview on 6/29/23 at 11:16 A.M., Nurse #3 and the surveyor observed Resident #3 together. Nurse #3 said the air mattress was not on the correct setting and said there were no bed alarms on the Resident's bed. When asked why she had already checked the order as complete, Nurse #3 said the TAR was inaccurate and that she intended to go back to finish the orders later but marked them as complete even though the orders were not completed. During an interview on 6/29/23 at 12:54 P.M., the Director of Nursing said she expects nurses to only mark orders complete if they have actually been completed. 43846 2. Resident #21 was admitted to the facility in October 2021 with diagnoses including vascular dementia, dysphagia and depression. Review of Resident #21's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairment. Review of Resident #21's June 2023 Physician Orders, dated 1/5/2022, indicated Air Mattress - check placement and function every shift - set for optimal comfort. During an observation on 6/28/23 at 7:50 A.M.,11:31 A.M., and 1:27 P.M., Resident #21 was observed lying in bed on a regular mattress. During an observation on 6/29/23 at 7:08 A.M., 8:00 A.M., and 2:02 P.M., Resident #21 was observed lying in bed on a regular mattress. Review of Resident #21's June 2023 Treatment Administration Record (TAR), indicated that nursing staff signed off the air mattress check placement and function every shift as administered from 6/1/23 to 6/28/23. During an interview and observation on 6/29/23 at 11:30 A.M., Nurse #3 said Resident #21 does have an order for an air mattress to be in place and said if a nurse signs off an order it should be in place. During an interview on 6/29/23 at 11:51 A.M., the Director of Nursing (DON) said she expects nursing to follow the doctors orders and said nurses should only sign the order off if it is completed. The DON said Resident #21 does not have an air mattress on his/her bed. 48671 15016 3. Resident #13 was admitted to the facility in April 2023, and had diagnoses which included hypertension and dementia. Review of Resident #13's physician orders dated 12/9/22, indicated furosemide tablet 20 mg. Give one tablet by mouth one time a day for hypertension. Review of Resident #13's June 2023 medication administration record indicated staff documented that furosemide 20 mg was administered every day from 6/15/23 through 6/29/23. During the medication administration pass on 6/29/23 at 9:30 A.M., Nurse #1 said Resident #13 did not have furosemide 20 mg in the medication cart and that she needed to open the emergency medication kit to administer the medication. Nurse #1 said she would administer the medication later this morning. Nurse #1 then documented that his/her furosemide was not given on 6/29/23 and was on hold. During an interview with the Pharmacy Representative on 6/29/23 at 10:30 A.M., she said a 14-day supply of furosemide 20 mg for Resident #13 was delivered to the facility on [DATE], and the next available refill date was scheduled for 6/12/23. The Pharmacy Representative said the facility did not request a refill and none had been delivered to the facility. During an interview with Nurse #5 on 6/30/23 at 9:30 A.M., she said furosemide 20 mg was not administered on 6/29/23 because it was not in the medication cart and it required a refill prescription from the physician. Nurse #5 said there was no documented communication from the physician to indicate the furosemide was on hold, and instead it was unavailable. Nurse #5 said she needed to open the emergency kit to obtain and administer the furosemide. Nurse #5 said there was no documentation to indicate that on 6/29/23 Nurse #1 had opened the emergency kit, administered the furosemide or contacted the physician to request a refill. During an interview with the Director of Nurses (DON) on 6/30/23 at 10:00 A.M., she said she did not know how staff were able to administer furosemide 20 mg to Resident #13 if the supply had run out by 6/15/23. The DON said she did not have documentation to show that furosemide was refilled for Resident #13 to cover the period from 6/15/23 through 6/29/23. The DON said staff documented on the medication administration record that furosemide 20 mg was administered between 6/15/23 to 6/29/23, but that this was inaccurate and she did not know how this was possible since Resident #13's furosemide supply had run out by 6/15/23.

Based on record review, interview and observation, the facility failed to implement the plan of care for air mattresses for 2 Residents (#21 and #24) out of a total sample of 13 Residents. Findings Include: Review of the facility policy titled, Maintaining Skin Integrity, dated 11/2021, indicated It is the practice of the facility to take those steps necessary to maintain skin integrity. Care plan is initiated to address the pressure ulcer prevention and treatment. 1. Resident #21 was admitted to the facility in October 2021 with diagnoses including vascular dementia, dysphagia and depression. Review of Resident #21's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairment. During an observation on 6/28/23 at 7:50 A.M.,11:31 A.M., and 1:27 P.M., Resident #21 was observed lying in bed on a regular mattress. During an observation on 6/29/23 at 7:08 A.M., 8:00 A.M., and 2:02 P.M., Resident #21 was observed lying in bed on a regular mattress. Review of Resident #21's pressure injury risk care plan, dated 10/27/2022, indicated an intervention for Air mattress in place. Review of Resident #21's June 2023 Physician Orders, dated 1/5/2022, indicated and order for Air Mattress - check placement and function every shift - set for optimal comfort. Review of Resident #21's most recent Norton_Score, dated 5/31/23, indicated a Norton_Score of 8 which indicated that he/she was at high risk for skin breakdown. During an interview and observation on 6/29/23 at 11:30 A.M., Nurse #3 said Resident #21 does have an order for an air mattress to be in place and said he/she should have one on his/her bed but does not. During an interview on 6/29/23 at 11:51 A.M., the Director of Nursing (DON) said Resident #21 does not have an air mattress and said if he/she does have an order for one then the Resident should have one. 45984 2. Resident #24 was admitted to the facility in July 2020 with diagnoses that include unspecified dementia and psychosis. Review of Resident #24's most recent Minimum Data Set (MDS) dated [DATE], indicated that the resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status exam which indicated that he/she has severe cognitive impairment. Further review of Resident #24's MDS revealed that he/she requires total dependence with all activities of daily living. The MDS also indicated that the resident has a history of a stage 4 pressure ulcer of the left heel and is at risk of developing pressure ulcers/injuries. During observations on 6/28/23 at 10:03 A.M., 6/28/23 at 12:57 P.M., 6/29/23 at 7:14 A.M., and 6/29/23 at 10:41 A.M., Resident #24 was observed sleeping in bed with his/her air mattress set to the setting of 180 pounds. Review of Resident #24's physician's orders dated 3/22/2023 indicated the following: *Air Mattress - Check placement and function every shift - set for optimal comfort weight setting currently 155 lbs. (pounds) upright mode max infiltrate off bolsters bilateral edge defining every shift Review of Resident #24's Weight and Vitals Summary indicated that the Resident's weight was 154.2 lbs. on 3/21/2023, one day before the physician's order was created. Review of Resident #24's care plan for pressure ulcer/injury risk indicated the following intervention dated and revised 2/28/2022: *Resident with air mattress in place. Check function every shift. Set for comfort. Review of Resident #24's assessment titled RHG Norton_Scale for Predicting Risk of Pressure Ulcer (an assessment to assess the risk of developing pressure ulcers) dated 6/2/23 revealed that the Resident had a Norton_Score of 6 which indicates a high risk for developing pressure ulcers. During an interview on 6/29/23 at 11:16 A.M., Certified Nursing Assistant (CNA) #1 said maintenance is responsible for checking the settings of air mattresses. During an interview on 6/29/23 at 2:26 P.M., the Director of Nursing said it is the nurse's responsibility to follow orders and she expects them to be followed. She continued to say that Resident #24's air mattress should be set to 155 pounds.

Based on observations, record review and interview, the facility failed to identify and treat a skin tear for 1 Resident (#31) out of a total sample of 13 residents. Findings include: Resident #31 was admitted to the facility in October 2022 with diagnoses including dementia, lack of coordination and muscle weakness. Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicates Resident #31 requires supervision for ambulation and extensive assistance for activities of daily living. On 6/28/23 at 8:15 A.M., Resident #31 was observed lying in bed. The Resident had a dime sized open area on his/her left hand with a red substance similar to dried blood. The Resident was unable to answer any questions about the origin of the open area. On 6/29/23 at approximately 8:45 A.M., and again at 1:25 P.M., Resident #31 was observed lying in bed sleeping. The same open area was observed on the Resident's left hand. There was no bandage or treatment to the area. Review of Resident number 31's medical record indicated he/she sustained a fall on 6/23/23 resulting in a skin tear on his/her left hand. The following physician order was initiated on 6/24/23: *Skin tear left hand proximal to 2nd finger. Steri strips. House wound cleanser, pat dry F/B small amount of bacitracin and cover with gauze, wrap daily until healed. Every day shift for skin tear daily until healed. Review of the Treatment Administration Record for June 2023, indicated the following: *A skin assessment was completed on 6/26/23 and Resident #31's skin was documented as having no skin alteration. *The treatment for the skin tear was discontinued as of 6/26/23, indicating the area was healed. During an interview on 6/29/23 at 1:30 P.M., the Corporate Nurse #1 said Resident #31 had sustained a fall a week ago that resulted in a skin tear. Corporate Nurse #1 said the skin tear had healed so all treatments had been discontinued. Corporate Nurse #1 said the skin tear must have somehow reopened and would need a new treatment. When asked if a skin tear on the hand would be something staff would have seen while providing care over the past two days, Corporate Nurse #1 said yes. Corporate Nurse #1 said the nursing assistants providing care should have identified the reopened area and brought it to the attention of the nurse.

Based on observations, record review and interviews, the facility failed to provide comprehensive treatment for edema for 1 Resident (#13) out of a total sample of 13 residents. Findings include: Resident #13 was admitted to the facility in December 2022 with diagnoses including dementia with other behavioral disturbance, hyperlipidemia, dysphagia and type 2 diabetes. Review of Resident #13's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she scored a 7 out of possible score of 15 on the Brief Interview for Mental Status exam which indicated he/she had a severe cognitive impairment. Further review of the MDS indicated he/she required extensive assist of a staff member for dressing. Review of Resident #13's physician orders indicated the following: *Spanda Sleeve (a compression sleeve): Apply to Left hand/arm daily in the morning and remove at HS (at night) every morning and at bedtime for dependent edema left arm. Initiated on 3/24/23. *Apply compression socks to BLE (bilateral lower extremities), on in AM (morning), off at HS, initiated on 12/22/22. *Furosemide tablet 20 MG (milligrams) give 1 tablet by mouth one time a day for HTN (hypertension). On 06/28/23 at 10:03 A.M., and 11:37 A.M., Resident #13 was observed in his/her room. The Resident did not have compression socks on or a compression sleeve on his/her left arm. On 6/29/23 at 8:28 A.M., Resident #13 was observed eating breakfast in the dining room. The Resident did not have compression socks on or a compression sleeve on his/her left arm. The Resident was observed to be wearing a bracelet on his/her left arm and the bracelet was tight around his/her wrist. The Resident moved the bracelet when the surveyor asked, and the Resident was observed to have an indentation mark on his/her arm where the bracelet was. On 06/29/23 at 12:48 P.M., Resident #13 was observed walking in the front lobby. The Resident did not have compression socks on or a compression sleeve on his/her left arm. Review of Resident #13's care plan failed to include an edema management care plan. Review of the Treatment Administration Record for June 2023 failed to indicate Resident #13 refused the compression sleeve or stockings. Review of Resident #13's physician orders dated 12/9/22, indicated furosemide tablet 20 mg. Give one tablet by mouth one time a day for hypertension. Review of Resident #13's June 2023 medication administration record indicated furosemide 20 mg was administered every day 6/15/23 through 6/29/23. During the medication administration pass on 6/29/23 at 9:30 A.M., Nurse #1 said Resident #13 did not have furosemide 20 mg available in the medication cart or medication room and that she needed to open the emergency medication kit to obtain and administer the medication. Nurse #1 said she would administer the medication to Resident #13 later this morning. During an interview with Nurse #5 on 6/30/23 at 9:30 A.M., she said furosemide 20 mg was not administered on 6/29/23 because it was not in the medication cart and it required a refill prescription from the physician. Nurse #5 said she needed to open the emergency kit to obtain and administer the furosemide. Nurse #5 said there was no documentation to indicate that on 6/29/23 Nurse #1, or any other staff, had opened the emergency kit, administered the furosemide or contacted the physician to request a refill. During an interview with the Pharmacy Representative on 6/29/23 at 10:30 A.M., she said a 14 day supply of furosemide 20 mg for Resident #13 was delivered to the facility on [DATE], and the next available refill date was scheduled for 6/12/23. The Pharmacy Representative said the facility did not request a refill and none had been delivered to the facility. During an interview with the Director of Nurses (DON) on 6/30/23 at 10:00 A.M., she said she did not know how staff were able to administer furosemide 20 mg to Resident #13 if the supply had run out by 6/15/23. The DON said she did not have documentation to show that furosemide was refilled for Resident #13 to cover the period from 6/15/23 through 6/29/23. During interviews on 6/29/23 at 1:51 P.M., and 6/30/23 at approximately 10:30 A.M., the DON said Resident #13 has edema in his/her left arm when he/she sleeps on it and that this happens frequently. The DON said a care plan should have been developed to address the edema. The DON said the order should be followed to apply compression stockings and the sleeve. The DON said furosemide is a medication used for fluid retention and Resident #13 should be taking it as ordered. 15016

Based on record reviews and interviews, the facility failed to follow the recommendations of the eye doctor to obtain an appointment with a glaucoma specialist for 1 Resident (#18) out of a total sample of 13 residents. Findings include: Resident #18 was admitted to the facility in July 2019 with diagnoses including dementia. Review of Resident #18's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #18 requires minimal assistance from staff for oral hygiene. During an interview on 6/30/23 at 9:30 A.M., Resident #18 said he/she had glasses in the past and he/she would like to wear them again. He/she would like to see the glaucoma specialist for new glasses because he/she likes to knit, do puzzles, and can't see well without them. Review of Resident #18's medical record indicated a consent for vision services by the consulting ophthalmologist signed by Resident #18's legal guardian dated 10/19/22. Review of Resident #18's visual care plan last revised 6/30/23 indicated the following: *Arrange consultation with eye care practitioner as required. Review of Resident #18's eye appointment dated 7/19/22 indicated the following: *Recommend consult with glaucoma specialist. Patient educated on findings and need for referral to glaucoma specialist. Untreated glaucoma can lead to irreversible vision loss and potential blindness. Review of Resident #18's eye appointment dated 11/18/22 indicated the following: *Assessment: 1. Glaucoma suspect, open angle with borderline findings, high risk; Both eyes; mildly elevated IOP OU with large stable cupping OU. 2. Cataract, mixed; Both eyes. 3. Myopia and presbyopia; Both eyes *Plan: 1. Monitor IOP; Follow-Up: 4-5 Months. 1. Recommend consult w/glaucoma specialist; Follow-Up: 3-4 Months; Referral: Ophthalmology Consult (Glaucoma Specialist); Spoke with patient and RN on findings. Discussed pros and cons of being managed with glaucoma specialist for condition or being managed by the NH optometrist for glaucoma. Patient wishes to be managed by glaucoma specialist. RN states NH will arrange transportation and scheduling for patient. **No glaucoma consult has been made for patient despite 2 referrals. Please schedule patient for glaucoma evaluation** Review of Resident #18's eye appointment dated 6/5/23 indicated the following: *Recommended consult with glaucoma specialist, Follow-up: Priority comprehensive 11/18/23, Referral: Ophthalmology consult (glaucoma specialist); patient as started on glaucoma drop on March 2023, but patient and RN does not remember patient going for glaucoma consult. No record of consult in patient's record either. If patient went to glaucoma specialist, please attend follow ups as scheduled. If no glaucoma consult was made, recommend glaucoma evaluation. During an interview on 6/30/23 at 8:01 A.M., the Director of Nursing (DON) said she looks through all after visit summaries to ensure all recommendations are implemented. The DON said she was unsure if Resident #18 had been out to see a glaucoma specialist. During an interview on 6/30/23 at 9:12 A.M., Regional Nurse #2 said the recommendation for Resident #18 was never completed and he/she had not been out to see a glaucoma specialist.

Based on observations, record reviews and interviews, the facility failed to follow the plan of care for prevention of a pressure ulcer for 1 Resident (#3) out of a total sample of 13 residents. Findings include: Resident #3 was admitted to the facility in October 2022 with diagnoses including Alzheimer's Disease. Review of Resident #3's most recent Minimum Data Set (MDS) dated [DATE] indicates Resident #3 is unable to complete the Brief Interview for Mental Status (BIMS) exam and the staff assessed him/her to have severely impaired cognition. The MDS also indicates Resident #3 is dependent on staff for all functional daily tasks. On 6/28/23 at 8:00 A.M. 8:42 A.M., 10:53 A.M. and 1:42 P.M., Resident #3 was observed lying in bed on an air mattress. The air mattress was set on the highest setting firmness. The Resident's feet were directly on the bed. There were no protective booties in the bed, on the bed side table or in the Resident's closet. On 6/29/23 at 7:30 A.M., and 11:16 A.M., Resident #3 was observed lying in bed on an air mattress. The air mattress was set on the highest firmness. The Resident's feet were directly on the bed. There were no protective booties in the bed, on the bed side table or in the Resident's closet. Review of Resident #3's physician orders indicated the following orders: *Air mattress - check placement and function every shift - set for optimal comfort setting is 1/2 on setting dial like indicates on dial, intermittent, normal pressure light on every shift, initiated on 3/22/23. *Bilateral feet apply soft boots for pressure relief every shift check for placement and position every shift, initiated on 6/15/23. Review of Resident #3's pressure injury risk care plan last revised 2/21/23 indicated the following interventions: *Air mattress as ordered *Monitor/document/report to MD PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length x width x depth), stage. During an interview on 6/29/23 at 11:16 A.M., Nurse #2 said Resident #3's air mattress should not be on the firmest setting, and he/she should be wearing protective heel booties while in bed. During an interview on 6/29/23 at 11:23 A.M., the Physician Assistant (PA) said Resident #3 requires an air mattress and protective heel booties for skin protection. The PA said Resident #3 is prone to pressure injuries on both the sacrum and feet and because of this, the air mattress should not be at the firmest setting, and he/she should be wearing protective heel booties. During an observation on 6/29/23 at 1:20 P.M., Nurse #2 and the surveyor observed Resident #3's coccyx area. The area was observed to have a 2 cm x 2 cm reddened fragile area. Nurse #2 said this area looks concerning and is an area that would need to be monitored for potential breakdown. Review of Resident #3's medical record failed to indicate Nurse #2 wrote a note about Resident #3's skin or completed a skin assessment. During an interview on 6/29/23 at 2:27 P.M., the Director of Nursing said the nurse is responsible for ensuring all orders are followed as ordered.

Based on observations, record review, policy review and interviews, the facility failed to implement fall prevention interventions and prevent falls for 3 Residents (#31, #3 and #9) out of a total sample of 13 residents. Findings include: Review of the facility policy titled, Managing Falls and Fall Risk Policy Statement, undated, indicated the following: *The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. *The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 1. Resident #31 was admitted to the facility in October 2022 with diagnoses including dementia, lack of coordination and muscle weakness. Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicates Resident #31 requires supervision for ambulation and extensive assistance for toileting tasks. Review of the incident report dated 4/29/23 indicated the following: *Resident #31 was entering the bathroom near the social worker office, and he/she bent down to pick up a paper and lost his/her footing and was found on his/her knees. The Resident also bumped his/her forehead on the handle of the toilet seat railing. *The fall was unwitnessed. Review of Resident #31's activity of daily living care plan indicated that at the time of the fall the following interventions were in place: *Toileting: Assist of 1 *Mobility: walks with continual supervision Review of the incident report dated 6/23/23 indicated the following: *Resident #31 was found on the floor in the hallway. There were no witnesses to the fall. Review of Resident #31's activity of daily living care plan indicated that at the time of the fall the following interventions were in place: *Mobility: walks with continual supervision Review of Resident #31's medical record failed to indicate a fall assessment was completed after the fall on 6/23/23. During an interview on 6/29/23 at 12:54 P.M., the Director of Nursing (DON) said fall assessments are completed after each fall with new interventions put into place to prevent further falls. The DON said she expects all fall interventions to be followed. The DON said Resident #31 requires supervision with ambulation and said he/she was not being supervised when either fall occurred. The DON said it would be impossible to have continual supervision for Resident #31 and said it may not be an affective or appropriate intervention. 2. Resident #3 was admitted to the facility in October 2022 with diagnoses including Alzheimer's Disease. Review of Resident #3's most recent Minimum Data Set (MDS) dated [DATE] indicates Resident #3 is unable to complete the Brief Interview for Mental Status (BIMS) exam and the staff assessed him/her to have severely impaired cognition. The MDS also indicates Resident #3 is dependent on staff for all functional daily tasks. On 6/29/23 at 8:15 A.M. and on 6/30/23 at 9:00 A.M., Resident #3 was observed lying in bed. His/her bed not not have a bed alarm in place. Review of the incident report dated 6/1/23 indicated the following: *Resident #3 was observed on the floor next to his/her bed at 10:30 P.M. There were no witnesses to the fall out of bed. Review of Resident #3's fall prevention care plan indicated that at the time of the fall the following interventions were in place: *Bed alarm when in bed to alert staff that resident may need positioning or at risk for falling out of bed. Review of Resident #3's physician orders indicated the following active order at the time of the fall: *Bed alarm when in bed every shift for falls risk. During an interview on 6/29/23 at 12:54 P.M., the Director of Nursing said she expects all fall interventions to be implemented to prevent falls as much as possible. When told of the observations of Resident #3's bed, the DON said she was not aware the Resident did not currently have a bed alarm in place. The DON said she was not sure if Resident #3 had an alarm on his/her bed at the time of the fall. During a follow-up interview on 6/29/23 at 2:29 P.M., the DON said she spoke with the staff member that found Resident #3 on the floor after he/she fell . The DON said the alarm was not in place at the time of the fall. 45984 3. Resident #9 was admitted to the facility in August 2022 with diagnoses including unspecified dementia, Alzheimer's disease and unspecified fall subsequent encounter. Review of Resident #9's most recent minimum data set (MDS) dated [DATE] indicated that the Resident scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating that he/she has moderate cognitive impairment. Further review of the MDS revealed that Resident #9 requires extensive assistance with all activities of daily living and that a bed alarm is used daily. During observations on 6/29/23 at 2:13 P.M. and 6/30/23 at 6:39 A.M., Resident #9 was observed sleeping in his/her bed, there were fall mats folded in the corner of the room, not on the floor beside the bed. There was also no bed alarm plugged into the bed alarm pad. Review of the incident report dated 2/22/23 indicated the following: *Heard resident yelling that he/she fell . We went into his/her room and he/she was on the floor. Review of Resident #9's physician's orders dated 1/17/23 indicated the following: *Alarms: bed alarm - check function and placement every shift Review of Resident #9's high risk for falls care plan indicated the following interventions: *Dated 1/17/23: Bed alarm on at all times when in bed *Dated and revised 3/6/23: Floor mats on either side of bed when in bed *Dated and revised 2/28/23: Floor mats to floor when in bed Review of Resident #9's Fall Risk evaluation dated 2/2/23 indicated that the Resident scored an 11 on the evaluation indicating that he/she is at risk for falling. Review of Resident #9's Kardex (a resident's care card) indicated the following under the safety section: *Floor mats on either side of bed when in bed *Floor mats to floor when in bed During an interview on 6/30/23 at 7:05 A.M., Certified Nursing Assistant (CNA) #1 said Resident #9 has had falls in the past. She continued to say when a resident has a fall, nurses will put in interventions including bed mats and alarms. During an interview on 6/30/23 at 7:18 A.M., Nurse #4 said when a resident has falls, interventions will be put in place which includes fall mats on sides of bed and sometimes bed alarms. The surveyor and Nurse #4 observed Resident #9 sleeping in bed with no fall mats in place or bed alarm plugged in. She said she was not sure why these were not being used. During an interview on 6/30/23 at 7:24 A.M., the Director of Nursing (DON) said interventions for Resident #9 include a low bed, bed alarms and floor mats. The surveyor and the DON entered Resident #9's room and observed him/her sleeping in bed, the fall mats were folded in the corner in the room, not beside the bed and there was no bed alarm plugged in. The DON located the bed alarm in the bedside table and said staff likely unplugged it because it kept going off. The DON further said the interventions should be in place since he/she is care planned for them and he/she is at risk of injury with the interventions not being used.

Based on observation, record review and interview the facility failed to maintain respiratory equipment according to professional standards of practice for 1 Resident (#29) out of a total sample of 13 Residents. Findings Include: Review of the facility's policy titled, Nebulizer/Care and Use of, dated 9/19, indicated Cleaning: Single Resident Use, 1. Nursing will replace tubing, mask/mouthpiece weekly. 2. Tubing will be dated and replacement documented in resident record. 3. Equipment will be stored in a loosely covered plastic bag. Resident #29 was admitted to the facility in February 2022 with diagnoses including dementia, major depressive disorder and asthma. Review of Resident #29's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she scored a 12 out of a possible 15 on the Brief Interview for Mental Status exam which indicated he/she had a moderate cognitive deficit. During an observation on 6/28/23 at 7:22 A.M., the surveyor observed Resident #29's nebulizer mask and machine on top of personal items on the night stand. The nebulizer tubing was not dated or labeled. During an interview on 6/28/23 at 7:23 A.M., Resident #29 said he/she had a bad cold and uses the nebulizer many times a day and said that staff never put the mask in a bag. During an observation on 6/28/23 at 7:50 A.M., 8:32 A.M., 11:36 A.M., 12:28 PM., 12:38 P.M., 2:18 P.M., the surveyor observed Resident #29's nebulizer mask and machine on top of personal items on the night stand. The nebulizer tubing was not dated or labeled. Review of Resident #29's June 2023 Physician Orders, indicated Ipratropium-Albuterol Solution 0.5-2.5, 3 MG/3 ML, 1 unit inhale orally every 6 hours for respiratory infection. Review of Resident #29's June 2023 Medication Administration Record (MAR), indicated he/she received the Ipratropium-Albuterol nebulizer treatment four times a day on 6/25/23, 6/26/23 and three times daily on 6/27/23 and 6/28/23. During an interview on 6/29/23 at 7:55 A.M., Nurse #2 said that nebulizer tubing should be dated and labeled weekly. Nurse #2 said that the nebulizer mask should always be in a bag when it is not in use. During an interview on 6/29/23 at 1:49 PM, The Director of Nursing (DON) said that when the nebulizer is not in use the mask should be in an oxygen bag and said the tubing should be labeled when the tubing was put into place and then weekly.

Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. One of two nurses observed made 3 errors in 31 opportunities, resulting in an error rate of 9.68%. These errors impacted 3 Residents (#30, #10 and #13) out of 5 residents observed. Findings include: Review of the facility policy titled Administering Medications (undated) indicated medications are to be administered according to the physician's orders within the professionally accepted standard of within 1 hour of ordered time. 1. For Resident #30, the facility failed to administer a medication at the right dose. Review of the current physician's orders (June 2023) indicated an order for the following: A. Zinc give 220 mg (milligrams) by mouth one time a day for wound healing at 8:00 A.M. During medication pass on 6/29/23 at 7:44 A.M., the surveyor observed Nurse #1 prepare and administer the following medication: A. Zinc 200 mg 1 tablet. Nurse #1 did not attempt to contact Resident #30's physician to determine if a dose of zinc 200 mg was acceptable and could be administered. During an interview at 7:50 A.M., Nurse #1 said the medication dosage was acceptable because it approximated the physician's order and zinc tablets for 220 mg were not available in the medication cart. 2. For Resident #10, the facility failed to administer a medication at the right dose. Review of the current physician's orders (June 2023) indicated an order for the following: A. Calcium carbonate-vitamin D3 tablet 600-400 mg-unit (calcium carb-cholecalciferol give 625 mg by mouth two times a day for minerals and electrolytes. During medication pass on 6/29/23 at 7:44 A.M., the surveyor observed Nurse #1 prepare and administer the following medication: A. Calcium carbonate 600 plus D3, 5 mcg 1 tablet. 3. For Resident #13, the facility failed to administer a medication at the right dose. Review of the current physician's orders (June 2023) indicated an order for the following: A. Escitalopram oxalate 10 mg tablet. Give 30 mg by mouth one time a day for anxiety related to dementia in other diseases classified elsewhere, (unspecified severity), with anxiety. During medication pass on 6/29/23 at 10:16 A.M., the surveyor observed Nurse #1 prepare and administer the following medication: A. Escitalopram oxalate 10 mg 2 tablets (a total of 20 mg). Nurse #1 was unavailable for an interview following the administration of the calcium carbonate and escitalopram oxalate. During an interview with the Director of Nurses on 6/29/23 at 10:41 A.M., she said it was facility policy and a professional standard to administer medications according to the physician's orders.

Based on observations, record reviews and interviews, the facility failed to obtain dental services for 2 Residents (#18 and #3) out of a total sample of 13 residents. Findings include: 1. Resident #18 was admitted to the facility in July 2019 with diagnoses including dementia. Review of Resident #18's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #18 requires minimal assistance from staff for oral hygiene. During interviews on 6/28/23 at 8:41 A.M., and 6/30/23 at approximately 9:00 A.M., Resident #18 was observed to have discolored teeth and a built-up substance on his/her teeth. Resident #18 said he/she would like to be seen by the dentist for a routine visit. Review of Resident #18's medical record indicated the Resident's legal guardian requested dental services on 10/22/19. Further review of Resident #18's medical record failed to indicate the Resident had ever been seen by a dentist. During an interview on 6/30/23 at 7:48 A.M., Nurse #4 said she was unaware of how residents receive dental services. During an interview on 6/30/23 at 8:01 A.M., the Director of Nurses (DON) said the consulting dental service maintains a list of individuals needing to be seen by the dentist. The DON said she was unaware if Resident #18 was ever seen by the dentist and would check. During an interview on 6/30/23 at 9:12 A.M., Regional Nurse #2 said Resident #18 was never seen by the dentist as requested and would be making an appointment for him/her to go. 2. Resident #3 was admitted to the facility in October 2022 with diagnoses including Alzheimer's Disease. Review of Resident #3's most recent Minimum Data Set (MDS) dated [DATE] indicates Resident #3 is unable to complete the Brief Interview for Mental Status (BIMS) exam and the staff assessed him/her to have severely impaired cognition. The MDS also indicates Resident #3 is dependent on staff for all functional daily tasks. During an observation on 6/28/23 at 8:20 A.M., Resident #3 was observed lying in bed. He/she was observed to have several missing teeth. Resident #3 was unable to be interviewed about his/her oral status. Review of Resident #3's medical record indicated the Resident's legal guardian requested the Resident to obtain dental services. Review of Resident #3's physician orders indicated the following order: *May have dentist, podiatrist and ophthalmologist eval and treat as indicated, initiated 10/8/22. Further review of Resident #3's medical record failed to indicate the Resident had ever been seen by a dentist. During an interview on 6/30/23 at 7:48 A.M., Nurse #4 said she was unaware of how residents receive dental services. During an interview on 6/30/23 at 8:01 A.M., the Director of Nurses (DON) said the consulting dental service maintains a list of individuals needing to be seen by the dentist. The DON said she was unaware if Resident #3 was ever seen by the dentist and would check. During an interview on 6/30/23 at 9:12 A.M., Regional Nurse #2 said Resident #3 was never seen by the dentist as requested and would be making an appointment for him/her to go.

Based on observations, record reviews and interviews, the facility failed to provide a diet of personal preferences to 1 Resident (#3) out of a total sample of 13 residents. Findings include: Resident #3 was admitted to the facility in October 2022 with diagnoses including Alzheimer's Disease. Review of Resident #3's most recent Minimum Data Set (MDS) dated [DATE] indicates Resident #3 is unable to complete the Brief Interview for Mental Status (BIMS) exam and the staff assessed him/her to have severely impaired cognition. The MDS also indicates Resident #3 is dependent on staff for all meals. On 6/28/23 at 9:00 A.M. and on 6/29/23 at 8:45 A.M., Resident #3 was observed eating eggs for breakfast. Review of Resident #3's admission paperwork indicated he/she had an allergy to fish, eggs, and pork. Review of Resident #3's initial nutritional assessment indicated Resident #3 did not have an allergy to eggs, however strongly disliked eggs and would prefer not to eat them. Review of Resident #3's meal tickets provided by the kitchen failed to indicate Resident #3's food dislikes/preferences were listed for the kitchen staff when plating the Resident's meals. During an interview on 6/29/23 at 9:43 A.M., the Registered Dietitian (RD) said she knows Resident #3 from both this facility and the facility the Resident resided at prior. The RD said Resident #3 has a very strong dislike of eggs and chooses to avoid those foods. The RD was unaware Resident #3 had been receiving eggs. The RD said all food preferences should be honored by the facility and Resident #3's meal ticket should list his/her dislike of eggs and he/she should not receive eggs for any meal. During an interview on 6/29/23 at 12:54 P.M., the Director of Nursing said all resident food preferences should be obtained upon admission and honored by the facility. During an interview on 6/30/23 at 10:57 A.M., the Food Service Associate said all resident requests and dislikes are supposed to be on the meal ticket to ensure the kitchen serves the appropriate menu to the residents. The Food Service Associate said he was aware Resident #3 did not like eggs and should not be served eggs.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be at risk for elopement from the facility and required use of a wanderguard bracelet (a device used to alert staff when a resident attempts to exit the Facility), the Facility failed to ensure that he/she was provided adequate supervision to maintain his/her safety to prevent an incident of elopement. -On 06/26/22, around dinner time, staff were unable to locate Resident #1 anywhere inside the Facility or on Facility grounds. It was later discovered that at least twice that day, the alarm on the door in the dining room that led out to the patio area, was disengaged (deactivated) by staff, and the door was left opened, so residents could access the patio area (that had an unalarmed gate through which anyone could exit off Facility grounds). However, there was not always sufficient staff present to supervise the residents in both the dining room and out on the patio at the same time, each time the alarm was disengaged and the patio door was left open. Resident #1 was later found at an airport (over 20 miles away) and transferred to a nearby Hospital where he/she was treated for hypoxemia (low oxygen levels in the blood) and mild acute kidney injury secondary to dehydration. Findings Include: Review of the Facility Policy titled Resident Elopement and Wandering, dated as revised 01/2022, indicated the Facility would take appropriate steps to identify the risk of, prevent, detect, and respond promptly to resident wandering and elopements. The Policy indicated that alarm systems shall be on at all times, as appropriate. Resident #1 was admitted to the Facility in October 2021, diagnosis included dementia, hypertension, [CONDITION(S)], and unspecified sequelae of cerebral infarction (residual effects following an episode of necrosis or tissue death, due to stroke). Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of two (scores between 0-7 suggest severe cognitive impairment). Review of Resident #1's Elopement Evaluation, dated 04/29/22, indicated that he/she was at risk for elopement from the Facility. Review of Resident #1's Risk for Wandering/Elopement Care Plan, dated as revised on 05/19/22, indicated that he/she voiced wanting to go home, tried to pay staff and visitors to bring him/her to the airport, and had a history of taking off his/her wanderguard bracelet. Review of Resident #1's Nurse Progress Note, dated 06/26/22, indicated that Nurse #2 was notified that he/she was missing at 7:20 P.M., the Facility was searched, he/she was not found, and the Police Department was notified at 7:35 P.M. The Note indicated that when the Police arrived, at approximately 7:40 P.M., as Nurse #2 was giving report to a Police Officer, a call was received from a Hospital (which was located 19 miles away from the Facility) to notify them that Resident #1 had been transferred to the Hospital after being found with increased confusion at a major airport. Review of the Police Report, dated 06/26/22, indicated that the Police Department was contacted at 7:29 P.M. and notified that Resident #1 had been missing for approximately one hour. The Report indicated that upon arrival to the Facility, an Officer was told that Resident #1 had last been seen at the Facility eating dinner at approximately 5:00 P.M. The Report indicated that a code was required to enter and exit the Facility and it was unknown how Resident #1 was able to exit the Facility. The Report indicated that as the Officer spoke with a nurse, a phone call was received from a Hospital to report that Resident #1 was there and had been entered as a patient at approximately 6:09 P.M. The Report indicated that there was no information available as to how Resident #1 got to the Hospital. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/28/22, indicated that after Resident #1 eloped from the Facility on 06/26/22, an investigation was completed and it was determined that Resident #1 had cut off his/her wanderguard bracelet and left the Facility via the dining room patio. The Report indicated that Resident #1 told staff that after he/she left the Facility, he/she walked two building down from the Facility where he/she asked someone to drive him/her to the airport. Review of Resident #1's Hospital Summary, dated 06/27/22, indicated that Resident #1 was taken from the airport, where he/she was found to be confused and hypoxic (decreased oxygen level), and transferred by Emergency Medical Services (EMS) to the Hospital. The Summary indicated that Resident #1 arrived at the Hospital at 6:09 P.M. and his/her oxygen saturation level was 84% (normal is typically between 95-100%, 84% dangerous and requires treatment). The Summary indicated that Resident #1 had mild acute kidney injury secondary to chronic kidney disease on dehydration and he/she was treated with intravenous fluids. Review of Accuweather.com weather history for 06/26/22 indicated that it was 94 degrees Fahrenheit in the town where the Facility is located and 90 degrees Fahrenheit in the city where the airport was located. During an interview on 07/27/22 at 1:34 P.M., the Activity Director said she did not work on 06/26/22 but said she was notified that Resident #1 had eloped so she came to the Facility to help look for him/her. The Activity Director said a former Activity Aide (no longer employed at the Facility) had been scheduled to work on 06/26/22 from 10:00 A.M. to 7:00 P.M. and said the former Activity Aide was stationed to be in the dining room during his shift. The Activity Director said she told the former Activity Aide that it was important to follow the activity schedule that she made. The Activity Director said Resident #1 was at risk for elopement and said she did not schedule patio time for residents on the weekends if she was not working because Resident #1, if outside, needed all eyes on him/her. The Activity Director said she did not feel comfortable with the patio being open on the weekends. The Activity Director said the former Activity Aide had taken residents out to the patio area a few times that day, which had not been a scheduled Activity. During an interview on 07/27/22 at 2:17 P.M., the Clinical Coordinator said she was the Manager on Duty on 06/26/22 and said the alarm on the patio door in the dining room could be disabled by staff so residents could go in and out to the patio area. The Clinical Coordinator said she decided it was alright to leave the dining room patio door opened on 06/26/22 and said the door was opened and the alarm disabled until approximately 12:00 P.M. when it was time for lunch. The Clinical Coordinator said after lunch they again disabled the dining room patio door alarm and left the door opened at approximately 12:40 P.M. The Clinical Coordinator said she was aware Resident #1 was an elopement risk. The Clinical Coordinator said although she was in the dining room with the former Activity Aide, she left the area at approximately 1:50 P.M. to check on a resident and administer medications. The Clinical Coordinator said when she left the dining room, the former Activity Aide was the only staff member in the dining room. The Clinical Coordinator said the last time she saw Resident #1 that day was at 1:30 P.M. and said she saw Nurse #2 close the patio door at 4:00 P.M. The Clinical Coordinator said dinner was at 5:00 P.M. that day, that she was in the dining room from 5:00 P.M. to 5:40 P.M., and said she did not see Resident #1 in the dining room for dinner. The Clinical Coordinator said she left the Facility at approximately 6:45 P.M. and staff did not mentioned Resident #1 was missing. During an interview on 07/27/22 at 2:57 P.M., the Dietary Aide said that on 06/26/22 she brought meal trays to the dining room and helped serve the meal trays to residents. The Dietary Aide said Resident #1 always ate dinner in the dining room and said she did not see him/her in the dining room at dinner time that day. During an interview on 07/27/22 at 3:13 P.M., Nurse #1 said he arrived at the Facility for his shift sometime between 5:00 P.M. and 5:30 P.M. Nurse #1 said when he was administering medications at approximately 6:00 P.M. he did not see Resident #1 in his/her room or bathroom, and said shortly after that when he still did not see Resident #1, he checked all the rooms and bathrooms on the unit, notified the charge nurse, a Facility wide search was conducted, and the Police were called. Review of the former Activity Aide's written Witness Statement, dated 06/26/22, indicated that at 1:00 P.M. he opened the door in the dining room that lead to the patio and observed Resident #1 go outside on the patio from 1:10 P.M. until approximately 2:00 P.M. The Statement indicated that at 3:00 P.M. he closed the patio door and indicated that at approximately 3:50 P.M. while letting a visiting family out of the Facility, he saw Resident #1 peeking around a corner. During an interview on 07/27/22 at 3:31 P.M., Nurse #2 said she worked the 3:00 P.M.-11:00 P.M. shift on 06/26/22. Nurse #2 said Resident #1 was not on her assignment but she was aware that he/she was an elopement risk. Nurse #2 said she did not see Resident #1 when she arrived for her shift at 3:00 P.M. Nurse #2 said she went into the dining room at approximately 3:20 P.M. and saw the doors in the dining room that went out to the patio were propped open. Nurse #2 said the former Activity Aide was not outside on the patio with residents and said he was inside the Facility in the middle of the dining room. Nurse #2 said it was too hot for residents to be outside so she told the former Activity Aide to bring the residents inside from the patio and said she told him to shut the doors. Nurse #2 said the door alarm was not activated and she asked the former Activity Aide to activate the door alarm. Nurse #2 said that she was notified by Nurse #1 at approximately 7:20 P.M. that they could not locate Resident #1. Nurse #2 said they called the Assistant Director of Nursing (ADON), searched the Facility, called the Police and said while she was giving the Police Officer a report, the Unit phone rang and it was the Hospital who informed her that Resident #1 had been transferred to their Emergency Department after being found confused at a major airport. Nurse #2 said Resident #1 most likely left through the patio doors that were left opened with the alarm disabled because all the other exit doors were alarmed and would have sounded if he/she tried to open them. Nurse #2 said the Hospital called her back at approximately 10:00 P.M. to tell her that Resident #1 was being admitted for [CONDITION(S)] (low oxygen levels in tissues causing confusion, restlessness, and difficulty breathing) and mental status change. During an interview on 07/27/22 at 4:04 P.M., the Director of Nursing (DON) said Resident #1 had cut his/her wanderguard off in the past and said she was made aware that he/she cut his/her wanderguard off prior to his/her elopement on 06/26/22 because scissors were found in his/her room. The DON said the Facility was able to determine that Resident #1 left the Facility through the dining room patio door because Resident #1 him/herself told the Activity Director that was the door from which he/she exited the Facility. The DON said although staff saw Resident #1 throughout the day, no-one saw him/her leave the Facility and said they were unsure what time he/she left the Facility. The DON said the former Activity Aide did not follow the activity calendar because it indicated right on the calendar for residents and staff to see, that there was to be no patio access that day. The DON said when the patio doors are opened in the dining room, staff must watch the doors and the residents at all times. On 07/27/22, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 06/28/22, Resident #1 was placed on fifteen minute safety checks which included checking for wanderguard placement. B) 06/29/22, Resident #1 was provided with a new personal alarm bracelet that will notify police of his/her location via radar if he/she goes missing and will notify the police if it is tampered with. C) 06/27/22, DON and designee completed an audit to ensure all residents at risk for elopement were identified using a color coded name tag outside their room. The Certified Nurse Aide (CNA) behavior sheets, Care Cards and Care Plans were also updated. D) 06/27/22, Executive Director ensured elopement drills were initiated. Weekly elopement drills will continue to be conducted weekly for four weeks and monthly thereafter. E) 06/27/22, Maintenance Director attached an additional alarm outside on the gate in the patio that alarms when the patio gate is opened. F) 06/27/22, Maintenance Director changed the code on the patio doors which no longer allows staff to de-activate (disengage) the patio door alarm. G) 06/27/22, Maintenance Director installed an additional video camera facing the outside patio. H) 07/01/22, Maintenance Director added additional door alarms to the hall exit door and dining room exit door. I) 07/01/22, Staff Development Coordinator updated and will continue to maintain an Elopement Log Book, which will be brought to and reviewed at morning meeting. J) 07/04/22, DON and Executive Director ensured all residents at risk for elopement were put on thirty minute safety checks. K) 07/07/22, DON and designee completed education to all staff related to the Elopement Policy and Procedure, wanderguard management, not leaving residents outside unsupervised, and elopement risks. L) July 2022, DON presented Plan of Correction to the Facility Quality Assurance Performance Improvement Committee. M) DON and Executive Director are responsible for overall compliance.

Based on observation, record review and interview the facility failed to ensure one Resident (#7) was free from involuntary seclusion, out of a total of 16 sampled residents. Specifically, Resident #7, against his/her wishes, was confined to a locked dementia unit, wearing a wanderguard and unable to leave or go outside unaccompanied, despite being his/her own person. There is no indication in Resident #7's medical record to indicate the need for a locked dementia unit or need to wear a wanderguard, resulting in the Resident having persistent feelings of sadness and anxiety. Findings include: The facility policy titled Abuse, Neglect, Misappropriation of Resident Property, and Involuntary Seclusion, revised 1/9/18, indicated the following: * The law is: Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. The facility policy titled Resident Elopement and Wandering, reviewed 1/2021, indicated: * It is the policy of this facility to take appropriate steps to identify the risk of, prevent, detect, and respond promptly to resident wandering and elopement. * Resident wandering is defined as that situation where a cognitively impaired resident exhibits random or repetitive locomotion which may be goal directed or aimless. Resident #7 was admitted to the facility in November 2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 2/23/21, indicated Resident #7 scored a 12 out of a possible 15 on the Brief Interview for Mental Status Exam, indicating moderate impaired cognition. During an interview on 5/18/21 at 10:08 A.M., Resident #7 became weepy. Resident #7 said that there is nothing to do here all day. Resident #7 said that twice a day staff take him/her outside for a cigarette and that otherwise he/she stays in his/her room. During review of Resident #7's medical record on 5/18/21 at 10: 02 A.M., the following was indicated: 1.) Review of the May 2021 physician's failed to indicate an order in place to activate the Resident #7's HCP. 2.) An elopement care plan, initiated 1/8/21, indicated the following: - I am at risk for elopement because I do not want to be here and I have cognitive impairment; - My goal is that staff will monitor me so I do not leave. - Interventions are to monitor where I am, check wanderguard as ordered (A wanderguard is a device that when worn, prevents doors from unlocking and sounds an alarm if a resident attempts to go outside.) 3.) A discharge planning care plan, initiated 2/1/21, that indicated - I'm young and want to leave to be on my own, I want to be transferred to a group home. - Intervention is will update and provide support. 4.) A progress note by the Physician's Assistant (PA), dated 4/22/21, indicating Resident #7 is most of the time isolated because he/she is not able to interact with demented population in this facility. 5.) A social service quarterly assessment note, dated 3/8/21, indicating Resident #7: - completes another quarter at Royal [NAME]. He/she is alert and oriented X 3 with some forgetfulness; - mood has been down due to the population of the facility. 6.) An evaluation from the Psychiatric Nurse Practitioner (PNP) dated 5/6/21, indicating Resident #7 has persistent feelings of sadness and anxiety. During a follow-up interview on 5/19/21 at 2:02 P.M., Resident #7 approached the surveyor and asked to speak. Resident #7 became teary and said, he/she is depressed and wants to leave but that the Social Worker (SW) does not help him/her. Resident #7 said that when he/she was at another facility, prior to this one, he/she was crying and said he/she wanted to leave. Resident #7 said that the staff at that facility said that they were sending me here because it's much more comfortable. And then I got here and I can't leave because the door is locked. During an interview with the Director of Nursing (DON) on 5/20/21 at 10:07 A.M., she reviewed the clinical record with the surveyor and said: * We know that Resident #7 doesn't want to be here (on a locked dementia unit) and that this population is not appropriate for him/her, that's why the SW is working on getting him/her into a group home; * The most recent elopement assessment, dated 2/19/21, is not complete, and therefore there is not an indication as to whether wearing a wanderguard is indicated. * Resident #7 does not have an order to have an activated HCP, so if he/she wants to leave he/she has the right to. During an interview with the Nurse Practitioner (NP) #1 on 5/20/21 at 10:42 A.M., she said that Resident # 7 had no behaviors of attempting to leave the facility and that the facility makes Resident #7 more depressed, there is nothing to do there and no one to talk to. During an interview with Resident #7's Certified Nursing Assistant (CNA) #1 on 5/20/21 at 11:20 A.M., she said Resident #7 is nice, with no behaviors, but always says to me I want to go home. During an interview with Resident #7's Physician (MD) on 5/20/21 at 11:46 A.M., that he did not think Resident #7 should have the wanderguard. During an interview with the facility's SW on 5/20/21 at 11:29 A.M., she said: * Resident #7 Resident #7 should never been transferred here (on a locked dementia unit), I just don't know why he/she is here, he/she is really looking for people his/her age and people to talk to. * She was working to get Resident #7 into a group home but that the process was very lengthy. * She is not sure why Resident #7 still wears a wanderguard bracelet but the group home wants it off because when he/she gets there he/she will be free to come and go as he/she pleases. and he/she should have that freedom here I think. * Resident #7 is very depressed here due to his/her age and the population. * Resident #7 can get out for fresh air when staff are available but that there is no formal plan to make that happen.

Based on observation, record review, and interview, the facility failed to 1. ensure residents received care in accordance with the comprehensive person-centered care plan for 2 Residents (#30 and #35) and 2. ensure that residents receive treatment and care in accordance with professional standards of practice for 1 Resident (#3). Findings include: 1. Resident #30 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #30 scored a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. Review of Resident #30's medical record/weight summary indicated the following: -[DATE]: 146.6 lbs (pounds) -[DATE]: 131.2 lbs (a 10.5% weight loss from [DATE] after intravenous diuresis during a hospitalization from -[DATE]-[DATE]) Review of Resident #30's medical record indicated he/she was hospitalized on [DATE], and review of Resident #30's hospital discharge paperwork dated [DATE] indicated the following: -Principle Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Changed [MEDICATION(S)] dose from 80 mg daily to 40mg daily given acute kidney injury. -Recommend giving [MEDICATION(S)] in the afternoon so dose may be adjusted based on oral intake. -Recommendation for [MEDICATION(S)] 40mg by mouth daily -Resident #30 received diuresis with intravenous [MEDICATION(S)] (a diuretic medication) twice daily while in hospital. Review of Resident #30's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident #30 received [MEDICATION(S)] 80 mg by mouth at 9:00 A.M., from [DATE] through [DATE]. Review of Resident #30's clinical progress notes from [DATE], failed to indicate the hospital recommendation for [MEDICATION(S)] 40mg daily in the afternoon was ever reported to the Resident's physician. Review of Resident #30's Dietician progress note dated [DATE] indicated the following: -Resident #30's weight on readmit from hospital [DATE] 131.2 lbs, weight loss 15.6 lbs, 10.6%. -Reweigh requested. -Resident #30 sent to emergency roiagnom on [DATE]. -Full weight review on readmit to facility. Review of Resident #30's hospital discharge paperwork dated [DATE] indicated the Resident discharged from the hospital with recommendations for [MEDICATION(S)] 40 mg by mouth daily. Further Review of Resident #30's progress notes for [DATE] failed to indicate a full weight review occurred after his/her readmission to the facility on [DATE]. Further review of Resident #30's medical record/weight summary indicated the following: -[DATE]: 137 lbs (a 5.8 lb increase from [DATE]) -[DATE]: 142.2 lbs (an 8.4% increase from [DATE] and a 5.2 lb increase from [DATE]) -[DATE]: 151.6 lbs (a 15.55% weight gain from [DATE], and a 6.6% increase from [DATE]) Review of Resident #30's Physician Assistant's (PA) progress notes indicated the following: -Resident #30's PA notes dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] all indicated Resident #30 was ordered for [MEDICATION(S)] 20 mg oral daily. - Resident #30's PA note dated [DATE] indicated the Resident's weight was 142 lbs and had a mild increase in weight (despite having gained 5.2 lbs from the previous week and 8.4% overall from [DATE].) -Further review of Resident #30's medical record failed to indicate any Physician or PA notes/visits after [DATE]. Review of Resident #30's physician consult note dated [DATE] indicated the following: -Resident #30 was seen for [NAME] pulmonary hypertension. -It is not clear Resident #30 is receiving the correct doses of his/her medication -Resident should be receiving 20mg [MEDICATION(S)] daily. Review of Resident #30's clinical progress notes from [DATE], failed to indicate the following: -The significant weight increase on [DATE] was ever reported to the Resident's physician. -The hospital recommendations for [MEDICATION(S)] 40mg was ever reported to the Resident's physician. -The consult recommendations from [DATE] were ever reported to the Resident's physician. On [DATE] at 8:25 A.M., the surveyor observed Resident #30 eating breakfast in his/her room. The meal ticket on his/her tray indicated the following: -No added salt diet, puree texture, no [NAME], sausage, ham, reg soup, macaroni and cheese. Review of Resident #30's physician's orders indicated the following: -An order dated [DATE] for no added salt diet, puree texture, nectar consistency, 2 liter fluid restriction (1 liter with meals, 1 liter with nursing.) -An order dated [DATE] for [MEDICATION(S)] (a diuretic medication used to treat fluid retention) 80 mg (milligrams) by mouth daily. -An order dated [DATE] for [MEDICATION(S)] 80 mg by mouth daily. Review of Resident #30's MAR from [DATE], indicated Resident #30 received [MEDICATION(S)] 80 mg by mouth at 9:00 A.M., from [DATE] through [DATE]. Review of Resident #30's nutritional care plan dated [DATE] indicated the following: -Resident #30 has fluid overload or potential fluid volume overload related to disease process. -An intervention dated [DATE] for diet as ordered -An intervention dated [DATE] and revised [DATE] for monitor/document any signs or symptoms of fluid overload, sudden weight gain. -An intervention dated [DATE] to weigh at the same time of day and record per MD order. Notify physician and dietician of sudden weight changes greater than 5 lbs in one week. Review of the facility policy titled Weight Assessment and Intervention, undated, indicated the following: -Nursing staff will measure resident weight on admission, readmission, the next day, and weekly for four weeks thereafter. -Any weight change greater than 3 pounds between consecutive weekly weights and 5 pounds between consecutive monthly weights necessitates a reweight within 24 hours with licensed staff present to verify. -Weekly interdisciplinary at-risk or weight meeting is to be held to address weight trends and/or significant weight issues. -Significant weight changes are defined as a. 5% or more within 30 days b. 7.5% or more within 90 days c. 10% or more within 180 days. -Discontinuance of weight monitoring due to end of life/comfort care will be discussed at the weekly At-Risk or Weight Meeting, reviewed with the Healthcare Proxy and physician, with an order written [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy titled Reconciliation of Medications on Admission, dated [DATE], indicated the following: -Gather the information needed to reconcile the medication list: -Discharge summary from referring facility; -Most recent Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. -Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. -If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. -Contact the admitting and/or Attending Physician. During an interview on [DATE] at 2:10 P.M., the Food Service Director said no residents were currently on a fluid restriction. She said Resident #30 had been on a fluid restriction but after his/her last hospitalization ([DATE]) he/she was not on a fluid restriction anymore (despite his/her current diet order dated [DATE] included a 2 liter fluid restriction). During an interview on [DATE] at 2:15 P.M., Nurse #1 said Resident #30 was on a 2 liter fluid restriction and said the staff don't document total fluid intakes for the day or shift. During an interview on [DATE] at 3:54 P.M., the Director of Nursing (DON) said when a resident is readmitted to the facility, the hospital discharge medication list should be reconciled with the resident's attending Physician or PA. She said Resident #30 should not be on a fluid restriction as of now because he/she was on hospice. She said the weight obtained on [DATE] had not been reported to the PA because she had not been in during that week to review the weight in risk meeting. The DON said any significant increase in resident weight should be reported the resident's Physician. During an interview on [DATE] at 8:24 A.M., the DON said Resident #30's PA was coming in to review his/her medical record, because there were issues with the Resident's fluid management. During an interview on [DATE] at 11:14 A.M., Resident #30's PA said she was going to keep him/her prescribed on 40mg of [MEDICATION(S)]. She was unaware Resident #30 was currently on 80 mg of [MEDICATION(S)] daily, and did not know about the additional significant weight gain on [DATE] until [DATE]. The PA said she would have ordered the initial hospital recommendations for daily [MEDICATION(S)] dose of 40mg. She said Resident #30 is compromised secondary to his/her potential for fluid overload. 2. For Resident #35 the facility failed to notify the physician or nurse practitioner of Resident #35's change in condition. Resident #35 died in the facility on [DATE]. Resident #35 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 had severe cognitive impairment. Review of Resident #35's nursing progress note dated [DATE] indicated the following: -Resident continues with wheezing with intermittent shortness of breath. -Use of accessory muscle noted when breathing. -Non-compliant with oxygen administration -Scheduled and as needed (PRN) [MEDICATION(S)] (an inhaled medication used to treat shortness of breath) given with no effect. -Poor diet/fluid intake Review of Resident #35's nursing progress note dated [DATE] indicated the following: -Resident had increased fatigue, poor appetite, and anxiety. -Oxygen saturation 94% on room air this morning then dropped to 89% this afternoon. -Healthcare Proxy (HCP) called to give update on recent decline, no response, left voice message. Review of Resident #35's medication administration notes dated [DATE] indicated the Resident was unable to swallow medication or anything by mouth. Review of Resident #35's Social Service note dated [DATE] indicated the following: -Nurses over the weekend tried to call the HCP to inform them about a rapid decline with Resident #35. -Resident #35 had a significant decline and is not medically cleared to be transferred to a new facility. Review of Resident #35's nursing progress note dated [DATE] indicated the following: -Resident #35's HCP was informed about his/her health status and told due to his/her rapid decline it is not medically advised for the resident to be transferred. Review of Resident #35's facility's Discharge Summary dated [DATE], indicated the following: -Over the weekend, Resident #35 began to rapidly decline. -Resident #35 was barely eating and increased fatigue. -Today the family was made aware Resident #35 had declined very rapidly. -Resident #35 was pronounced dead on [DATE] at 3:10 P.M. Review of Resident #35's Physician's orders indicated the Resident was a Do Not Resuscitate (DNR) status. Review of Resident #35's right to formulate advance directive care plan, dated [DATE], failed to indicate any goals or interventions for the care plan. Review of Resident #35's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated [DATE], indicated the following: -DNR -Do not intubate and ventilate (DNI) -Do not use non-invasive ventilation -Transfer to hospital Review of Resident #35's progress notes from [DATE] and [DATE] failed to indicate the decline/change in condition first observed on [DATE], nor Resident #35's inability to swallow his/her medication or anything by mouth was ever reported to the Resident's Physician. Review of Resident #35's Physician and Physician Assistant (PA) notes failed to indicate any notes or visits after [DATE] nor any notification of the Resident's rapid decline/change in condition described in his/her progress notes from [DATE] and [DATE]. Review of the facility policy titled, Change in Resident's Condition or Status, reviewed [DATE], indicated the following: -The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical/emotional/mental condition -Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status. Review of the facility policy titled Advance Directive/HCP Invocation/Legal Representation, reviewed [DATE], indicated the following: -The resident's attending physician will clarify and present any relevant medical issue and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. During an interview on [DATE] at 12:30 P.M., the Social Worker (SW) said Resident #35 had a decline over the weekend of [DATE]-[DATE]; he/she went to bed and didn't get up that weekend is what the SW was told. She said the HCP wanted the Resident transferred to another facility, but the other facility could not accept Resident #35 based on his/her condition. The SW said she was not sure about whether the HCP wanted Resident #35 transferred to the hospital or not. She said the Resident's code status was DNR/DNI. During an interview on [DATE] at 12:50 P.M., the Director of Nursing (DON), said if a resident has a change in condition or significant change, the Physician or PA should be notified right away to determine if a resident needed a change in treatment at the facility or if a resident needed to be transferred to an acute care setting. She said the resident MOLST decisions should be honored, including transfer to hospital status. 3. For Resident #3 a facility staff member failed to notify anyone that a resident was found on the floor resulting in pain and a delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility Incident Reporting Policy, undated, indicated all incidents, accidents and injuries of unknown origin must be reported, investigated and results to the DON. An accident is defined to include but not limited to a fall, skin tear of known or unknown origin, bruise of known or unknown origin. Resident #3 was admitted to the facility in ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she had adequate hearing and vision; spoke clearly, was understood and could understand. Resident #3 was not able to complete the Brief Interview for Mental Status (BIMS) exam and the facility staff assessment of Resident #3's cognitive skills for daily decision-making indicated moderate cognitive impairment. Resident #3 had poor decision making ability and required the need for cues and supervision daily. Resident #3 was also delusional and had physical and verbal behaviors. Resident #3 was not ambulatory, required 2 persons for bed mobility, moving from bed to chair and toileting. He/she was totally dependent for dressing, personal hygiene, bathing and was incontinent of both urine and bowel. Review of Resident #3's care plan dated, [DATE], indicated Resident #3 was at high risk for falls and injury related to decreased mobility, impaired safety awareness, use of antidepressant medication, chronic pain, comorbidities and a history of falls. Review of Resident #3's clinical record indicated a fall had occurred on [DATE] in Resident #3's room. Review of Resident #3's nursing progress note, dated [DATE] at 8:50 P.M., indicated that Resident #3 complained of pain to the upper left rib cage. The documentation indicated that Resident #3 continued to tell Nurse #3 and a certified nurse assistant (CNA) that he/she fell the previous night before dinner. Resident #3 said that he/she was trying to get from the chair to the bed and fell between the bed and the side table. Resident #3 said that a male helped him/her up and that he/she did not report the fall to a nurse or any other staff member. The Nurse #3 assessed the painful area and indicated that there was no bruising. Resident #3 also reported a cough for the previous few days. Pain medicine and cough medicine were administered with good effect. The Director of Nursing (DON) #2 was notified of the incident. Review of Resident #3's nursing progress note dated [DATE] at 8:11 P.M., indicated Resident #3 had complained of pain to the left side of his/her rib cage. [MEDICATION(S)] (pain medication) had been administered at 9:40 A.M., with somewhat good effect. The facility physician's assistant ordered an X-ray for the morning of [DATE]. Review of Resident #3's nursing progress note dated [DATE] at 9:57 P.M., indicated that Nurse #3 observed Resident #3 grimacing and holding his/her left side. The Resident was given [MEDICATION(S)] at 6:00 P.M., with some effectiveness. X-ray results were reported to Nurse #3 as fractures of the left 4th and 5th ribs. The physician, DON #2 and Resident #3's family were notified. During an interview on [DATE] at 12:12 P.M. DON #1 was not able to provide an incident report regarding the [DATE] fall for Resident #3. DON #1 said she was not employed at the facility during that time and could not locate it. The facility completed an investigation and reported the injury to the Department of Public Health on [DATE] at 9:00 P.M. Based on review of the information obtained through the investigation a positive identification was made of the male staff member and the Resident's fall was validated.

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent accidents for 3 Residents (#11, #22, and #24) from a total sample of 16 sampled residents, resulting in a laceration for Resident #22. Findings include: 1. Resident #22 was admitted to the facility in July 2020 with diagnoses including dementia and [CONDITION(S)]. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 had moderate cognitive impairment. Resident #22 was independent with bed mobility and transfers, and required supervision with ambulation. Review of Resident #22's progress note dated 3/13/21 indicated the following: -Resident #22 came to the nurses' station saying someone had hit him/her and he/she had a cut to the back of his/her head. Review of Resident # 22's Physician Assistant (PA) History and Physical note dated 3/13/21 indicated the following: -Resident #22 had an altercation with his/her roommate at the time. -Resident #22's roommate reported Resident #22 threw the roommate's pencils on the floor and Resident #22 tried to hit the roommate. -Resident #22 blocked his/her roommate from leaving the room and the roommate pushed the Resident into the wall to get out. -Resident #22 has a history of dementia and significant behavior problems in the last 5 months. -Resident #22 sustained a 3 cm (centimeter) x 0.5 cm abrasion to his/her posterior head following head strike. The facility failed to provide an incident report for the resident to resident altercation on 3/13/21 Review of Resident #22's care plans indicated the following: -A risk for adverse effects from receiving antipsychotic medication for treatment of dementia with behavioral disturbances care plan dated 7/17/20 -A care plan dated 8/14/20 for staff to monitor Resident #22's movements to prevent intrusive behaviors (dated one day after the resident to resident altercation) -An intrusive behavior care plan initiated on 10/9/20 -An elopement/wandering care plan initiated on 10/21/20 -A care plan for physical behaviors including hitting related to dementia and poor impulse control initiated on 3/25/21 (12 days following the resident to resident altercation on 3/13/21) -Resident #22's plan of care failed to identify interventions prior to the resident to resident altercation that occurred on 3/13/21 despite the Resident admitting to the facility with significant behavior problems. Review of Resident #22's progress note dated 3/25/21 indicated the following: -Around 12:05 P.M., Resident #22 had punched another resident in the forehead and abdomen. During an interview on 5/19/21 at 3:45 P.M., the Director of Nursing said based on assessments of behaviors/prior history, an initial plan of care should be developed on admission and developed as changes to assessments of the resident occur. 2. Resident #11 was admitted to the facility in November 2020 with a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had severe cognitive impairment. Resident #11 required supervision with bed mobility, transfers, and walking. Review of Resident #11's hospital discharge summary dated 11/3/20 indicated he/she had physical behaviors and had previously tried to strangle another resident at another facility. Review of Resident #11's incident note dated 11/4/20 at 3:58 P.M., indicated he/she got into an incident with another resident by hitting the other resident with a box of tissues. Review of Resident #11's social services note dated 11/4/20 indicated Resident #11 had entered another resident's room, picked up a Kleenex box, and struck the other resident in the head with the Kleenex box. Review of Resident #11's elopement assessment dated [DATE] at 6:18 P.M., indicated the following: -Resident #11 wanders -Wandering behavior is likely to affect the safety or well-being of self/others. -Wandering behavior is likely to affect the privacy of others. Review of Resident #11's care plans indicated the following: -An initial plan of care was not developed for wandering behaviors until 11/4/20. -An initial plan of care for intrusive behaviors failed to be developed until 3/15/21. Review of the facility policy titled Resident Elopement and Wandering, dated 6/21/17 and reviewed in January 2021, indicated the following: -All residents shall have an elopement assessment done and immediate plan of care for risk of wandering and elopement developed on admission if appropriate. During an interview on 5/19/21 at 3:45 P.M., the Director of Nursing said based on assessments of behaviors/elopement/prior history, an initial plan of care should be developed on admission and developed as changes to assessments of the resident occur. 3. Resident #24 was admitted to the facility in February 2021 with diagnoses including Alzheimer's Disease and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24 had severe cognitive impairment. Resident #24 required assistance with bed mobility and transfers, and required supervision with walking. Review of Resident # 24's progress note dated 3/2/21 indicated the following: -Resident #24 was in another resident's room around 6:00 P.M. during dinner, and fell on to his/her back when the other resident told him/her to leave the room. Review of Resident #24's progress note dated 3/6/21 indicated the following: -At 7:50 P.M. staff heard a loud noise from the nurses' station and found Resident #24 on his/her back in the hallway. -Resident #24 had been attempting to enter another resident's room, the other resident closed the door which pushed Resident #24 and he/she fell on to the floor. -Resident #24 was wandering prior to the fall. Review of Resident #24's Elopement evaluation dated 2/10/21 indicated Resident #24 wanders aimlessly and is likely to affect privacy of others. Review of Resident #24's Fall risk evaluation dated 2/10/21 indicated the following: -Resident #24 obtained a score of 13, indicating he/she was at risk for falls. Review of Resident #24's care plans indicated the following: - Resident #24's Risk for wandering care plan was initiated on 3/8/21 (6 days after his/her initial fall while wandering on 3/2/21). - Care plan initiated 3/8/21 risk for peer to peer altercation secondary to wandering/intrusive behavior (6 days after his/her initial fall while wandering on 3/2/21). On 5/18/21 at 3:25 P.M., the surveyor observed Resident #24 in another resident's room, not redirected by staff, and no staff were present at the time. On 5/19/21 at 12:30 P.M., the surveyor observed Resident #24 in another resident's room. Resident #24 had carried his/her plate and drinks from his/her room into another resident's room and managed to get behind another resident in their wheelchair and sat on the other resident's bed. On 5/19/21 at 4:00 P.M., the surveyor observed Resident #24 in another resident's room, touching another resident and items on that resident's bed. Review of the facility policy titled Resident Elopement and Wandering, dated 6/21/17 and reviewed in January 2021, indicated the following: -All residents shall have an elopement assessment done and immediate plan of care for risk of wandering and elopement developed on admission if appropriate. During an interview on 5/19/21 at 3:45 P.M., the Director of Nursing said based on assessments of behaviors/elopement/prior history, an initial plan of care should be developed on admission and developed as changes to assessment of resident occur.

Based on interview and record review, for 1 of 3 sampled residents (Resident #1), the Facility failed to implement Resident #1's Care Plan for Resistance to Care. At approximately 10:00 P.M. on 5/19/15, staff forcefully transferred Resident #1 into bed to provide incontinence care and to sleep for the night, while he/she was yelling that he/she did not want to go to bed. Once in bed, Resident #1 became combative and Certified Nurse Aide (CNA) #1, CNA #2 and CNA #3 held onto and restrained Resident #1's hands and legs. Resident #1's Plan of Care for Resistance to Care did not include the use of restraints to enable care. Findings include: Resident #1's Care Plan for Resistance to Care, dated 2/15/15, indicated he/she was resistant to care, related to his/her [DIAGNOSES REDACTED]. Resident #1's Care Plan did not include the use of restraints to enable care. Resident #1's quarterly Minimum Data Set, dated dated [DATE], indicated he/she had severely impaired cognition; exhibited physically aggressive behaviors toward others; required extensive one-person staff assistance for activity of daily living care; used a walker or wheelchair for mobility and was diagnosed with [REDACTED]. The Surveyor interviewed CNA #1 at 2:47 P.M. on 7/2/15. CNA #1 said Resident #1 was sitting in his/her wheelchair and was incontinent of urine and feces. CNA #1 said he needed to clean and change Resident #1 and put Resident #1 to bed because, everyone had to go to bed. CNA #1 said Resident #1 told him that he/she did not want to go to sleep for the night and refused to be transferred to bed. CNA #1 said he asked for CNA #2 and CNA #3 to help transfer Resident #1 to bed, which they did, even though Resident #1 became combative. CNA #1 said he changed Resident #1's soiled brief and while cleaning him/her, Resident #1 punched him in the stomach and face. CNA #1 said that CNA #2 held Resident #1's legs and that CNA #3 took over and changed Resident #1's brief. CNA #1 said he held Resident #1's hands. Review of CNA #2's written statement, dated May 2015, indicated CNA #1 asked him and CNA #3 to put Resident #1 to bed. CNA #2 indicated that, while trying to put Resident #1 to bed, Resident #1 punched CNA #1 in the stomach and face. CNA #2 indicated CNA #1 grabbed Resident #1's hands while CNA #2 and CNA #3 held his/her legs and put him/her on the bed. CNA #2 indicated they were able to change Resident #1's brief, but unable to clean him/her because he/she was too aggressive. The Surveyor interviewed CNA #3 at 2:00 P.M. on 7/1/15. CNA #3 said that at approximately 10:00 P.M. on 5/19/15, CNA #1 told him that Resident #1 was refusing to go to bed and asked him to help transfer Resident #1 into bed. CNA #3 said that CNA #2 wheeled Resident #1 into his/her bedroom and Resident #1 repeatedly told them (CNA #1,CNA #2 and CNA #3) that he/she did not want to go to sleep. CNA #3 said they transferred Resident #1 to bed, despite his/her objections. CNA #3 said that CNA #1 began to change Resident #1's soiled brief and Resident #1 continued to tell them that he/she did not want to go to bed. CNA #3 said that Resident #1 then punched CNA #1 in the stomach and face. CNA #3 said he held onto Resident #1's hands to prevent further hitting and CNA #2 held onto Resident #1's legs. CNA #3 said that CNA #1 reflexively moved his arm to block a punch and hit Resident #1's chest. CNA #3 said Resident #1 then told staff, Okay, I'm sorry, I give up - you can do what you want, or words to that effect. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 12:00 P.M. on 7/15/15. The ADON said she interviewed CNA #1, CNA #2, and CNA #3 and they told her that they did not reapproach Resident #1 after he/she refused to be transferred to bed. Review of Resident #1's clinical record indicated there was not a physician's orders [REDACTED]. The Surveyor did not interview Resident #1 because of his/her impaired cognition. Resident #1 had escalating response to being forcefully placed in bed, physical restrained by three staff, which resulted in being accidentally hit in the chest by staff. A reasonable person would experienced psychological harm as a result of being physically restrained by three people.

Based on record reviews and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1, who was at risk for falls, had a chair alarm that functioned properly, per the plan of care. On 8/25/12 at 6:30 P.M., Resident #1 was found on the floor, in the prone position, in the dining room and the chair alarm was not sounding. Resident #1 sustained a left proximal humerus fracture and bilateral pubis ramus fractures. The findings include: The Admission Record indicated Resident #1 was admitted to the Facility in August 2012 with [DIAGNOSES REDACTED]. The Fall Risk Assessment, dated 8/12/12, indicated Resident #1 scored 23. According to the scale used, a score above 10 indicated a high risk for falls. The Certified Nurse Aide Care Plan, dated 8/12/12, indicated Resident #1 used a restraint free alarm, chair and bed alarm. The admission Minimum Data Set (MDS) assessment, dated 8/23/12, indicated Resident #1 exhibited difficulty with short and long term memory and was severely impaired for decision making. The MDS indicated Resident #1 experienced falls prior to the assessment period. The Incident Report, dated 8/25/12, indicated Resident #1 was found on the floor in the dining room at 6:30 P.M., and Resident #1's restraint free alarm was not sounding even though the pin was detached from the control box. Resident #1 complained of pain in the left arm. The Residents Personal Safety Alarm Check Log, dated 8/25/12, for the 3:00 P.M. to 11:00 P.M. shift indicated Certified Nurse Aide #2 documented that she checked Resident #1's alarm for placement and functionality. The log indicated that Resident #1's alarm was in place and working. The Surveyor interviewed the Dietary Aide on 10/12/12 at 5:00 P.M. The Dietary Aide said that when he entered the dining room on 8/25/12 at approximately 6:30 P.M., he saw Resident #1 on the floor and there was no alarm sounding. The Dietary Aide said there was no staff in the dining room. The Surveyor interviewed Nurse #3 on 10/16/12 at 11:40 A.M. Nurse #3 said that on 8/25/12, she was in the dining room giving medications and supervising residents, while CNAs were transporting residents out of the dining room when a call light rang and she left to answer it. Nurse #3 said Resident #1 fell out of the wheelchair in the dining room within 5 minutes of her leaving the room. Nurse #3 said there was no policy at that time except that a nurse had to be in the dining room when residents were eating. She said that all the residents had finished their meal when she left the dining room to answer a call light The Surveyor interviewed Certified Nurse Aide (CNA) #2 on 10/12/12 at 1:40 P.M. CNA #2 said when she got Resident #1 out of bed for supper and applied the restraint free alarm, she did not ensure that it was working. CNA #2 said she assumed it was working. CNA #2 said that safety rounds were not done at change of shift. When asked if CNA #2 made any changes to her practice after the incident she said she made sure the alarms worked and then after a period of silence she said she guessed that she didn't do anything different, that she assumed they worked. The Surveyor interviewed Nurse #2 on 10/12/12 at 1:50 P.M. Nurse #2 said that on 8/25/12, at approximately 6:30 P.M., she was at the nurse's station when Resident #1 fell in the dining room. Nurse #2 said Resident #1 had a restraint free alarm on that did not sound. Nurse #2 said that no staff member was in the dining room when Resident #1 fell . The Surveyor interviewed Nurse #1 on 10/12/12 at 12:15 P.M. Nurse #1 said she was the Director of Nursing at the time of the incident. Nurse #1 said that there was no system in place at the time of the incident to check the restraint free alarms for function. Nurse #1 said there was no written policy relative to staff supervising residents in the dining room after meals were finished, but that the expectation was that residents were not left alone, unsupervised in the dining room. Nurse #1 said that when questioned, nurses on duty thought that the CNA's were in the dining room and the CNA's said they were transporting residents out of the dining room after supper. The Surveyor interviewed the Assistant Director of Nursing (ADON) on 10/12/12 at 10:00 A.M.. The ADON said a nurse should have been in the dining room until all residents were removed. The ADON said when she worked on the floor as a staff nurse, Resident #1 was always kept where staff could observe him/her. The Surveyor interview the Executive Director (ED) on 10/12/12 at 2:20 P.M. The ED said the policy and practice at the Facility was that no resident was left alone in the dining room at anytime The ED said that now written policies are in place relative to staff in the dining room and alarms being checked for functionality. The ED said Resident #1's alarm did not work properly on 8/25/12. The ED said it was CNA #1's job to ensure that CNA staff was checking alarms properly.