Every finding on record at Southbridge Rehabilitation & Health Care Center

Based on interviews, and record review, the facility failed to ensure one Resident (#107) out of a total sample of 26 residents, was seen by a Physician at the required regulatory frequency for physician visits.Specifically, the facility failed to ensure Resident #107 was seen by a Physician:-for the Resident's initial visit following admission to the facility.-for alternating visits with the Nurse Practitioner (NP) every 30 days for the first 90 days following admission to the facility.-for alternating visits with the NP every 60 days, after the Resident was in the facility for 90 days. Findings include:Resident #107 was admitted to the facility in October 2025 with diagnoses including Chronic Respiratory Failure, Heart Failure, and Hypertension. Review of Resident #107's clinical record on 4/3/26 failed to indicate any evidence the Resident was seen by a Physician since the Resident was admitted to the facility in October 2025 (greater than five months). During an interview on 4/3/26 at 11:00 A.M., the Assistant Director of Nursing (ADON) said resident physician notes were located in the electronic health record (EHR). At this time, the ADON reviewed Resident #107's EHR and said that she could not locate any Primary Care Physician (PCP) and Primary NP visit notes in the Resident's EHR. During an interview on 4/3/26 at 11:04 A.M., the Director of Nursing (DON) said she thought Resident #107's Physician completed paper visit notes and that she thought the paper visit notes were located in the Resident's paper medical record on the unit. The surveyor alerted the DON that the surveyor did not observe any evidence of Physician visits with Resident #107 in the Resident's paper medical record on the unit and requested evidence that the required Physician visits were provided for Resident #107. During an interview on 4/3/26 at 12:00 P.M., the Administrator said he contacted Resident #107's PCP office and that the office was going to fax evidence of the required Physician visits to the facility. During an interview on 4/3/26 at 1:00 P.M., the Administrator provided evidence of two NP notes to the surveyor and said that the PCP office was still faxing Physician visit notes to the facility. During an interview on 4/3/26 at 1:15 P.M., during the survey exit conference, the Administrator said the facility would fax evidence of the required Physician visits for Resident #107 to the surveyor when the facility received the Physician notes. Review of Resident #107's faxed documents, dated 4/6/26, did not include any evidence that the Physician performed:-an initial visit with the Resident following the Resident's admission to the facility.-alternating visits with the NP every 30 days for the first 90 days following the Resident's admission to the facility.-alternating visits with the NP every 60 days, after the Resident was in the facility for 90 days. During an interview on 4/7/26 at 9:44 A.M., following the survey exit, the Administrator said that the Physician had not performed any visits with Resident #107 since the Resident was admitted to the facility.

Based on observations, records reviewed and interviews, the facility failed to provide a clean, sanitary or homelike environment for three Residents (#73, #9 and #52) out of a total sample of 26 residents, and in five rooms on two units (Second Floor and Third Floor) out of three resident units to prevent the potential for the spread of infection and maintain resident safety. Specifically, the facility failed to: 1. for Resident #73, clean and maintain a wheelchair in good condition on the Third Floor unit. 2. maintain privacy curtains in a clean and sanitary manner for three rooms out of twelve rooms observed on the Second Floor unit. 3. for Resident #9 and Resident #52, ensure window curtains were maintained in homelike condition on the Third Floor unit. Findings include: Review of the facility policy for Environmental Cleaning and Rounds, last reviewed 1/2026, indicated: -it is the policy of this facility to reduce and/or prevent the spread of infection through indirect contact by cleaning, sanitizing and disinfecting resident equipment, medical devices and the environment. -it is the policy of this facility that the Infection Preventionist (IP), Charge Nurses or Supervisors, complete nursing unit rounds on a regular basis, but at least quarterly. -The focus of this program is to observe practices carried out by nursing personnel that increase the risk of infection or pose a resident safety concern. -Environmental rounds will be an integral part of daily routine and also will be performed regularly throughout the entire facility, with detailed reporting to all units and departments as needed. 1. Resident #73 was admitted to the facility in August 2022 with diagnoses including Dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #73's Minimum Data Set (MDS) dated [DATE], indicated: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of a total possible score of 15. -required substantial/maximal assistance with Activities of Daily Living (ADL's). -was diagnosed with cerebral infarction and difficulty walking. Review of the facility's wheelchair cleaning schedule for January 2026 through March 2026 indicated that Resident #73 had his/her wheelchair cleaned monthly on: 1/13/26, 2/10/26, and 3/13/26. On 3/31/26 at 9:04 A.M., 4/1/26 at 9:43 A.M., and 4/1/26 at 2:59 P.M., the surveyor made the following observations of Resident #73's wheelchair: -the wheelchair armrests were cracked and worn, with padding exposed on the left and right sides and a smeared gray substance on the right armrest. -the seat of the wheelchair was cracked and peeling on the left and right corners. -all four wheels of the wheelchair were covered in a layer of gray and white speckled dust. -the right wheel bearing was wrapped in long multicolored strands of hair with multiple dust balls inside. On 4/2/26 at 8:10 A.M., the surveyor and the Infection Preventionist (IP) observed Resident #73's wheelchair while he/she was sitting in the day room and the Resident's wheelchair condition remained unchanged. During an interview at the time, the IP said that the Resident's wheelchair did not appear to have been cleaned and maintained and it should have been. The IP also said that the concern with the ripped/torn areas of the wheelchair was the potential for skin tears to the Resident. 2.On 3/31/2026 at 8:05 A.M. the surveyor observed the following on the Second Floor nursing unit: - a privacy curtain in room [ROOM NUMBER] was soiled with two large brown stains. -a privacy curtain in room [ROOM NUMBER] was soiled with four dark brown smudge stains. -a privacy curtain in room [ROOM NUMBER] was soiled with two large yellow stains and a smaller brown stain. On 4/2/26 at 8:08 A.M., the surveyor and Nursing Supervisor #1 observed the soiled privacy curtains Rooms 204, 208 and 210. During an interview at the time, Nursing Supervisor #1 said that the housekeeping department is responsible for maintaining the privacy curtains in resident rooms and that any staff member can call housekeeping to let them know about a soiled privacy curtain. Nursing Supervisor #1 said that the privacy curtains in rooms [ROOM NUMBER] were dirty and should be changed and cleaned and she would make housekeeping staff aware that the curtains needed to be cleaned. During an interview on 4/2/26 at 8:25 A.M., the Housekeeping Director (HD) said he relies on all staff to let him know when a privacy curtain is soiled and needs to be changed. The HD said that the facility doesn't have extra stock of privacy curtains and housekeeping staff are required to take down the curtain that is soiled, wash it, and hang it back up. The HD also said that the privacy curtains should not be hanging if they are stained and soiled. 3a. Resident #9 was admitted to the facility in September 2020 with diagnoses including Parkinson's Disease, Dementia and Psychotic Disorder. Review of the Minimum Data Set (MDS) Assessment, dated 2/25/26, indicated Resident #9 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15. On 3/31/26 at 10:08 A.M., the surveyor observed Resident #9's right sided window curtain was detached from the curtain rod hardware and not in good working condition. On 4/1/26 at 2:03 P.M., the surveyor observed Resident #9's right sided window curtain was detached from the curtain rod hardware and not in good working condition. During an interview at the time, Resident #9 asked the surveyor to close the window curtain, but the surveyor was unable to move the curtain or close it completely. On 4/2/26 at 8:09 A.M., the surveyor observed Resident #9's right sided window curtain remained detached from the curtain rod hardware and not in good working condition. During an interview on 4/2/26 at 2:31 P.M., the Assistant Maintenance Director said that if someone tries to open or close Resident #9's curtains, the curtains pull down off the rod and should not be like that. During an interview on 4/2/26 at 2:49 P.M., Certified Nurse Aide (CNA) #2 said she was unsure how long the curtains had been in disrepair but did not think that it was homelike for Resident #9. During an interview on 4/2/26 at 2:53 P.M., the Housekeeping Director said that he had been aware Resident #9's curtains were in disrepair, and the facility did not have approval to purchase replacement curtains at this time. 3b. Resident #52 was admitted to the facility in December 2019 with diagnoses including Dementia and Depression. Review of the MDS assessment dated [DATE], indicated Resident #52 was moderately cognitively impaired as evidenced by a BIMS score of 5 out of 15. On 3/31/26 at 10:38 A.M., the surveyor observed Resident #52 sitting in his/her room beside the window with the curtains pulled closed. The surveyor observed two large holes to the right sided curtain. During an interview at the time, Resident #52 said that the curtains should not be ripped and staff should have fixed it. On 4/1/26 at 2:28 P.M., the surveyor observed Resident #52 sitting in his/her room beside the window with the curtains pulled closed and the right sided curtain had two large holes. During an interview at the time, Resident #52 said he/she was uncertain how long the curtain had been damaged but thinks it had been there since he/she moved into the room. Resident #52 said he/she felt annoyed that the curtains were ripped, and staff knew about the ripped curtain and were supposed to have fixed it. During an interview on 4/2/26 at 2:33 P.M., the Assistant Maintenance Director said that Resident #52's curtains should not have holes in them and that the housekeeping department oversaw the curtains. During an interview on 4/2/26 at 2:53 P.M., the Housekeeping Director said that he was aware that Resident #52's curtains have had holes for about one year and said the facility did not have approval to purchase replacement curtains.

Based on observations, interviews, and record review, the facility failed to ensure a grievance was initiated for prompt resolution relative to missing personal items for one Resident (#39) out of a total sample of 26 residents. Specifically, the facility failed to assist Resident #39 in appropriately filing a grievance when he/she reported missing two personal blankets to staff, staff was unable to find the missing blankets and did not report the Resident's complaint and missing personal items to the facility grievance officer as required. Findings include:Review of the facility's Grievance Policy, undated, indicated the following:-Residents have the right to voice grievances .-The facility will make prompt efforts to resolve any grievances in accordance with this policy.-Upon receipt of a grievance, the staff person receiving the grievance shall immediately notify the grievance officer. Resident #39 was admitted to the facility in November 2025 with mild neurocognitive disorder. Review of Resident #39's Minimum Data Set (MDS) Assessment, dated 2/20/26, indicated:-has clear speech.-is understood and understands others. During an interview on 4/1/26 at 8:59 A.M., Resident #39 said he/she received two blankets (one brown and one blue and white) as gifts from family members and that both blankets were missing. Resident #39 said the blankets had been missing for a couple of weeks, that he/she told staff members the blankets were missing, and he/she could not recall the names of the staff members he/she told. Resident #39 said staff did not offer assistance to file a grievance for the missing blankets and staff said they could not find the blankets. Review of the facility's 2026 Grievance Book did not include any evidence that a grievance had been filed relative to Resident #39's report of the two missing blankets. Review of the facility's 2025-2026 Missing Items Book did not include any evidence a missing item report had been filed relative to Resident #39's report of two missing blankets. During an interview on 4/1/26 at 11:19 A.M., Certified Nurse Aide (CNA) #4 said Resident #39 had two personal blankets and that the Resident told CNA #4 on 3/31/26 that both blankets were missing. CNA #4 said the blankets were probably in the laundry and that she had not checked the laundry yet for the blankets. CNA #4 said if she could not locate the blankets in the laundry, then she would alert administration. The surveyor observed a posting on the wall across from the nurses' station as follows:-How to file a grievance or complaint: -Grievance forms located on each unit and with the social service department. -Please return grievance to staff or reception. -Grievance Officer is the Social Worker (SW) #1. During an interview on 4/1/26 at 12:30 P.M., CNA #4 said she went to the laundry and could not locate the blankets. CNA #4 said she would let someone in administration know that Resident #39's blankets were missing. During an interview on 4/2/26 at 11:08 A.M., Resident #39 said staff had not come to speak with him/her about his/her missing blankets after the Resident told the surveyor his/her blankets were missing on 4/1/26. During an interview on 4/2/26 at 12:37 P.M., SW #1 said she had not been alerted by staff that Resident #39 reported his/her blankets missing. SW #1 said when residents alerted staff of missing personal items, staff were required to fill out a Missing Items Form and give the form to her. SW #1 said CNA #4 should have completed a Missing Items Form and given the form to her on 4/1/26, when CNA #4 was unable to locate Resident #39's blankets after the Resident reported the blankets missing. SW #1 said a Missing Items Form had not been completed and provided to her relative to Resident #39's missing blankets, as required.

Based on observations, interview, and record review the facility failed to ensure one Resident (#129) out of a total sample of 26 Residents, was free from physical restraints. Specifically, the facility failed to ensure Resident #129's wheelchair brakes were unlocked while he/she was seated at a table when the Resident was unable to release the wheelchair brakes independently and was unable to move him/herself from the table. Findings include: Review of the facility policy titled Restraint Management revised August 2018, indicated a physical restraint is any manual, mechanical or physical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Also included as restraints are facility practices that meet the definition of a restraint, such as: -using devices in conjunction with a chair, such as trays, tables, bars or belts, that the resident cannot remove easily, that prevent the resident from rising. Resident #129 was admitted to the facility in April 2023 with diagnoses including Metabolic Encephalopathy, Aphasia, Wernicke's Encephalopathy, and acquired absence of right leg below the knee. Review of the Fall Care Plan initiated on 5/10/23, indicated the Resident was at risk for a fall-related injury secondary to a history of self-transfers, losing balance, refusal to ask for help, and remained determined to self-transfer independently. Review of the Velcro Seatbelt Care Plan revised on 6/18/25, indicated Resident #129 used an alarmed Velcro seatbelt: Remove seatbelt during all meals, and included the following interventions: -check for self-release of Velcro seatbelt per order - review use at least quarterly to ensure least restrictive device is being utilized. Review of the Resident #129's Restraint Assessment, last completed on 6/30/25 indicated: -no restraints were in use at the time -he/she was able to self-release the seatbelt Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #129: -has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 2 out of 15. -utilized a wheelchair for mobility. -did not utilize restraints. On 3/31/26 at 3:26 P.M., the surveyor observed Resident #129 self-propelling in a wheelchair in the activity room. Resident #129 was placed by a staff member at a table, and the staff member locked the Resident's wheelchair brakes. Resident #129 was observed to repeatedly make attempts to push the wheelchair away from the table using his/her left leg, causing the wheelchair to tip backward. The Resident's wheelchair was observed to have an anti-tipping device which prevented the wheelchair from tipping backwards and an anti-rollback device on the wheels, which was preventing the Resident from moving the wheelchair. Resident #129 became agitated, was using profanities, and released his/her Velcro seatbelt which started alarming. Resident #129 was then approached by a staff member who re-fastened the seatbelt. During an interview on 3/31/26 at 3:26 P.M., Certified Nurse Aide (CNA) #3 said Resident #129 had the ability to self-propel in the wheelchair, release the seatbelt and had the ability to release the wheelchair brakes. On 4/1/26 at 1:57 P.M., the surveyor observed Resident #129 seated in a wheelchair at a table with his/her wheelchair brakes engaged, an alarmed Velcro seatbelt around his/her waist and anti-rollback device on the wheels and anti-tipping devices. On 4/2/26 at 8:04 A.M., the surveyor observed Nurse #1 assisting Resident #129 into the dining room and placed him/her at a table and locked the wheelchair brakes. Resident #129 was observed wearing an alarmed Velcro seatbelt. The Resident's wheelchair was placed with the wall about one foot away from the wheelchair's rear wheel, restricting his/her movement away from the table. During an interview on 4/2/26 at 9:25 A.M., CNA #2 said Resident #129 was a wanderer in his/her wheelchair, so staff placed the Resident at a table and lock the wheelchair brakes. CNA #2 said Resident #129 tried to stand up a lot and the anti-rollback device on his/her wheelchair prevented the wheelchair from rolling backwards if he/she attempted to stand up unexpectedly. CNA #2 said she thought Resident #129 could release the wheelchair brakes. On 4/2/26 at 9:31 A.M., the surveyor observed Resident #129 seated in his/her wheelchair at a table with the left brake on the wheelchair engaged. The Staff Development Nurse was observed repeatedly asking Resident #129 to unlock the left brakes on his/her wheelchair, but the Resident was unable to follow direction and cues to release the brake. During an interview at the time, the Staff Development Nurse said Resident #129 was unable to move away from the table and having the wheelchair brake engaged restricted his/her freedom of movement and could be a restraint. During an interview on 4/2/26 at 9:47 A.M., Nurse #1 said staff should not engage the brakes on the wheelchair because Resident #129 was able to move around in the wheelchair independently. Nurse #1 said if Resident #129 could not release the brakes, it could restrain him/her from moving around independently. During an interview on 4/2/26 at 10:02 A.M., the Nurse Supervisor said Resident #129 should not have been seated at a table with the brakes engaged because it would limit him/her from moving away from the table which is a restraint. During an interview on 4/2/26 at 3:35 P.M., the Assistant Director of Nursing (ADON) said when Resident #129 was seated at a table with the wheelchair brakes engaged and was not able to release the brakes it would be a potential restraint.

Based on observations, record review, and interview, the facility failed to ensure that services were provided to maintain hearing abilities for one Resident (#108) out of a total sample of 26 residents. Specifically for Resident #108, the facility failed to assist with providing routine audiology care, when the Resident Representative consented to and requested audiology care services and the Resident was diagnosed with bilateral hearing loss. Findings include: Review of the facility's policy, titled Consultant Services, dated April 2015, indicated: -the facility will identify and facilitate consultant services to meet the resident's needs to ensure optimum care for each resident/patient through consultant services. -If a consultant is required in another specialty area, the Physician must specify the person he/she wishes to use. -once the consultant is identified by the Physician and after the family has been notified and given the permission for the consult, the staff will call the consultant to notify him/her of the request and document the response in the medical record. Resident #108 was admitted to the facility in April 2024 with diagnoses including Dementia and bilateral hearing loss. Review of Resident #108's medical record indicated: -Physician's order for Consults: Audiology Consult as needed, dated 4/22/24. -Request for Audiology Services Form, signed by the Resident's Representative on 4/22/24. -Decrease in Hearing Care Plan, last revised 7/22/25. -No documented evidence that the Resident had been seen by Audiology since his/her admission to the facility. Review of Resident #108's recent Minimum Data Set (MDS) assessment dated [DATE], indicated: -severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of a total possible of 15. -hearing was highly impaired and did not have a hearing aid. -diagnosed with bilateral hearing loss. On 3/31/26 at 9:31 A.M., the surveyor observed Resident #108 in the day room eating breakfast and was yelling rather than talking in a normal level to his/her tablemates. When the surveyor attempted to engage in conversation with the Resident, he/she said that he/she could see the surveyor speaking but that he/she could not understand what the surveyor was saying. The surveyor did not observe any hearing devices in the Residents' ears or other means to communicate with the Resident at the breakfast table. During an interview on 4/1/26 at 9:08 A.M., the Director of Nursing (DON) said that Resident #108 should have been seen by Audiology and has not been seen by Audiology since his/her admission to the facility.

Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for two Residents (#55 and #37) and on three units (Second Floor, Third Floor and Forth Floor) out of three total units observed. Specifically, the facility failed to: 1. maintain comfortable water temperatures for bathing in resident rooms and unit shower rooms, resulting in Resident #55 and #37 not receiving showers as desired and requested due to cold water temperatures. 2. maintain comfortable water temperatures in resident rooms and for three of three unit shower rooms as needed. Findings include: Review of the facility policy titled Showers, dated April 2015, indicated the following procedure: -Resident/patient will receive a shower, assisted/and given by the nursing staff as desired. -Procedure: >Prepare shower room and equipment >Run water for the shower, checking to ensure that temperature is not greater than 100-102 degrees (*) Fahrenheit (F) -Documentation: >Document the procedure Review of the facility policy titled Bathing Assisted/Partial/Personal Hygiene, dated April 2015, indicated: -Residents who need assistance to perform bathing/personal hygiene will be provided assistance. -Procedure: >Place wash basin, cleaning product, washcloth, towels, and lotion over bed table in front of resident/patient within reach. >Water temperature should be tested on inner wrist. -Documentation: >Chart bathing and personal care on designated forms. 1a. Resident #55 was admitted to the facility in February 2017 with diagnoses including Congestive Heart Failure. Review of Resident #55's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible 15. -was dependent on staff assistance for bathing and showering, personal hygiene, and both upper and lower body bathing and dressing. During an observation and interview on 12/12/24 at 10:33 A.M., Resident #55 was observed in bed and dressed for the day with a shirt and pants on, with the head of the bed elevated and bilateral side rails in place. Resident #55 said that he/she was scheduled for showers on Mondays on the 7:00 A.M. to 3:00 P.M (7-3) shift and Thursdays on the 3:00 P.M. to 11:00 P.M. (3-11) shift and that he/she anticipated receiving a shower that evening. During an observation and interview on 12/13/24 at 8:49 A.M., Resident #55 said he/she had not received his/her scheduled shower on 12/12/24 at approximately 9:30 P.M., as there was no hot water available. Resident #55 said that he/she notified Unit Manager (UM) #1 that morning. Review of Resident #55's December 2024 Certified Nursing Assistant (CNA) Flow Sheet indicated that showers were scheduled for Thursdays on the 3-11 shift and Mondays on the 7-3 shift. Further review of the CNA Flow Sheet documentation indicated that Resident #55 refused a shower on 12/12/24. 1b. Resident #37 was admitted to the facility in May 2023 with diagnoses including Chronic Obstructive Pulmonary Disease. Review of Resident #37's MDS assessment dated [DATE], indicated the Resident: -was cognitively intact as evidenced by BIMS score of 15 out of a total possible 15. -required partial to moderate assistance by staff for personal hygiene, showering and bathing, and upper and lower body dressing and bathing. During an observation and interview on 12/12/24 at 1:05 P.M., Resident #37 was observed dressed for the day and seated in a chair at his/her bedside with oxygen in use via a nasal cannula. Resident #37 said that the facility did not have hot water for showers. Resident #37 said that he/she has chronic respiratory issues and therefore could not take cold showers. Resident #37 said he/she was scheduled to take a shower today, but refused because the water was cold. The surveyor observed the water in Resident #37's bathroom sink at the time of the interview, was hot to touch and warmed quickly. Resident #37 said the water temperatures were inconsistent, and that staff would often come to his/her room to obtain hot water for other residents at times. During an interview on 12/13/24 at 7:36 A.M., UM #1 said there have been challenges with the hot water which was discussed with the maintenance team. UM #1 said residents receive showers weekly and if there was no hot water available on the 7-3 shift, then the 3-11 shift would assist with showers. UM #1 said there were times during the day when hot water was less available and that the CNAs know the times during the day when hot water was available for residents' showers and bed baths, and in what areas of the building. During an interview on 12/13/24 at 9:08 A.M., with CNA #2 who said she regularly worked with Resident #37 and that he/she received showers on Thursdays. CNA #2 said Resident #37 had respiratory issues, required the assistance of staff with showers, and that cold water for showers could make his/her symptoms worse. CNA #2 said the facility water for resident showers could be either hot or cold, and often start hot, but do not remain hot. CNA #2 said sometimes she and other staff must go to other resident bathrooms to obtain hot water for the residents' bed baths. CNA #2 said she knew Resident #37's bathroom had a good supply of hot water and that if a resident refused a shower on her shift, she would report it to the next shift for follow-up so that they can offer the resident another opportunity to shower, and that this would be communicated on the resident shower list. 2. During an interview on 12/13/24 at 7:43 A.M., Maintenance Staff #1 said the facility administration was aware of the hot water usage. At this time, Maintenance Staff #1 demonstrated checking the water temperature in a resident bathroom near the Nurses' station on the Second Floor Unit, and the surveyor observed the water was hot to touch and warmed quickly. During an interview on 12/13/24 at 7:47 A.M., the Maintenance Director (MD) said the facility had two boilers and one mixing valve for the whole facility, and that the hot water was in use for the facility all day long by the kitchen and the nursing departments. The MD said when the kitchen was not serving meals, the dish machine was running and using hot water. The MD further said the best times for hot water availability for resident showers/bathing were in the early morning and late evening hours. During a subsequent interview on 12/13/24 at 8:06 A.M., the MD said there were areas of the building where water ran a bit colder due to the distance of those areas from the mixing valve. The MD said that he typically took temperatures in the morning several times a week, in different resident bathrooms, and in the three unit shower rooms, in addition to other areas of the facility. The MD said the water temperatures obtained in the resident bathrooms and shower rooms were between 100*F and 120*F, and should ideally be around 110*F. On 12/13/24, the following water temperature observations were made by the surveyor with temperatures taken by the Maintenance Director after running the water for two minutes: >Second Floor Unit: -1:22 P.M- Shower Room, Shower A: 111.7*F, warm -1:26 P.M.- Shower Room, Shower B: 90.0*F, lukewarm -1:31 P.M.- room [ROOM NUMBER]: 109.6*F, warm -1:35 P.M.- room [ROOM NUMBER]: 95.2*F, lukewarm -1:39 P.M.- room [ROOM NUMBER]: 82.9*F, cool -2:00 P.M.- room [ROOM NUMBER]: 80.8*F, cool >Third Floor Unit: -1:45 P.M.- Shower Room: 75.6*F, cold >Fourth Floor Unit: -1:49 P.M.- Shower Room: 77.4*F, cold -1:55 P.M.- room [ROOM NUMBER]: 82.6*F, cool During an interview on 12/13/24 at 1:49 P.M., while performing temperature checks in the Fourth Floor Unit shower room, the Maintenance Director said the 77.4*F temperature obtained was not even lukewarm. During an interview on 12/13/24 at 2:32 P.M., the Administrator said that in her time in the role of Administrator during the past month, she was not aware of any water temperature issues, resident complaints of cold showers, or cold water temperatures. During a follow-up interview on 12/17/24 at 11:12 A.M., CNA #2 said the issues with the availability of hot water remained and when she provided a bed bath to a resident in room [ROOM NUMBER] that morning, the water was barely lukewarm.

Based on observation, record review, and interview, the facility failed to implement the comprehensive person-centered plan of care for two Residents (#88, #104) out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #88, implement the fall risk intervention for non-skid strips to the Resident's bedside and bathroom placing the Resident at risk for falls and injury. 2. For Resident #104, implement the nutritional risk intervention for a lip plate with meals placing the Resident at risk for calorie deficit. Findings include: Review of the facility policy titled Comprehensive Care Plans, date with revision date November 2017 indicated: -The facility is committed to providing residents with all the necessary care and services to enable them to achieve the highest quality of life. -Recognizing each resident as an individual, we identify and meet those needs in a resident centered environment. -Care plans are oriented toward preventing avoidable decline in clinical and functional levels services and treatment. 1. Resident #88 was admitted to the facility in February 2024 with diagnoses including weakness and Wernicke's Encephalopathy (neurological symptoms caused by low vitamin B1 levels often leading to confusion, impaired balance and weakness of eye muscles). Review of Resident #88's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident: -was severely cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of four out of a possible total score of 15. -required substantial/maximal assist to transfer to and from bed, chair and/or toilet. Review of Resident #88's clinical record indicated: -The Resident was at moderate to high risk for falling as evidenced by the most recent falls risk assessment, dated 12/7/24. -The Resident had been moved into his/her current room since 11/19/24. Review of Resident #88's comprehensive person-centered care plan indicated: -The Resident was at risk for falls and related injuries secondary to history of self transferring, loss of balance and landing on buttocks and refusal to ask for help with transferring. -The Resident had fall risk interventions which included non-skid strips (adhesive floor strips with non-skid surface used to prevent slipping of the foot/feet when making contact to the floor) to bedside and bathroom, effective 5/23/24. The surveyor observed Resident #88 lying in his/her bed with no non-skid strips observed at the Resident's bedside or in the bathroom on the following days: -12/12/24 at 11:45 A.M. -12/16/24 at 7:46 A.M. During an interview and observation on 12/16/24 at 11:28 A.M., Certified Nurses Aide (CNA) #1 said that he was assigned to Resident #88. The surveyor and CNA #1 observed Resident #88 lying in bed without any non-skid strips at the bedside or in the bathroom. CNA #1 said that the Resident had a history of falling. CNA #1 said that fall interventions were listed on the CNA Care Kardex (a paper record, kept in a binder that included daily care needs for each individual resident). The surveyor and CNA #1 reviewed the CNA Care Kardex which indicated the need for bilateral (both sides) non-skid strips to bedside and bathroom. CNA #1 said sometimes if a Resident has a room change the non-skid strips don't get put back on. CNA #1 said Resident #88 had a few room changes since being at the facility. During an interview and observation on 12/16/24 at 11:46 A.M., Nurse #1 said she was the Nurse assigned to Resident #88. The surveyor and Nurse #1 observed Resident #88 lying in bed without non-skid strips beside the bed or bathroom. Nurse #1 said that Nurses need to be familiar with care plans to prevent falls for each Resident. Nurse #1 said interventions for non-skid strips are listed on both the Resident's CNA Care Kardex and the Resident's care plan. Nurse #1 said that the non-skid strips should be in place to prevent Resident #88 from falling but the non-skid strips were not in place. During an interview on 12/16/24 at 11:57 A.M., the Director of Nursing (DON) said that Resident #88 had several room changes since being at the facility. The DON said that all room changes are reported during morning report to all departments, including the maintenance department. The DON said that the non-skid strips should have been placed at Resident #88's bedside and bathroom to prevent injury and falls. 2. Resident #104 was admitted to the facility in October 2023 with diagnoses including Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment, weight loss, decreased appetite or poor nutrition and inactivity) and Dementia. Review of Resident #104's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident: -was severely cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of three out of a possible total score of 15. -required supervision or touching assist for eating. Review of Resident #104's clinical record indicated: -The Resident had a Physician's order for regular consistency diet with thin liquids, extra sauce/gravy to all meals, Italian sausage and baked hams need to be ground, and a scoop lip plate (often called a lip plate), effective 10/27/23. Review of Resident #104's comprehensive person-centered care plan indicated: -The Resident was at risk for nutritional decline and had interventions including lip plate at all meals, last revised on 12/12/24. -The Resident had a 12-pound weight loss between November 2024 and December 2024. On 12/16/24 at 9:09 A.M., the surveyor observed facility staff setting up the breakfast tray for Resident #104 without a lip plate in place. The surveyor observed Resident #104 attempt to scoop his/her breakfast food with a spoon and then spilled breakfast foods over the edge of the plate and onto the table surface. On 12/17/24 at 9:00 A.M., the surveyor observed Resident #104 seated in the multi-purpose room on the unit eating a breakfast of two fried eggs and toast with his/her hands. The surveyor observed the Resident was not provided with a lip plate or utensils for the duration of the breakfast meal. During an observation and interview on 12/17/24 at 4:42 P.M, the surveyor and the Registered Dietitian (RD) observed Resident #104 to be served his/her evening meal tray by a staff member without a lip plate in place. The RD said the lip plate should be listed on the meal ticket to be sent from the kitchen but was not. During an interview on 12/18/24 at 10:01 A.M., the Speech Therapist (ST) said that Resident #104 was actively being treated by the ST due to his/her identified weight loss, effective 12/10/24. The ST said that Resident #104 had been ordered for a lip plate because he/she was known to knock food off his/her plate during mealtimes. The ST said that Resident #104 had been ordered for lip plate since 10/16/23, to aid in filling the utensils during mealtimes. The ST said a lip plate was ordered so that Resident #104 would not push the food off the plate and would support filling the utensil with a whole bite of food. The ST said that a calorie deficit can occur if food falls off the utensil or over the edge of the plate which could result in weight loss.

Based on record review and interview, the facility failed to maintain complete and accurate medical records for two Resident's (#77 and #5) out of a total sample of 26 residents. Specifically, the facility failed to: 1. for Resident #77, maintain documentation relative to behavioral health services that the Resident was receiving from a consulting firm. 2. for Resident #5, document that Physician/NPP was notified when Resident #5 had a significant change in condition relative to: A) blood sugar readings greater than 350 mg/dL (milligrams per deciliter) as indicated by a Physician's order, and B) when a laboratory value for Hemoglobin A1C (test that measures the average blood sugar level over the past three months) was out of normal range and noted as high, putting the resident at risk for complications related to hyperglycemia (high blood sugar levels). Findings include: Review of the facility policy titled Consultant Services dated 4/2015, indicated the following: -A note should be recorded on the consultation form by any health care consultant who sees the resident/patient at the request of the MD or the family. The consultant should document findings and recommendations on this form. -A consultant's report or some form of documentation pertaining to the results will be retained in the clinical record. Review of the Service agreement between the facility and the Mental Health Provider, signed by the Administrator on 1/10/23 indicated the following in part: -Confidential Information: --both parties acknowledge and agree that in the course of performance under this agreement, each may have access to certain confidential information belonging to the other party including but not limited to . Patient information . -Record Keeping and Confidentiality of Medical Information: --To the extent possible both parties shall abide by all applicable federal state and local laws, rules, regulations, and standards with respect to clinical record keeping and maintenance of the confidentiality of medical records . 1. Resident #77 was admitted to the facility in February 2021 with diagnoses including Alcohol dependence, Anxiety and Bipolar Disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #77 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. During an interview on 12/17/24 at 11:59 A.M., Resident #77 said that he/she meets with the Substance Use Disorder counselor monthly and also meets with a Therapist every Friday. Review of Resident #77's medical record indicated no documented evidence that the Resident was meeting with a Therapist weekly every Friday. During an interview on 12/17/24 at 2:12 P.M., Social Worker (SW) #1 said that the Therapist identified by Resident #77, works for the Nurse Practitioner's Consulting Firm that provided talk therapy to the facility residents. SW #1 said that two Therapists come into the facility from this Consulting Firm two times a week. When the surveyor asked where the documentation could be found that Resident #77 received services from the Consulting Firm, SW #1 said that the facility does not have any documentation regarding any of the Therapist visits. SW #1 said that documentation has been an ongoing conversation between the facility and the Consulting Firm. 48206 2. Review of the facility policy titled Hyperglycemia, dated April 2015, indicated: -Hyperglycemia, or high blood sugar, is a condition that causes changes in physiological status. -Procedure if a resident has signs and symptoms of high blood sugar: >Check physician orders for specific acceptable blood glucose (sugar) range for the resident. >Perform a glucose test by finger stick: If over 400 mg/dL, recheck for accuracy. >Notify Physician immediately for further directions if blood sugar is not within the acceptable range for high parameters. -Document relevant evaluations, interventions, and resident's response to interventions in the medical record. Resident #5 was admitted to the facility in July 2022 with diagnoses including Type 2 Diabetes Mellitus (Type 2 DM) with Hyperglycemia. During an observation and interview on 12/12/24 at 3:16 P.M., the surveyor observed Resident #5 was in bed, dressed in a hospital gown, with his/her head of the bed elevated. Resident #5 said he/she had issues with high blood sugars, and he/she usually had values around 320 [mg/dL]. The Resident further said that staff check his/her blood sugars three times a day and he/she received Insulin (a hormone that controls blood sugar) after meals. Review of Resident #5 Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident: -was severely cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of one out of a total possible 15. -received Insulin by injection seven out of seven total days during the assessment look-back period. Review of Resident #5's December 2024 Physician's orders indicated: -Insulin Lispro Injection Solution (fast-acting Insulin medication), 100 unit/ml subcutaneously (beneath the skin) before meals for DM, Inject as per sliding scale, if blood sugar is: 0 - 149 mg/dL = 0 units 150 - 199 mg/dL = 2 units 200 - 249 mg/dL = 4 units 250 - 299 mg/dL = 6 units 300 - 349 mg/dL = 8 units Greater than 350 mg/dL = 10 units -If blood sugar is lower than 60 mg/dL or greater that [sic] 350 mg/dL . Call Nurse Practitioner (NP), Physician Assistant (PA), Medical Doctor (MD)., initiated 6/19/24 -Insulin Lispro Injection Solution 100 unit/ml, Inject 30 units subcutaneously with meals for DM, initiated 6/19/24 -Insulin Glargine- Subcutaneous Solution (long-acting Insulin medication) 100 UNIT/ML (Insulin Glargine), Inject 72 units subcutaneously at bedtime for DM, initiated 11/20/24 -Jardiance Oral Tablet (medication that helps control blood sugar levels) 10 milligrams (mg), Give 1 tablet by mouth in the morning for DM, initiated 12/4/24 -Metformin HCl Oral Tablet (medication that lowers blood sugar levels) 500 mg, Give 1000 mg by mouth two times a day for DM, initiated 9/16/24 -Monitor for [signs and symptoms] of hyper/hypoglycemia, every shift, initiated 11/1/24 -Lipids (laboratory test that measures amount of fats within the blood) /Triglycerides (specific fat in the blood) /HemoglobinA1c (HgbA1c: blood test that measures average blood sugar over a two to three month period), every three months. Nursing to put lab on the following lab draw, initiated 12/3/22. Review of Resident #5's Care Plan for Diabetes initiated 6/20/24, and last revised 10/15/24, indicated the goal was for the Resident to remain free of complications from Diabetes and/or signs of hypergylcemia/ hypogylcemia (low blood sugar), and included the following interventions: -perform Accucheck (blood sugar check) per Physician order. Utilize sliding scale [insulin] as ordered, initiated 6/20/24. -signs of hyperglycemia may include clammy skin, shallow respirations, mental status or vision changes, restlessness, dizziness, or irritability, initiated 6/20/24. Review of Resident #5's Blood Sugar Summary Report provided to the survey team from 9/23/24 through 12/17/24 indicated the following blood sugar levels greater than 350 mg/dL were obtained: -10/5/24 at 12:22 P.M.: 417.0 mg/dL -10/11/24 at 5:32 P.M.: 386.0 mg/dL -10/12/24 at 5:40 P.M.: 388.0 mg/dL -10/18/24 at 5:30 P.M.: 364.0 mg/dL -10/22/24 at 5:51 P.M: 413.0 mg/dL -10/24/24 at 3:31 P.M.: 354.0 mg/dL -10/25/24 at 8:23 P.M: 422.0 mg/dL -10/26/24 at 9:50 A.M.: 399.0 mg/dL -10/30/24 at 5:10 P.M.: 391.0 mg/dL -11/2/24 at 8:48 A.M.: 366.0 mg/dL -11/3/24 at 4:24 P.M.: 436.0 mg/dL -11/5/24 at 5:48 P.M.: 358.0 mg/dL -12/5/24 at 4:44 P.M.: 360.0 mg/dL Review of the Nursing Progress Notes did not indicate evidence that the Physician/NP/PA were notified of the Resident's elevated blood sugar readings over 350 mg/dL from 10/5/24 - 12/5/24 as required. Review of the Physician's Encounter Visit Note, dated 11/20/24, indicated: -Diagnosis of Uncontrolled Diabetes with Hyperglycemia and Long- term insulin use. -Resident has history of refusing Glargine/Metformin/ regular insulin. -Continues with noncompliance with PO (by mouth) medications. -Discussed with nursing, reports patient refused all medication except insulin, non-compliant with oral DM II (Diabetes Type 2) medications . -Discussed obtaining lab work . Review of the Nursing Progress note dated 11/20/24, indicated: -Physician's Assistant in to see Resident -New orders for . HgbA1c level -Increased Lantus to 72 units Review of the Resident #5 laboratory results collected on 11/22/24 indicated the following: -Hemoglobin A1c result was 9.5 %. -Flagged as H (High). -A1c Reference Range of 4.8-5.6 %. -Signature line for ordering Physician was blank. Review of the Nursing Progress Notes did not indicate evidence that the Physician/NP/PA was notified of the Resident's elevated Hgb A1c value obtained on 11/22/24. Review of the Physician's Encounter Note dated 12/3/24, indicated: -Diabetic screening: Assess glycemic status at least quarterly in diabetic patients with A1C not under control. -No Physician documentation of review of the Hemoglobin A1C value obtained on 11/22/24. Review of the Nursing Progress Note dated 12/3/24, indicated: -New order from PA to start Jardiance 10 mg daily. -No PA documentation of review of the Hemoglobin A1C value obtained on 11/22/24. During an interview on 12/17/24 at 11:38 A.M., Nurse #2 said that Resident #5 typically tests high on his/her blood sugars, but levels have improved more recently. Nurse #2 said Resident #5 was non-compliant with taking oral medications but was compliant to have his/her blood sugars tested and accepted injectable insulin. Nurse #2 said if a Resident's blood sugar test were over 400 (mg/dL), she would contact the Physician/NPP (Non-Physician Practitioner) to discuss concerns about hyperglycemia or adjustment to the sliding scale insulin. Nurse #2 said she monitors for signs and symptoms of hyperglycemia which can include sluggishness, increased thirst, and confusion. Nurse #2 also said that when lab reports come in, she would contact the Physician to review the results and obtain any orders for change in treatment. During an interview on 12/17/24 at 1:55 P.M., Unit Manager (UM) #1 said that Resident #5 received sliding scale injectable insulin and had a standing order for injectable insulin. UM #1 further said that Resident #5 would often refuse oral medications that manage his/her diabetes, but allowed the staff to check his/her blood sugars as ordered and was accepting of the injectable insulin. When the surveyor requested evidence that the Physician was notified relative to the Resident's high blood sugars over 350 mg/dL or the HgbA1c lab value obtained on 11/22/24, UM #1 said she would follow-up with the surveyor. During an interview on 12/17/24 at 2:46 P.M., the Director of Nursing (DON) said that there was no documentation that the Physician/NPP was notified of Resident #5's high blood sugars from 10/1/24 - 12/5/24. The DON further said there was no documentation that the Physician/NPP was contacted on 11/22/24 to review the Resident's HgbA1c laboratory value, and the Physician review of the lab values should have been documented.

Based on observation, record review, and interview, the facility failed to preserve the dignity of one Resident (#107) out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #107's wheelchair was maintained in a clean manner for use by the Resident. Findings include: Resident #107 was admitted to the facility in September 2022 with diagnoses including Dementia, generalized muscle weakness and unsteadiness on feet. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #107: -was severely cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of one out of a possible total score of 15 -used a wheelchair for mobility. Review of Resident #107's clinical medical record indicated the following: -An Activated Health Care Proxy (HCP- a legally appointed person that has authority to make health care decisions for someone that is unable to do so themselves), effective 3/3/21. -A comprehensive, person-centered care plan indicating a focus of impaired mobility with intervention of wheelchair use for mobility, effective 10/1/22. On 12/12/24 at 1:14 P.M., the surveyor observed Resident #107 seated in his/her wheelchair during the lunch meal. The surveyor observed dried yellow and brown debris on the left arm rest and both sides of the seat cushion of the wheelchair. The surveyor also observed a thick coating of dried debris and dust on the seat platform and lower frame of the wheelchair. On 12/16/24 at 1:33 P.M., the surveyor observed Resident #107 seated in his/her wheelchair during a group activity and the wheelchair remained with the same dried yellow and brown debris on the left arm rest and both sides of the seat cushion. The surveyor further noted the thick coating of dried debris and dust remained on the seat platform and lower frame of the wheelchair. On 12/16/24 at 2:39 P.M., the surveyor observed Resident #107 lying in bed with his/her wheelchair along the side of the bed. The surveyor observed that the wheelchair seat cushion surface had a smeared white substance, and dried yellow and brown debris on the left arm rest and both sides of the seat cushion. The surveyor further observed the thick coating of dried debris and dust on the seat platform and lower frame of the wheelchair was still present. On 12/17/24 at 1:00 P.M., the surveyor observed Resident #107 seated in his/her wheelchair and being assisted with the lunch meal by MDS Nurse #1. During an interview at the time MDS Nurse #1 said that Resident #107's wheelchair was very dirty and needed to be cleaned. MDS Nurse #1 further said that the housekeeping department is responsible for cleaning wheelchairs in the facility. On 12/17/24 at 1:51 P.M., the surveyor and the Director of Housekeeping (DOH) observed the Resident's wheelchair. During an interview at the time, the DOH said that Resident #107's wheelchair was very dirty and needed to be cleaned immediately. The DOH said he could not provide evidence of when Resident #107's wheelchair was last cleaned but cleaning should have been done on 12/5/24 when the total room cleaning had occurred but did not appear that the wheelchair had been cleaned at the time. The DOH said Resident #107's dirty wheelchair was concerning because the wheelchair was a high contact surface and could spread germs. The DOH further said that the dirty wheelchair could also be a dignity concern because it did not look good. On 12/17/24 at 1:57 P.M., the surveyor and the Infection Preventionist (IP) observed Resident #107's wheelchair. During an interview at the time, the IP said the wheelchair was dirty. The IP further said that she was concerned about the dirtiness of the Resident's wheelchair and the wheelchair needed to be cleaned. The IP said that even for residents that are unable to speak for themselves a dirty wheelchair was concern for a resident dignity. The facility did not provide evidence of policy or procedure for wheelchair cleaning to the survey team prior to the end of the survey.

Based on record review and interview, the facility failed to resolve a grievance timely for one Resident (#40), out of a total sample of 26 residents. Specifically, the facility staff failed to reimburse Resident #40 timely when money was reported missing, an investigation was completed, and the grievance was resolved 80 days after the initial grievance was filed. Findings include: Review of the Grievance Policy, undated, indicated: -Upon receipt of a grievance, the staff person receiving the grievance shall immediately notify the grievance officer. -The grievance officer shall begin the grievance process by logging a summary of the grievance (if oral), the date the grievance was received and by initiating an investigation. -Review of any grievances filed should be completed within seven days. If the review cannot be completed within this timeframe, the grievance officer should communicate the status of the review and an updated time in which it is expected the review will be completed. -Upon completion of the review, the grievance officer should document the following: >A summary of the pertinent findings or conclusions regarding the grievance, >A statement as to whether the grievance was confirmed or not; and >Any corrective action taken or to be taken in response. Resident #40 was admitted to the facility in August 2021 with diagnoses including Seizure Disorder, Hypertension and Hyperlipidemia (an excess of fatty substances called lipids, largely cholesterol and triglycerides, in the blood). Review of Resident #40's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible 15. During an interview on 12/12/24 at 12:29 P.M., Resident #40 said that he/she was missing $54.00 a few months ago and had noticed it when he/she returned to his/her room. The Resident further said the lock to his/her drawer was broken and he/she was missing money out of a wallet. Resident #40 said he/she had been told that the money would be replaced and that an investigation had occurred, but he/she had not received any reimbursement. Review of the Missing Item Report dated 9/30/24, indicated: -Resident #40 reported he/she was missing $54.00 which was last seen on 9/28/24. -Resident stated that the money was in a wallet and the wallet was behind a box of tissues in a locked drawer and that the drawer had been locked. -Reported to the nurse on the unit on 9/28/24. -Action taken to locate the missing item: >Checked and have been unable to find. >Stated lock was broken and maintenance fixed the broken lock on 10/1/24. -Submitted for reimbursement. During an interview on 12/18/24 at 9:11 A.M., the Administrator said that they were resolving the grievance by reimbursing the Resident and provided evidence of a Check Request Form dated 10/14/24 for $54.00. The Administrator said that she was unsure of the status of the check request as it would be processed by the corporate office and would get back to the surveyor. During a subsequent interview on 12/18/24 at 2:43 P.M., the Administrator provided an Invoice #101424 for a reimbursement check for $54.00 to Resident #40. The Administrator said that the check would be delivered to Resident #40 on 12/19/24. Review of the documentation provided to the survey team indicated that Resident #40 would receive reimbursement 80 days after the initial grievance was filed.

Based on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for two Residents (#81 and #70), out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #81, ensure a Physician's order was in place for the use of oxygen (O2) therapy. 2. For Resident #70, ensure that oxygen therapy was administered as ordered by the Physician. Findings include: Review of the facility policy titled Oxygen Administration Nasal Cannula, revised November 2020, indicated the following: -To deliver low flow oxygen, per the physician's order (generally one to six liters per minute and 24% to 45% concentration) via nasal cannula. 1. Resident #81 was admitted to the facility in October 2020 with diagnoses including Acute Respiratory Failure with Hypoxia, morbid obesity, Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Review of the COPD care plan indicated the following in part: -O2 via n/c (nasal cannula) as ordered per MD/PA (Medical Doctor/Physician Assistant), initiated 9/12/24. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident did use oxygen therapy while a Resident at the facility. Review of the Order Summary Report, Active Orders as of 12/17/24, indicated no Physician order in place for the use of oxygen therapy. On 12/12/24 at 12:25 P.M., the surveyor observed Resident #81 had a nasal cannula in place and was receiving O2 at 4 liters per minute (LPM). During an interview and observation on 12/17/24 at 9:22 A.M., the surveyor and UM #1 observed Resident #81 was receiving 4 LPM O2 via nasal cannula. UM #1 said that the Resident had been receiving O2 for about three months, since he/she returned from the hospital after having hypoxia. The surveyor and UM #1 reviewed the current Physician orders and found there was no oxygen order for Resident #81. When the surveyor asked UM #1 how staff knew what liter flow to set the O2 level at, UM #1 said that she was not sure how the staff knew what liter flow to set because there were no orders in place. During a follow-up interview on 12/17/24 at 9:41 A.M., UM #1 said without an order the Resident should not be receiving O2. UM #1 said after reviewing the Resident's record it appeared that the O2 order had been discontinued in October 2024, but the Resident had continued to use the O2. 37400 2. Resident #70 was admitted to the facility in June 2023 with diagnoses including Acute Respiratory Failure with Hypoxia, shortness of breath, weakness, dependence on supplemental oxygen, COPD and Asthma. Review of the Resident #70's Care Plan, initiated 7/7/23 and revised 4/4/24, indicated the Resident had a diagnosis of COPD and shortness of breath, and included the following interventions: -Administer oxygen and monitor effectiveness by checking saturation as/if indicated, initiated 7/7/23 -Resident was unable to lie flat, causes shortness of breath, elevate the head of the bed and utilize pillows to relieve shortness of breath, initiated 10/7/24 -Resident takes rest periods as exertion causes shortness of breath, initiated 10/7/24 -Oxygen as ordered, initiated 10/7/24 Review of the MDS assessment dated [DATE], indicated Resident #70: -was cognitively intact as evidenced by a Brief Interview of Mental Status score of 15 out of a possible 15. -utilized oxygen while in the facility. Review of the December 2024 Physician's orders indicated the following: -Oxygen continuously via nasal cannula at 2 LPM, check every shift, check pulse oximetry (measures blood oxygen levels and pulse) and liters per minute, initiated 11/1/24. On 12/12/24 at 10:04 A.M., the surveyor observed Resident #70 lying in bed with the head of the bed elevated and oxygen was being administered via a nasal cannula and was set at 1.5 LPM on the oxygen concentrator. During an interview at the time, Resident #70 said he/she had been on oxygen therapy for a long time, that the nursing staff just changed the oxygen tubing, and he/she had no concerns. On 12/18/24 at 1:42 P.M., the surveyor observed the Resident lying in bed with the head of the bed elevated. Oxygen was being administered at 1 LPM via a nasal cannula and was connected to the oxygen concentrator positioned near the bed. During an interview at the time, Resident #70 said he/she was on continuous oxygen therapy and was usually on 2 LPM, but the Nurse put him/her on 1 LPM today and was having no issues (shortness of breath, difficulty breathing). The Resident said the Nurses check the oxygen and change the tubing. Review of the December 2024 Medication Administration Record (MAR) indicated oxygen was administered at 2 LPM as ordered on all shifts except the following dates/shifts: -12/2/24 on 11:00 P.M. to 7:00 A.M., oxygen was set at 15 [sic] LPM -12/9/24 on 3:00 P.M. to 11:00 P.M., oxygen was set at 3 LPM -12/11/24 on 3:00 P.M. to 11:00 P.M., oxygen was NA -12/14/24 on 7:00 A.M. to 3:00 P.M., oxygen was NA -12/16/24 on 3:00 P.M. to 11:00 P.M., oxygen was set at 3 LPM -12/17/24 on 3:00 P.M. to 11:00 P.M., oxygen was set at 3 LPM Review of the Resident's clinical record indicated no documented evidence as to the reason/rationale for the Resident's liter flow change in oxygen therapy that corresponded with the MAR documented dates/shifts. During an interview on 12/18/24 at 2:58 P.M. and 3:14 P.M., Nurse #3, who was taking care of Resident #70, said the Resident's respiratory status was stable and was monitored every shift. Nurse #3 further said the Resident was on continuous oxygen set at a flow rate of 2 LPM, which the Nurses monitor every shift. Nurse #3 said the Resident does not adjust the liter flow rate for the oxygen settings. On 12/18/24 at 3:16 P.M., the surveyor and Nurse #3 observed Resident #70. The Resident remained lying in bed and the nasal cannula was observed out of his/her nose. Nurse #3 provided verbal education to Resident #70 and was observed to re-apply the Resident's nasal cannula. The oxygen concentrator positioned near the Resident's bed was observed to be set at 1 LPM. During an interview at the time, the Resident said that he/she worked with Physical Therapy (PT) that morning. Nurse #3 said that the Resident had an order for oxygen to be administered at 2 LPM and she would look into who worked with the Resident for PT that morning to see if it was adjusted. Nurse #3 further said that the Respiratory Therapist (RT) also worked with the Resident, had last worked with the Resident on 12/12/24 and indicated he/she was tried on 1 LPM of oxygen and had an oxygen saturation level of 94%. Nurse #3 said if there were recommendations to change the Resident's oxygen liter flow rate, the RT would notify the Nurses and the Physician so that the oxygen orders could be changed. During an interview on 12/18/24 at 3:27 P.M. and 3:41 P.M., Unit Manager (UM) #1 said Resident #70 had a Physician's order to administer continuous oxygen to be set at 2 LPM. UM #1 said there was no order to titrate (adjust the flow rate of supplemental oxygen to achieve a specific target oxygen saturation level) the Resident's oxygen flow rate and that if there was a recommendation by the RT to change or titrate the oxygen flow rate, the Physician would need to be notified, agree to the change, and the oxygen order updated. UM #1 said she would follow up with the Rehabilitation Director to see if the Resident's oxygen was adjusted during PT that morning. During an interview on 12/18/24 at 4:13 P.M., the Director of Rehabilitation (DOR) said Resident #70 had therapy that morning and provided the surveyor with the Therapy Encounter Note dated 12/18/24. The DOR said the therapists who worked with Resident #70 indicated in their documentation note that the Resident was on 1 LPM of oxygen during the therapy session on 12/18/24. The DOR said the Physical and Occupational Therapists would not typically adjust a Resident's oxygen liter flow unless there was a Physician's order to titrate the flow rate.

Based on interview, and record review, the facility failed to ensure that one Resident (#24) was free from the use of unnecessary medications out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #24 did not receive extra doses of Insulin (medication used to control elevated blood sugar levels) when his/her blood sugar was under the 150 mg/dL (milligram per deciliter) level specified by the Physician. Findings include: Review of the facility policy titled Medication Administration by Route or Dosage, revised 3/2017, indicated the following: -Subcutaneous Injections: >Verify medication order on the Medication Administration Record (MAR). >Check against Physician order. Resident #24 was admitted to the facility in April 2017 with diagnoses including Type II Diabetes (DM- chronic condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident #24's November 2024 Physician's orders indicated: -Lantus (brand name for insulin glargine) Injection 100/milliliters (ml): Inject 50 units subcutaneously at bedtime for antidiabetic related to Type II Diabetes Mellitus without complications. Hold (do not give) if fasting blood sugar (FSBS) is less than 150 mg/dL or if resident not eating, initiated 5/15/24 and discontinued 11/15/24. -Lantus Injection 100/milliliters ml: Inject 46 units subcutaneously at bedtime for antidiabetic related to Type II Diabetes Mellitus without complications. Hold if fasting blood sugar (FSBS) is less than 150 mg/dL or if resident not eating, initiated 11/15/24. Review of Resident #24's December 2024 Physician's orders indicated: -Lantus 100/ml: Inject 46 units subcutaneously at bedtime for antidiabetic related to Type II Diabetes Mellitus without complications. Hold if fasting blood sugar (FSBS) is less than 150 mg/dL or if resident not eating, initiated 11/15/24. Review of the November 2024 MAR for Resident #24 indicated Lantus was administered on: -11/1/24 with a blood sugar of 135 mg/dL -11/3/24 with a blood sugar of 134 mg/dL -11/4/24 with a blood sugar of 138 mg/dL -11/9/24 with a blood sugar of 123 mg/dL -11/14/24 with a blood sugar of 130 mg/dL -11/15/24 with a blood sugar of 143 mg/dL -11/30/24 with a blood sugar of 107 mg/dL Review of the December 2024 MAR for Resident #24 indicated Lantus was administered on: -12/1/24 with a blood sugar of 116 mg/dL -12/10/24 with a blood sugar of 101 mg/dL -12/15/24 with a blood sugar of 130 mg/dL During an interview on 12/17/24 at 11:32 A.M., Nurse #2 reviewed Resident #24's bedtime Lantus order and said the bedtime Lantus was only to be given if the Resident had a blood sugar level of 150 mg/dL or above, if it was below 150 mg/dL the Lantus should be held. Nurse #2 said if the Resident received extra doses of Insulin, it could put him/her at risk for hypoglycemia (low blood sugar). During an interview on 12/17/24 at 1:13 P.M., Unit Manager (UM) #1 reviewed Resident #24's bedtime Lantus order and said if the Resident's blood sugar is less than 150 mg/dL, the Lantus should be held. During an interview on 12/17/24 at 1:37 P.M., UM #1 said she believed the bedtime Lantus order was written incorrectly. UM #1 said staff should have reached out to the Resident's Medical Provider to clarify the order and this had not been done. During an interview on 12/17/24 at 2:30 P.M., UM #1 said on the dates in question Resident #24 did receive the bedtime dose of Lantus even though the Resident's blood sugar levels were under 150 mg/dL and as the Physician order was written he/she should not have received those doses.

Based on observation, interview, and record review, the facility failed to ensure that medications were stored in a secure and safe manner, and according to professional standards of practice in the second-floor medication storage room. Specifically, the facility failed to store Lorazepam Concentrated Oral Liquid (controlled substance medication [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction] used to treat anxiety disorders) in a safe manner when the Lorazepam was stored in a black metal box that was not fixed (could be removed) to the inside of the medication refrigerator in the second-floor medication storage room. Findings include: On 12/17/24 at 11:33 A.M., during an observation of the second-floor medication storage room, the surveyor and Unit Manager (UM) #1 observed a black metal box with a padlock located in the medication storage room refrigerator. During an interview at the time, UM #1 said that the black metal box was locked with a padlock because it contained controlled medications that required refrigeration. UM #1 then removed the black metal box from the refrigerator, placed the box on a counter and opened the box to reveal two (2) bottles of Lorazepam Concentrated Oral Liquid. The surveyor did not observe the black metal box to be fixed to the inside of the medication storage refrigerator. UM #1 said that the black box used to have a chain attaching it to the inside of the refrigerator, but there was no chain now, and the box was not attached to the refrigerator. UM #1 said she was unaware that the box containing controlled medications should have been fixed to the inside of the refrigerator. During an interview on 12/18/24 at 2:40 P.M., the Director of Nursing (DON) said that the black metal box in the medication storage refrigerator contained controlled medications and should have been fixed to the inside of the refrigerator as required.

Based on interview, and record review, the facility failed to implement an Antibiotic Stewardship Program for one Resident (#52) out of a total sample of 26 residents. Specifically, for Resident #52, the facility failed to ensure that documentation was reviewed for signs and symptoms of infection prior to requesting an order for antibiotics from the Physician and/or Non-Physician Practitioner (NPP) and administering antibiotics for a suspected urinary tract infection (UTI). Findings include: Review of the facility policy titled Antibiotic Stewardship dated 7/2017, indicated the following: -It is the policy of this facility to treat only symptomatic infection meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. -When symptoms of an infection are documented . Resident #52 was admitted to the facility in September 2016 with diagnoses including frontotemporal neurocognitive disorder (a form of Dementia that effects the frontal and temporal lobes), Traumatic Brain Injury, major depressive disorder, anxiety disorder, and was receiving Hospice services (care at the end of life). Review of Resident #52's December 2024 Physician's orders indicated: -Macrobid (a type of antibiotic) Oral Capsule 100 milligram (mg), Give one capsule by mouth two times a day for a UTI for five days, with a start date of 12/4/24. -Ativan (an antianxiety medication) Oral Tablet 1 mg, Give 1 mg by mouth every six hours as needed for anxiety, with a start date of 11/22/24. Review of the December 2024 Medication Administration Record (MAR) indicated Resident #52 was administered Macrobid twice daily as ordered from 12/5/24 through 12/9/24. During an interview on 12/17/24 at 8:41 A.M., Nurse #4 said she was unsure why Resident #52 was started on antibiotics and would need to ask Unit Manager (UM) #1. During an interview on 12/17/24 at 8:42 A.M., UM #1 said she was unsure why Resident #52 was on antibiotics and that she would need to go ask the Social Worker. During a follow-up interview on 12/17/24 at 8:59 A.M., UM #1 said the Resident was on Hospice services so no labs could be drawn on him/her to check for a UTI. UM #1 said the Resident had been experiencing increased episodes of behaviors including agitation and needed to be administered his/her as needed (PRN) Ativan to address the increased agitation and this could suggest a possible UTI. Review of the November 2024 MAR indicated Resident #52 had not been administered his/her PRN Ativan during the month of November. Further review of the November 2024 MAR indicated no documented behaviors. Review of the December 2024 MAR indicated Resident #52 had not been administered his/her PRN Ativan from 12/1/24 through 12/4/24. Further review of the December 2024 MAR indicated no documented behaviors from 12/1/24 through 12/4/24. Review of the Hospice Nursing assessment dated [DATE], indicated the Resident was experiencing an increase in agitation. Review of the Hospice Nursing assessment dated [DATE], indicated: -all of Resident #52's medications were to be stopped except for Ativan and Morphine (a pain medication). -this included stopping two antidepressant medications. During an interview on 12/17/24 at 10:06 A.M., the Infection Preventionist (IP) said staff should be looking for signs and symptoms of a UTI as Resident #52 was unable to verbalize if he/she was exhibiting signs of a UTI. The IP said staff should look for signs and symptoms such as pain, strong odor to the urine, dark urine, increase in urine, fever, and/or hematuria (blood in urine). The IP said she was unsure if the Resident exhibited clinical signs of a UTI and she would need to look at the Resident's chart. The IP said it was also a possibility to see a change in mental status since the Resident recently came off antidepressant medications. Review of the Nursing Progress Notes dated 11/25/24 through 12/4/24, indicated no documentation Resident #52 had increased agitation or signs and symptoms of a UTI. During an interview on 12/17/24 at 1:49 P.M., the Director of Nursing (DON) said he was unable to provide any documentation that would indicate Resident #52 was having signs and symptoms of a UTI. The DON said one Hospice Note dated 12/2/24, indicated the Resident had an increase in his/her agitation but there was no additional documentation to support the Resident had a suspected UTI as the Resident had a history of increased periods of agitation at baseline.

Based on record review, and interview, the facility failed to offer the Pneumococcal Vaccination as recommended to one Resident (#104), for five applicable residents, out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #104 was offered the Pneumococcal Conjugate Vaccine (PCV- a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia. Findings include: Review of the facility document titled Procedure for Pneumococcal Vaccination of Residents indicated the following: -Each resident or their representative will be asked on admission if they have previously had any pneumococcal vaccinations and their age at the time of vaccination. The records that accompany the resident will also be used to determine immunization status. -The pneumococcal conjugate vaccine will be offered to all eligible residents . -Adults aged [AGE] years and older who have not previously received a pneumococcal conjugate vaccine or whose vaccination history is unknown should receive a pneumococcal conjugate vaccine . Resident #104 was admitted to the facility in October 2023 with diagnoses including Adult Failure to Thrive. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #104 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of a total possible score of 15. Review of Resident #104's clinical record indicated no evidence that Resident #104 had received the PCV vaccine. Review of Resident #104's Resident Admission Vaccination Education Form did not indicate Resident #104 and/or the Resident Representative had been provided education for or offered the PCV vaccine. During an interview on 12/17/24 at 10:14 A.M., the Infection Preventionist (IP) said when Residents are admitted to the facility a Resident Admission Vaccination Education Form is filled out with the Resident or their Representative to evaluate the Resident's immunization status. The IP said that the form indicated whether the Resident had the vaccine previously, refused the vaccine, or consented to administration of the vaccine. During a review of Resident #104's Resident Admission Vaccination Education Form, the IP said that there was no evidence that Resident #104 had been administered the Pneumococcal vaccine. The IP further said that there was no evidence that Resident #104 or their Representative had been educated or offered the Pneumococcal vaccine, but they should have been offered the vaccine.

Based on observation, interview, and record review, the facility failed to develop a system to conduct regular maintenance and inspections of all bed frames, mattresses, and bed rails (side rails) as part of a regular maintenance program to identify areas of possible entrapment for two Residents (#5 and #70) out of three applicable residents for bed rail use, out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #5, provide inspection documentation for the Resident's bed frame, mattress, and side rails. 2. For Resident #70, provide documentation that the Resident's bed frame, mattress, and side rails were regularly inspected. Findings include: Review of the facility policy titled Restraints: Bed Rail Safety Check, undated, indicated the following: -Regularly inspect each of the seven areas (areas between the mattress and side rails, head board, and foot board) on each bed with restraints. -Maintenance and monitoring of the bed, mattress, and accessories (such as resident/caregiver assist items) should be ongoing. 1. Resident #5 was admitted to the facility in July 2022, with diagnoses including difficulty in walking, weakness, and Osteoarthritis (degenerative joint disease). On 12/12/24 at 3:16 P.M., the surveyor observed Resident #5 lying in bed with bilateral (both sides) side rails in place on his/her bed. Review of the most recent side rail evaluation dated 9/26/24, indicated Resident #5 used quarter (1/4) side rails for positioning or support bilaterally on his/her bed. 2. Resident #70 was admitted to the facility in June 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), Acute Respiratory Failure with hypoxia, dependence on oxygen, and weakness. On 12/12/24 at 10:04 A.M., the surveyor observed Resident #70 lying in bed with bilateral side rails in place on his/her bed. Review of the most recent side rail evaluation dated 9/6/24, indicated Resident #70 used 1/4 side rails for positioning or support bilaterally on his/her bed. During an interview on 12/18/24 at 9:40 A.M., the Maintenance Director said bed frames, mattresses, and side rails are only inspected if a new mattress is placed on a bed or if staff lets him know there is a problem with the bed. Review of the Bed System Measurement Device Test Results Worksheet Binder (Binder where the Maintenance Department documents when beds were last inspected), provided by the Maintenance Director indicated the following: -No documentation was available for when Resident #5's bed frame, mattress, and side rails were last inspected. -Documentation that Resident #70's bed frame, mattress, and side rails were last inspected on 9/4/18. During a follow-up interview on 12/18/24 at 1:11 P.M., the Maintenance Director said currently there was no program in place to regularly inspect the bed frames, mattresses, or side rails. He further said he was unable to provide any additional documentation that would show Resident #5 and Resident #70 had their bed frame, mattress, or side rails inspected recently. He said a procedure should be in place to regularly inspect the Resident's beds to ensure they are in safe working order.

Based on record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment was accurately coded for one Resident (#84) out of a total sample of 26 residents. Specifically, the facility staff incorrectly coded Clopidogrel (an antiplatelet [prevents platelets from sticking together] medication) as an anticoagulant on the MDS. Findings include: Resident #84 was admitted to the facility in February 2021 with diagnoses including Atrial Fibrillation (an irregular heart rate which can result in poor blood flow and blood clots forming). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #84 was currently prescribed an anticoagulant (blood-thinning medication which disrupts blood clot formation). Review of Resident #84's December 2024 Physician's orders indicated: -Clopidogrel 75 mg (milligrams) PO (by mouth) in the morning. -No Physician order for an anticoagulant medication. During an interview on 12/18/24 at 12:19 P.M., the surveyor and MDS Nurse #1 reviewed the MDS dated [DATE], and MDS Nurse #1 said she had coded that the Resident was taking an anticoagulant medication. MDS Nurse #1 said she followed the Resident Assessment Instrument (RAI) Manual guidelines for coding. MDS Nurse #1 said Resident #84 was not prescribed an anticoagulant and in fact was prescribed an antiplatelet medication. MDS Nurse #1 further said she had coded the MDS incorrectly and it would need to be changed. MDS Nurse #1 said that accurate assessments were important for resident care.

Based on observation and interview, the facility failed to post required nurse staffing information on a daily basis. Specifically, the facility failed to include daily posting of the following: -the resident census information on the daily posting for the facility nurse staffing. -total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs). Findings include: On 12/15/24 at 12:30 P.M., the surveyor observed a paper posting of nurse staffing information for 12/15/24 encased in a plastic sleeve and posted on a wall in the facility lobby area. The nurse staffing information posted contained the following: -the facility name -the current date -the 7:00 A.M. to 3:00 P.M. staff scheduled to work and the shift hours assigned to each staff member. Further review of the nurse staffing information posting did not indicate the facility census number, staff scheduled to work on the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts, and the total number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) for all shifts. During an observation and interview on 12/16/24 at 2:24 P.M., the surveyor and the Director of Nursing (DON)observed the nurse staff posting encased in a plastic sleeve and posted on a wall in the facility lobby area. The nurse staff posting was observed to contain the facility name, the current date, the 7:00 A.M. to 3:00 P.M. staff, and the shift hours assigned to each staff member. The nurse staff posting did not contain the facility census information or the total number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPN's), and Certified Nurse Aides (CNAs). The DON said that the nurse staff posting was a reference for the staff coming into work so that they knew which nursing unit they were are assigned to for that particular shift. The DON further said that the nurse staff posting did not contain the facility census information or the total hours worked for the staff and he was unaware of all the requirements for the nurse staff posting.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who experienced a change in health status, and had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing notified his/her Health Care Agent (HCA) in a timely manner, when on 11/22/24, Resident #1 required administration of oxygen therapy during the overnight shift due to low oxygen saturation levels, that was new for him/her, however his/her HCA was not notified until the day shift, when he/she was transferred to the Hospital Emergency Department (ED) for evaluation. Findings include: -Review of the Facility Policy, Titled Your Rights and Protections as a Nursing Home Resident, undated, indicated that the Health Care Agent must be notified when the following occurs: -Your physical, mental, or psychosocial status starts to get worse. -You have a life-threatening condition. -Your treatment needs to change significantly Resident #1 was admitted to the Facility in June 2024, diagnoses include prostate cancer, dementia, type 2 diabetes mellitus, and chronic kidney disease. Review of Resident #1's Medical Record indicated Resident #1's Health Care Proxy was permanently invoked on June 14, 2024. Review of Resident #1's Nurse Progress Note, dated 11/22/24 at 7:53 A.M., indicated his/her oxygen saturation level was 85 percent (normal range 90 - 96%) on room air during the night and oxygen was applied by nursing at 2 liters/minute via nasal cannula. The Note indicated nursing called the on-call provider during the night and new orders were received for oxygen at 2 liters/minute via nasal cannula. Review of Resident #1's Physician's Orders, dated 11/22/24, indicated he/she had a new order for Oxygen 2 liters/minute via nasal cannula every shift. Review of Resident #1's Medical Record indicated there was no documentation to support that Resident #1's HCA was notified of his/her change in condition with the need for oxygen therapy, that occurred on 11/22/24 on the night shift. During a telephone interview on 12/03/24 at 12:44 P.M., Nurse #1 said that he did not notify Resident #1's HCA of his/her condition change and need for oxygen, but said he should have. Nurse #1 said the change in condition occurred overnight, and he should have called in the morning. Nurse #1 said the HCA became aware Resident #1 was on oxygen therapy when visiting him/her on 11/22/24. During an interview on 12/03/24 at 2:00 P.M., the Director of Nurses (DON) said that it is the Facility's expectation when there is a condition change in a resident, that the Health Care Agent will be notified in a timely manner.

Based on record review, and interview, the facility failed to accurately code Minimum Data Set (MDS) assessments for four Residents (#87, #94, #121, and #25) out of a total sample of 26 residents. Specifically, the facility staff failed to accurately code: 1. for falls for Resident's #87 and #94 2. for visual acuity for Resident #121 3. for administration of antipsychotic medication for Resident #25 Findings include: 1a. Resident #87 was admitted to the facility in June 2023 with a diagnosis that included a history of falling. Review of the Resident's Fall Report dated 8/24/23, indicated the following: -Resident was sitting in a chair and scooted out of chair. -Resident landed on his/her coccyx area in front of the chair. -Fall was witnessed, no injuries reported. Review of the Resident's MDS dated [DATE], section J indicated that the Resident had no falls since the prior assessment on 7/20/23. During an interview on 10/24/23 at 8:13A.M., the MDS Nurse said that the MDS dated [DATE], section J was coded inaccurately and should have indicated that the Resident sustained a fall since the last MDS assessment on 7/20/23 as required. 1b. Resident #94 was admitted to the facility in April 2023 with diagnoses including difficulty walking and weakness. Review of the Resident's Progress Notes dated 4/19/23, indicated the following: -Patient was found sitting on the floor in the hallway. -Patient denied pain. Review of the Resident's Progress Notes dated 6/19/23, indicated the following: -CNA found the Resident's body (bottom half) in his/her bed, with his/her head on the floor. -red mark approximately 2 centimeters (cm) round was noted to [sic] the right side of his/her forehead. Review of the Resident's MDS dated [DATE], section J indicated that the Resident had one fall with no injury. During an interview on 10/24/23 at 8:13A.M., the MDS Nurse said that the MDS dated [DATE], section J was coded inaccurately and should have indicated that the Resident had two falls since the last MDS assessment on 4/18/23. 44222 2. Resident #121 was admitted to the facility in September 2023 with a diagnosis of cortical blindness (the total or partial loss of vision in a normal appearing eye caused by damage to the brain). Review of the Resident's admission paperwork including a history and physical (H&P) dated 9/13/23, indicated that the Resident had a diagnosis of cortical blindness. Review of the Resident's MDS dated [DATE], section B indicated that the Resident had adequate vision. During an interview on 10/24/23 at 12:21 P.M., the MDS Nurse said that the MDS dated [DATE], section B was coded inaccurately and should have indicated Resident #121 has impaired vision. 3. Resident #25 was admitted to the facility in February 2019 with diagnoses including Schizophrenia (a mental disorder characterized by continuous or relapsing episodes of psychosis) and anxiety. Review of the Resident's current Physician's orders included: -Perphenazine (an antipsychotic medication) tablet 2 mg (milligrams) Give 6 mg by mouth two times a day (BID) related to Schizophrenia . start date 10/24/22. Review of the August 2023 Medication Administration Record (MAR) indicated that the Perphenazine was administered BID each day as ordered. Review of the Resident's MDS dated [DATE], section N did not indicate any administration of antipsychotic medication. During an interview on 10/24/23 at 8:32 A.M. the MDS Nurse said that the Resident's MDS dated [DATE], section N should have indicated antipsychotic medication used 7 days, but it did not. The MDS Nurse said that this was a coding error.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, had a history of repeated falls, was assessed by nursing as being at risk for falls, and who required an extensive assist of two staff members during transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance during the transfer to maintain his/her safety, in an effort to prevent incidents or accidents resulting in an injury. On 4/18/23 at approximately 8:00 P.M., Certified Nurse Aide (CNA) #2 attempted to transferred Resident #1 from his/her wheelchair to the toilet without having another staff member present to assistance her, Resident #1 fell to the bathroom floor, fractured his/her right distal fibula (lower ankle bone), and was admitted to the Hospital, where he/she required surgical intervention to repair the fracture. Findings include: Review of the Facility's Policy, titled Falls Management, dated 4/2015, indicated that the Facility will: - Determine a resident's risk for falls, this information includes a fall risk evaluation and rehabilitation information. - The Interdisciplinary team will implement an appropriate individualized care plan based on the fall risk evaluation score. - A fall risk care plan will be developed to implement a safety plan. - Residents at risk on subsequent fall evaluations will be evaluated in accordance with nursing, medical and rehabilitation needs. Resident #1 was admitted in October 2019, diagnoses included a history of recurrent falls, a transmetatarsal amputation (mid foot), generalized muscle weakness, bipolar illness and chronic obstructive pulmonary disease. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, required an extensive two-person physical assist for bed mobility, and transfers, was non-ambulatory, and was not steady when moving from a seated to a standing position, only able to stabilize with staff assistance. Resident #1's Falls Care Plan, dated as revised 3/02/23, indicated he/she was at risk for falls, interventions included to reinforce Resident #1's safety awareness, lock brakes on bed and wheelchair before transferring, and he/she was educated to call for assistance prior to transfers. Resident #1's Mobility Care Plan, dated as revised 3/10/23, indicated he/she has impaired functional mobility related to behavior, illness and poor motivation, and his/her updated intervention, (written by the Occupational Therapist) indicated for transfers to provide a two-person physical assistance. Review of Resident #1's Occupational Therapist Note, dated 3/10/23, indicated that Resident #1 transferred with good hand and foot placement for stand pivot transfers. The Note also indicated to discontinue his/her mechanical lift transfer orders and to upgrade his/her status to physical assistance of two staff members for transfers. Review of Resident #1's Fall Risk Assessment, dated 4/06/23, indicated Resident #1 was at risk for falls. During an interview on 5/09/23 at 1:38 P.M., the Occupational Therapist said Resident #1 was evaluated by her on 3/10/23, for his/her ability to participate in transfers, that he/she had recently fallen on 3/09/23, while trying to self-transfer, and that no injuries occurred at that time. The Occupational Therapist said even with education and reinforcement with how to transfer, Resident #1 was still unsafe and he/she required a two-person physical assist for safe transfers. The Occupational Therapist said she communicated with the Nursing staff on 3/10/23, Resident #1's level of assistance needed for transfers. The Occupational Therapist said she updated Resident #1's Rehabilitation Care Plan (the Mobility Care Plan), for transfers to discontinue the mechanical lift transfer (with a two-person assist) and that he/she required a physical assist of two persons (without a mechanical lift). The Occupational Therapist said Resident #1 was never a one person assist for transfers, that he/she was always needed two-person physical assistance with transfers. The Occupational Therapist said that Resident #1 had a partial left foot amputation which throws off his/her balance, that Resident #1's transfers were unsafe, and he/she had poor balance with impulsive behaviors which would increase his/her potential for falls. Review of Resident #1's Nursing Progress Note, dated 4/19/23 (a late entry) at 12:49 A.M., indicated that (on 4/18/23 at approximately 8:00 P.M.), Nurse #1 heard screaming and Resident #1 was on the bathroom floor with CNA #2 present, Resident #1 had fallen and his/her leg was hurting. Nurse #1 discussed with Resident #1 about going to the Hospital multiple times and he/she initially refused to be transferred to the Hospital. Resident #1 was medicated with pain medication as needed. Review of Resident #1's Nursing Progress Note, dated 4/19/23 at 3:39 A.M., written by the Nursing Supervisor, indicated Resident #1 was transferred to the Hospital after he/she complained of severe pain in his/her right leg (from the fall on 4/18/23 at approximately 8:00 P.M.) and requested to be evaluated in the Emergency Department. Review the Facility's Internal Investigation Report, dated 4/19/23, indicated that on 4/18/23 at approximately 8:00 P.M., the Nurse (Nurse #1) heard screaming, Resident #1 was found on the bathroom floor, the CNA (CNA #2) was with Resident #1. The CNA (CNA #2) stated that the fall occurred when CNA #2 attempted to transfer Resident #1 to the toilet from his/her wheelchair without a second person to assist. Resident #1 stated that his/her right leg was hurting and that he/she was initially offered to be transferred to the Hospital, and that later, during the 11:00 P.M. to 7:00 A.M. shift, Resident #1 requested to be transferred to the Hospital for severe pain. The Investigation indicated that although Resident #1's Care Plan's were up to date and accurate, that the Resident Care Card that the CNAs used and followed for the resident's care needs, had inaccurate information. The Investigation indicated that Resident #1's CNA Care Card (including level of assistance for transfers) had indicated that Resident #1 was an assist of one (person for transfers) instead of two (persons for transfers). Review of CNA #1's Witness Statement, dated 4/20/23, related to Resident #1's fall on 4/18/23, indicated she had updated the CNA Assignment Sheets for Resident #1's from a two-person assist with a mechanical lift to an extensive one-person (physical) assist. The Statement indicated when CNA #1 made out the assignments sheets for the other CNA's, she made a typo (error) and documented that Resident #1 was an extensive assist of one (person) instead of extensive assist of two (persons). During an interview on 5/09/23 at 2:25 P.M., CNA #1 that said when Resident #1 was evaluated by Rehabilitation (the Occupational Therapist) on 3/10/23, that the Occupational Therapist said that Resident #1 was upgraded from a two person assist with a mechanical lift to a two-person physical assist without a mechanical lift. CNA #1 said she incorrectly updated Resident #1's CNA Assignment sheet, (not the CNA Care Card) for his/her transfer ability to a physical assist of one person, instead of a physical assist of two. Review of CNA #2's Witness Statement, undated for Resident #1's fall on 4/18/23, indicated, she was asked by Resident #1 for help to go to the bathroom, (she performed a one-person physical assist). Resident #1 started to stand up and (at the grip bar on the wall) and he/she went right down on the floor, she (CNA #2) heard his/her right ankle crack, Resident #1's shin hit the heater, and he/she said he/she was in pain. During an interview on 5/09/23 at 1:10 P.M. with Certified Nurse Aide (CNA #2) said she had followed the CNA Care Card on 4/18/23 for Resident #1's transfer requirements. CNA #2 on that day the Care Card indicated to transfer him/her with a one-person physical assist. CNA #2 showed the Surveyor that on the updated Care Card, dated 4/25/23, that there was the partially erased number one that had been written on the Card Care with the incorrect number for staff assistance with transfers, that there had been a one not a two indicated for Resident #1's physical assist needs for transfers. CNA #2 said that on 4/18/23, immediately prior to his/her fall in his/her bathroom, she had pushed (assisted) Resident #1 to stand up by holding the grip bar for a transfer to the toilet and then she stood by the back of Resident #1's wheelchair, and that no one was on either side of Resident #1 to physically assist with the transfer to the toilet (and support Resident #1 if he/she lost his/her balance). CNA #2 said Resident #1 went down to the floor with folded legs. CNA #2 said she heard a crack and Resident #1 screamed and he/she had a visible bump on his/her right lower leg. Review of the current Certified Nursing Aide (CNA) Care Card, dated as effective 4/25/23 (updated after the fall)now indicated that Resident #1's transfer status and toileting needs were dependent with a two-person physical assist for transfers. During an interview on 5/10/23 at 11:45 A.M., Resident #1 said that when he/she fell on [DATE] (at approximately 8:00 P.M.), he/she knew his/her right leg was broken, that it sounded like two snaps in his/her lower leg and then he/she felt the excruciating pain within the whole leg. Resident #1 said he/she may have initially denied that his/her leg was broken and that was why he/she declined to be transferred to the Hospital, but said he/she decided later (during the 11:00 P.M. to 7:00 A.M. shift) to be transferred to the Hospital. Review of Resident #1's Hospital Emergency Department (ED) Physician's Progress Note, dated 4/19/23, indicated Resident #1 was transferred to the ED on 4/19/23, when on 4/18/23 at 8:00 P.M., Resident #1 reported he/she fell in the bathroom and hit his/her right knee. On physical examination Resident #1 had a gross deformity of his/her right lower leg with internal rotation and excessive inward rotation (indicators of a fracture). X-ray results indicated, his/her right distal fibula (lower ankle bone) was fractured which required surgical repair. During an interview on 5/09/23 at 7:55 A.M., the Director of Nursing (DON) said that his expectation was that all of Resident #1's transfers were to be completed with a two-person physical assist. The DON said that their investigation determined that it was mistakenly documented on the CNA Care Card that Resident #1 was a one-person physical assist with transfers instead of a two-person physical assist, and that CNA #2 then followed the CNA Care Card requirements with the incorrect level of assistance with transfers. On 5/10/2023, the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. Resident #1's fall was investigated thoroughly and following the incident, the findings were as follows: The CNA Care Card and the CNA assignments did not reflect Resident #1's level of care (assistance) for transfers correctly. Resident #1's Care plan, CNA Care Card and CNA assignment sheets were reviewed. B. The Interdisciplinary team met and updated CNA Care Cards at care plan meeting to reflect recommendations by Therapy with transfers and ADL's. C. On 4/25/2023 staff education was completed by Nursing Admin staff on the care plan process with the following departments: MDS, Nursing Department, Social Services, Activity Department and Rehab Department. D. On 5/05/2023 additional staff education was completed by Nursing Admin staff on the CNA Care Card process with the following departments: Social Services, Rehab Department, Activity Department, and the Nursing Department to ensure that staff review plan of care prior to entering the residents room and providing the correct level of staff supervision or assistance required. E. The Director of Nursing monitored all care plan meetings weekly for 2 weeks, then will monitor monthly for 3 months. F. The Director of Nursing will do a facility wide audit to make sure all the care plans and Care Cards match and facility wide audits weekly for 2 weeks, then monthly for 3 months. G. On 4/27/2023, a Quality Assurance Performance Improvement (QAPI) meeting was conducted and will be held quarterly. There will be weekly risk meetings, they will continue to identify at risk patients during care plan meetings. More staff in place to monitor systems, continued education on CNA assignments and level of care. H. The CNA assignment sheets were changed to remove level of care and this information will be focused in one location, sheets will be updated at care plan meetings or as needed by the MDS coordinator. I. CNA assignments are kept in a binder with the assignment and Care Cards for all residents. J. The Rehab Department created a communication binder which has been distributed to each floor, reflecting any changes in resident level of care. Education on the care card updating process will go through the interdisciplinary team. K. A second Root Cause Analysis has been added, regarding who will continue monitoring of Care Cards, assignments, updates and compliance. L. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), the facility failed to ensure he/she was treated in a respectful and dignified manner, which included being free from all forms of restraints, when on 3/03/21, Certified Nurse Aide (CNA) #1 physically restrained Resident #1 using a flat bed sheet and bath blanket to restrict Resident #1's movements and limit his/her access to his/her legs and suprapubic catheter (a tube inserted through the stomach into the bladder, used to drain urine). Resident #1 sustained redness of the knees, documented as friction-related from Resident #1's legs repeatedly rubbing against the flat bed sheet that had been used to restrain him/her. Findings include: Review of the Facility's Restraint Management Policy, dated as revised August 2018, indicated that; also included as restraints were facility practices that met the definition of a restraint, such as: tucking in, or using Velcro to hold a sheet, fabric or clothing tightly so that a resident's movement is restricted. Resident #1 was admitted to the Facility in February 2021 with [DIAGNOSES REDACTED]. Review of Resident #1's clinical record indicated that he/she had a suprapubic catheter (a tube inserted through the stomach into the bladder, used to drain urine), and a Peripherally Inserted Central Catheter (PICC line; a catheter placed into a vein, typically used for long-term intravenous (IV) antibiotics, nutrition, medications, or blood draws). The Record also indicated that Resident #1 exhibited dyskinesia (abnormal or impaired voluntary (controllable) movement) of the arms and legs. Review of the Facility's Internal Investigation, dated 03/03/21, indicated that upon assessment of Resident #1, the skin on his/her knees was intact, but that both knees were observed to have reddened areas approximately one inch by 1.5 inches. The Investigation indicated that the tying of the flat sheet at the bottom of Resident #1's bed under the mattress most likely caused friction to the skin on Resident #1's knees, causing the reddened areas. Review of Resident #1's Nursing Progress Note, dated 03/02/21 at 5:02 A.M., indicated that Resident #1 was noted to have increased dyskinesia (abnormal or impaired voluntary (controllable) movement) of his/her upper and lower extremities, along with episodes of biting, pinching and slapping himself/herself. During an interview on 03/31/21 at 1:09 P.M., Nurse #1 said that at the time of the alleged incident, she and CNA #1 were assigned to the care of four residents on the Facility's designated COVID unit. Nurse #1 said Resident #1 exhibited frequent movement of his/her arms, and infrequent movement of his/her legs. Nurse #1 said she had not observed Resident #1 exhibit any other behavioral symptoms. Nurse #1 said she administered Resident #1 a PRN (as needed) medication for anxiety at the start of the 11:00 P.M. to 7:00 A.M. shift because he/she was agitated, but that the medication was ineffective. Review of Resident #1's Medication Administration Record (MAR) dated for March 2021 and an Orders-Administration Note written by Nurse #1, dated 03/02/2021 at 11:08 P.M., indicated that 25 milligrams (mg) of [MEDICATION NAME] (an [MEDICATION NAME] medication sometimes also used short-term to treat anxiety) every six hours as needed (PRN) was administered to Resident #1 for increased anxiety and agitation. Review of Resident #1's MAR and an Orders-Administration Note written by Nurse #1, dated 03/03/21 at 12:23 A.M., indicated that the administration was ineffective. Nurse #1 said she did not notify anyone that Resident #1's PRN [MEDICATION NAME] was ineffective because she did not observe any change in Resident #1's condition. However, review of Resident #1's Nursing Progress Note, dated 03/03/21 at 5:45 A.M. (approximately five hours after Nurse #1 documented that the [MEDICATION NAME] was ineffective) and written by Nurse #1, indicated that Resident #1 flailed his/her arms for most of the shift, PRNs were given with no effect, and that redirection was unsuccessful. During an interview on 03/26/21 at 9:43 A.M. and 2:05 P.M., Certified Nurse Aide (CNA) #1 said that at the time of the alleged incident, she and Nurse #1 were assigned to care for four residents on the Facility's designated COVID unit. CNA #1 said Resident #1 exhibited frequent movement of his/her arms and legs, would try to bite his/her feet, and would pull at his/her PICC line and the suprapubic catheter. CNA #1 said the other three residents on the unit also required frequent attention for medical and/or behavioral issues. CNA #1 said she attempted interventions to try and help calm Resident #1 which included providing care, talking with him/her, and repositioning him/her. CNA #1 said she repeatedly asked Nurse #1 to help her with Resident #1, but said that Nurse #1 said she had already medicated Resident #1, that she could not give him/her anything, and that Nurse #1 told her she could not do anything more. CNA #1 said because it was only her and Nurse #1 on the unit during that shift, and Resident #1's behaviors were increasing, that is why she kept asking Nurse #1 for help with him/her. CNA #1 said the last time she asked Nurse #1 for help, Nurse #1 said words to the effect of, what do you want me to do? CNA #1 said that approximately halfway through the shift (on 3/03/21) sometime before 3:00 A.M.), she was still unable to calm or redirect Resident #1. CNA #1 said she was afraid Resident #1 was going to hurt himself/herself or pull out his/her suprapubic catheter or PICC line because of his/her agitated, restless behaviors and repetitive movements. CNA #1 said that in an effort to prevent Resident #1 from injuring him/herself, she took a flat sheet, tied two ends together, and slipped it under the foot (bottom portion) of Resident #1's mattress, like a fitted sheet, or words to that effect. CNA #1 said she laid the remainder of the flat sheet (the two untied ends of the flat sheet) over Resident #1's lower body, and loosely tucked the sides of the flat sheet under the mattress. CNA #1 said she then took a bath blanket (a blanket typically used to prevent someone from becoming chilled after a bed bath or shower), folded it, and laid it on Resident #1's abdomen over his/her suprapubic catheter. CNA #1 said she then loosely tucked the ends of the bath blanket under Resident #1's mattress. CNA #1 said Resident #1 had access to and could move his/her arms and legs, and was able to reach under the bath blanket to access his/her suprapubic catheter. CNA #1 said she knew that what she had done with the flat sheet and bath blanket could be considered a physical restraint. CNA #1 said she felt like she had exhausted other behavioral interventions which were ineffective, and used the flat sheet and bath blanket because she was afraid Resident #1 would injure him/herself. Review of Resident #1's Nursing Progress Note, dated 03/03/21 at 5:45 A.M. and written by Nurse #1, also indicated that Resident #1 pulled off the dressing for his/her PICC line, pulled the PICC line out about five inches (approximately 12.7 centimeters (cm) of a total 42 cm length) at 5:30 A.M., and that the PICC line was removed. Nurse #1 said that during the shift of the alleged incident, she was stationed at the temporary nurses' station in the room across hall from Resident #1's room. Nurse #1 said that from where she sat, she could observe Resident #1 from the waist down while he/she was in bed. Nurse #1 said she was in Resident #1's room on multiple occasions throughout the shift, including at approximately 5:30 A.M. because Resident #1 had dislodged his/her PICC line, and at approximately 6:30 A.M. to administer him/her medications. Nurse #1 said that at no time did she observe Resident #1's sheet or any blankets tucked in and/or tied around the foot of the bed. Observations by the Surveyor on 03/16/21 at 9:34 A.M. indicated that: - Resident #1's room at the time of the alleged incident was across the hallway from a room arranged as a temporary nurses' station for the COVID unit. - Resident #1's bed at the time of the alleged incident, as identified by the Director of Nurses (DON), was the first bed inside of his/her assigned room. - Approximately 18 inches of the end of Resident #1's bed was in direct line of sight of the table used by nursing in the temporary nurses' station. - Untucked sheets on what was Resident #1's bed at the time of the alleged incident hung approximately six inches below the bottom of the mattress, and approximately three inches below the supporting frame. Based on the Surveyors observation and Nurse #1's interview in which she said she was able to see Resident #1 from the waist down in bed, while seated at the nursing station, and Nurse #1 also said that she was in Resident #1's room at least twice after 3:00 A.M. (which was when CNA #1 said she applied the flat sheet and bath blanket), Nurse #1 should have been able to observe how Resident #1 was situated in bed.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was diagnosed with [REDACTED].#1 was assessed for the ability to independently operate his/her insulin pump, including his/her ability to calculate and enter the carbohydrate values of the snacks and meals he/she consumed, which along with his/her blood sugar value administered the correct dose of insulin needed. - As a result, Resident #1 had uncontrolled diabetes with episodes of [MEDICAL CONDITION] (a blood sugar greater than 600 milligrams (mg), normal 70 mg to 120 mg), and was hospitalized twice due to Diabetic Ketoacidosis (DKA, a life-threatening condition resulting from a toxic build-up of acidic chemicals, [MEDICATION NAME], in the blood which, if not treated promptly, can lead to coma and death), which was probably caused by Resident #1 entering the incorrect carbohydrate values or not entering any values at all, into his/her insulin pump, not receiving the required dose of insulin from his/her insulin pump to treat his/her [MEDICAL CONDITION] and therefore having inadequate glycemic control of his/her diabetes. Findings include: The Instruction Manual for the Personal Diabetes Manager (PDM, the insulin pump) indicated that this is an insulin management system intended for subcutaneous delivery of insulin at set and variable rates for the management of diabetes. Safe Use of Pump therapy requires substantial caregiver involvement. Operation of the insulin pump requires accurate entry of the carbohydrate value and blood sugar value, so that the pump will administer the correct dose of insulin. The Hospital Discharge Summary, dated 11/22/19, indicated that Resident #1 had type 1 diabetes treated with an insulin pump with episodes of acute [MEDICAL CONDITION], (a blood sugar greater than 600 milligrams (mg) (normal 70 mg to 120 mg). The Summary indicated that in the community, Resident was fearful of his/her blood sugar dropping, and had been [MEDICATION NAME] his/her diet with orange juice and sugar cookies, without knowing the associated carbohydrate count. The Summary indicated Resident #1 was unable to calculate the carbohydrate count based on his/her intake, due to his/her [MEDICAL CONDITION]. The Summary indicated Resident #1 needs these values provided to him/her, to be able to enter these carbohydrate values into the insulin pump. Resident #1 was admitted to the Facility in November of 2019, [DIAGNOSES REDACTED]. Review of Resident 1's physician's orders [REDACTED]. Review of Resident #1's physician's orders [REDACTED].#1 is independent with the device (the insulin pump) as in the community. Review of Resident #1's clinical record indicated that there was no documentation to support that the facility assessed Resident #1's ability to independently operate his/her insulin pump, or for the ability to ensure he/she could correctly calculate the carbohydrates values of what he/she consumed, which were required to be entered into his/her insulin pump, so that the pump would administer the correct dose of insulin for meals and snacks. The Nurse Progress Note dated, 12/8/19 at 5:19 P.M., indicated Resident #1 informed the nursing staff of his/her blood sugar values four times a day and the 400 mg blood sugar was covered with sliding scale insulin. Review of Resident #1's blood sugar readings indicated his/her diabetes remained uncontrolled, as follows: - 12/8/19 at 7:49 A.M., 490 mg - 12/9/19 at 8:11 P.M., 400 mg - 12/10/19 at 2:03 P.M., 547 mg The physician's orders [REDACTED].#1 to the Emergency Department for evaluation. The Hospital Admission Note, dated 12/10/19, indicated Resident #1, had a [DIAGNOSES REDACTED]. The Emergency Department fingerstick blood sugar was close to 600 mg., he/she was started on an insulin drip, administered three liters of normal saline, and admitted to the Intensive Care Unit. Review of Resident #1's re-admission physician's orders [REDACTED].#1 may self-administer (referring to the insulin from the insulin pump). Review of Resident #1's physician's orders [REDACTED].#1 is independent with the device (PDM) as in the community. The Physician's Note, dated 12/18/19 at 1:19 P.M., indicated that Resident #1 independently takes care of his/her insulin pump in the community, see the physician's orders [REDACTED].>Review of Resident #1's clinical record upon re-admission to the facility, indicated that there was no documentation to support that the Facility assessed Resident #1's, after being admitted to the ICU for treatment for [REDACTED]. Review of Resident #1's blood sugar readings indicated, his/her diabetes remained under poor control 12/18/19 at 8:34 A.M., 286 mg 12/19/19 at 5:09 P.M., 380 mg 12/20/19 at 5:02 P.M., 424 mg Review of the Physician's Telephone Order, dated 2/2/20, indicated, to transfer Resident #1 to the Emergency Department for possible dehydration and uncontrolled blood glucose levels. The Hospital Admission Note, dated 2/2/20, indicated Resident #1 was admitted with a [DIAGNOSES REDACTED]. The Note indicated Resident #1 had changed insulin pods (the container for insulin attached to the pump) two days ago and did not realize that the pump was not working. Resident #1 had been unable to eat for the past three days due to continuous vomiting. Resident #1's serum blood sugar was 504 mg/dl, serum [MEDICATION NAME] were positive (acids accumulating in the blood stream). The Endocrinologist Note, dated 3/6/20, indicated that Resident #1 had uncontrolled type 1 diabetes and that Resident #1 had only entered 20 to 25 grams of carbohydrates for meals, which was unrealistically low. The Note indicated that when Resident #1's blood sugars ranged between 93 mg, 121 mg, and 170 mg, he/she did not enter any grams of carbohydrates into the insulin pump and that Resident #1 was advised to enter the correct amount of carbohydrates in to the pump. The Note indicated Resident #1's blood sugar control continues to be poor, reviewed with him/her the importance of aiming for tight glucose control in order to decrease the risk of microvascular complications. The Physician's Note, dated 4/30/20, indicated that Resident #1's blood sugars had been high, with most of the values greater than 200 mg/dl, and some greater than 300 mg/dl, and that Resident #1 monitors and treats his/her own blood sugars. The Physician's Note, dated 5/8/20, indicated that Resident #1 was concerned by an increase in his/her elevated blood sugars. The plan was to monitor blood sugars with a change in basal rate of 1.5 units an hour via the insulin pump. The Endocrinologist Note, dated 7/9/20, indicated that Resident #1's diabetes is managed with an insulin pump, with poor glycemic control. The Note indicated that unfortunately, the Residents' living circumstances (at the Facility) are not conducive to better glycemic control, that he/she was fed carbohydrates in large amounts at meals and frequently he/she does not bolus the insulin. During an interview on 8/28/20 at 7:30 A.M., Resident #1 said he/she determined the number of carbohydrates for each meal and snacks independently without supervision. Resident #1 said he/she then entered the carbohydrate values which he/she calculated, along with his/her blood sugar into the insulin pump, to administer a bolus of insulin. During an interview on 8/28/20 at 11:40 A.M., Unit Manager #1 said there was no documentation in the clinical record that Resident #1 was ever evaluated for self-administration of insulin via his/her insulin pump, as required by their policy. Unit Manager #1 said she was not aware that Resident #1 was unable to calculate the number of carbohydrates, and that he/she needed supervision to enter the correct values for the accurate dose of a bolus of insulin. Unit Manager #1 said that this information had not been communicated to her because Resident #1 had been on another unit before April of 2020. During an interview on 8/28/20 at 11:50 A.M., Nurse #1, who was assigned to Resident #1, said she was familiar with his/her care, and said she was not aware that Resident #1 gave him/herself insulin from the insulin pump based on his/her carbohydrate values entered for meals and snacks combined with his/her blood sugar. Nurse #1 said there was no documentation in the clinical record that Resident #1 had adequate skills to operate the insulin pump.

Based on observation, interviews and record review the facility failed to implement interventions to prevent a burn for 1 Resident (#6), in a total sample of 24 residents. Findings include: For Resident #6, the facility failed to ensure a hot beverage was safe to serve prior to giving it to the resident. Review of the undated facility policy for Hot Liquid Spill Burn and Scald Prevention indicated that the temperature of hot liquids was to be checked prior to serving, and should not be served at a temperature greater than 145 degrees. Review of the Inservice Sheet for this policy, dated (1/28/14), indicated that Certified Nurses' Aid (CNA) #2 had attended this inservice. Resident #6 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 4/10/14, indicated the resident had moderate cognitive impairment as evidenced by the Brief Interview for Mental Status (BIMS) score of 11 out of 15. Review of a Nurses' Progress Note, dated 1/28/15, indicated the resident had spilled coffee onto his/her upper right thigh at approximately 8:30 A.M. A slightly pink area, measuring approximately 10 centimeters (cm.) X 10 cm., was observed. Review of an Accident/Injury Report, dated 1/28/15, indicated the resident had spilled coffee on his/her upper right thigh at 8:50 A.M. A reddened area with slight blistering was observed. Ice was applied to the area and pain medication administered. Review of a witness statement, dated 1/28/15 and signed by CNA #2, indicated that she had heated the resident's coffee in a microwave oven for 30 seconds and failed to check the temperature of the coffee before serving it to the resident. Review of a Nurses' Progress Note, dated 1/28/14 at 10:30 P.M., indicated the resident was complaining of pain to his/her right upper thigh. A burn to the right thigh was observed to be 10 cm. X 10 cm., deep pink in color, with two large fluid filled intact blisters. Review of the Incident Report Form, dated 1/30/15, indicated that at approximately 8:45 A.M., CNA #2 heated coffee in a microwave oven per the resident's request. CNA #2 heated the coffee for 30 seconds, brought it to the resident, and left the resident's room. The resident knocked the cup of coffee off the table onto his/her lap causing a burn to the upper right thigh. Review of a Physician's Progress Note, dated 2/4/15, indicated the resident had sustained a burn to the right thigh, blistered area gone with yellowish slough under. The resident had complained of pain when the dressing was removed. During an interview with the Director of Nurses on 2/11/15 at 2:15 P.M., she said CNA #2 gave the resident coffee, heated in the microwave, without checking the temperature per the facility policy. The resident spilled the coffee onto his/her lap causing a burn. She said the Physician had said it was a second degree burn. On 2/12/15 at 9:30 A.M. the resident was observed in his/her room seated in a stationary chair. He/she was dressed and groomed with a bedside table beside him/her. Resident #6 told the surveyor that he/she was burned from spilling a cup of hot coffee after "one of the girls" microwaved it. The resident said the coffee was very hot.

Based on observation, record review and interviews the facility failed to follow the plan of care for 3 (#3, #5, and #8) Residents out of a total sample of 24 residents. Findings include: 1. For Resident #8, the facility failed to follow the plan of care for dining supervision, pain control, a dressing change and falls. Resident #8 was admitted to the facility in 5/2011 with a [DIAGNOSES REDACTED]. a. The facility failed to follow the plan of care to supervise the resident during meals. Review of the Occupational Therapy Discharge Summary, dated 10/15/13, indicated; - Patient requires set up and supervision for self feeding. Review of the Change in Status Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive impairment and was supervised for eating. Review of the plan of care for Assist of Daily Living, dated 1/30/14, indicated; - The resident requires supervision, assist if needed. Review of the Accident/Incident Report, dated 2/28/14, indicated the resident was on the supervised side of the main dining room at 5:00 P.M. Two Activity Assistants witnessed the resident drop a cup of hot cocoa on his/her lap. The report indicated the resident sustained [REDACTED]." During an interview on 3/6/14 at 10:10 A.M. with Activity Assistant #1, she said the dining room is divided into two sections, one for independent residents, and one for supervised residents. Resident #8 was on the supervised side of the dining room. She served meals after a nurse verified it was the correct meal for the resident, and poured and served beverages. She said she is not to supervise or assist residents with meals. She had served hot cocoa to Resident #8 when the burn occurred. She said she poured hot water from a carafe, mixed the hot cocoa and gave it to the resident. She turned her back to speak to Activity Assistant #2, then heard the resident yell. She quickly turned back to the resident, noticed that the resident had spilled the hot cocoa, and called for help. A Certified Nursing Assistant (CNA) and Supervisor #1 came to assist the resident. When the surveyor asked Activity Assistant #1 who was supervising the resident with his/her meal, she said she was not sure because two CNA's and Supervisor #1 were on the independent side of the dining room. During a telephone interview on 3/6/14 at 2:45 P.M. with CNA #1, she said she was assigned to the independent side of the dining room the night the resident spilled hot cocoa and did not see what happened. When she heard Activity Assistant #1 call for help, she went to assist the resident. When the surveyor asked CNA #1 who was supervising the resident, she said she did not know. During an interview on 3/6/14 at 3:15 P.M. with Supervisor #1, she said she always goes to the main dining room for dinner. It is her responsibility to assist with the dinner meal and to assign staff to the dining room. She said there are usually three CNAs and an Activity Assistant to help with dinner. The Activity Assistant helps serve drinks and food, and socializes with residents. One CNA is assigned to the supervised side of the dining room. Supervisor #1 and two CNAs are assigned to the independent side of the dining room. The night Resident #8 spilled the hot cocoa, the facility was short staffed. As a result of this, one CNA was assigned to the middle of the dining room to supervise both the independent and supervised sides, and one CNA was on the independent side with Supervisor #1. When the surveyor asked who was supervising Resident #8, she said that CNA #1 should have been because she was assigned to the middle to supervise both sides. When the surveyor informed Supervisor #1 that CNA #1 did not see what had happened and questioned how she could of been supervising the resident, she was unable to answer. During an interview on 3/6/14 at 3:45 P.M. with CNA #2, she said she was assigned to the independent side of the dining room and did not see what happened. When Activity Assistant #1 called for help, everyone went to assist the resident. She said usually the CNA from the 3rd floor is assigned to the supervised side of the dining room, but that night they were short staffed. She could not tell the surveyor who was supervising the supervised side of the dining room. On 3/6/14 at 5:25 P.M., the surveyor observed Resident #8 in the main dining room on the supervised side, eating dinner. The resident was holding two covered cups. One of the cups was empty and the other cup had a clear liquid in it. Activity Assistant #3 was sitting next to the resident assisting the resident to drink by holding a covered cup with a straw up to the resident's mouth. On 3/6/14 at 5:30 P.M. during an interview with Activity Assistant #3, the surveyor asked if she had been trained to assist the residents with meals. She said she is not allowed to supervise or assist because she does not have the training. She is only suppose to socialize and help out. b. The facility failed to follow the plan of care for pain when providing wound care for burns. Review of the resident's care plan for pain, initiated 1/30/14, indicated the following: -Administer medications as ordered, and -Give 1/2 hour before treatments or care if needed. Review of a 2/2014 Treatment and Administration Record indicated a treatment, initiated on 2/28/14, to cleanse bilateral and inner thighs with Normal Saline and apply Silver [MEDICATION NAME] 1% Cream ([MEDICATION NAME], a topical medication used to debride wounds), cover with [MEDICATION NAME] (non-adhering dressing) and Kling. Review of the physician's orders [REDACTED]. sublingually (under the tongue) every 4 hours as needed for pain. On 3/5/14 at 1:00 P.M. the surveyor, accompanied by Unit Manager (UM) #2, entered the resident's room to observe a dressing change to the resident's bilateral thighs. UM #2 removed the previously applied dressings. Two large open areas were observed. UM #2 said the areas [MEDICAL CONDITION] by the resident spilling hot cocoa. When UM #2 applied the [MEDICATION NAME] Cream to the open areas, the resident became agitated and struck UM #2 repeatedly on the lower back. The surveyor asked if the resident had been medicated for pain recently. UM #2 said no. Review of the Medication Administration Record,dated 3/2014, indicated the resident had not had any medication for pain since 8:30 A.M. on the morning of 3/5/14. During an interview with the Director of Nurses (DON) on 3/5/14 at 2:15 P.M., she said the resident should have been premedicated for pain prior to the dressing change. c. The facility failed to follow the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Change every day and as needed. On 3/6/14 at 1:35 P.M. the surveyor, accompanied by UM #2 and the DON, was in the resident's room to observe a dressing change. The surveyor observed UM #2 remove the Kling on the left thigh. Underneath the Kling was an ABD pad (a bulky cover dressing). When the ABD pad was removed, no [MEDICATION NAME] was observed. UM #2 then removed the Kling from the right thigh. An ABD pad, rather than the [MEDICATION NAME], was observed. UM #2 attempted to removed the ABD pad but it had adhered to the resident's wound. She was unable to remove it without soaking the ABD pad with normal saline. The surveyor asked why the [MEDICATION NAME] pad was not used. UM #2 was unable to answer. The DON said the 11:00 P.M. - 7:00 A.M. nurse performed the last dressing change and did not follow the physician's orders [REDACTED]. d. The facility failed to follow the plan of care for falls to prevent two falls. Review of the plan of care for falls, dated 10/14/12, included; - Assist of two for transfers and toileting, - Encourage proper, well fitting, non-skid footwear, - Pressure alarm at all times, and - Common area for monitoring when out of bed. Review of the Nurse's Note, dated 12/9/14, (facility unable to locate the Accident/Incident Report) indicated the resident had an unwitnessed fall (unclear what time, but was on the 3:00 P.M. - 11:00 P.M. shift). A CNA observed the resident sitting on the floor in the hallway with the wheelchair behind him/her. The alarm was attached to the chair, but was not functioning. Review of the Accident/Incident Report, dated 2/19/14 indicated the resident had an unwitnessed fall at 1:30 A.M. The resident was not wearing non-skid socks per the fall care plan. On 3/5/14 at 8:55 A.M., the surveyor observed the resident sitting in a wheelchair in the hallway. The resident was eating breakfast. During an interview on 3/6/14 at 9:00 A.M. with UM #2, she said she was not sure what else she could do to prevent the resident from falling, but said the plan of care was not followed. Please refer to F309 and F323. 2. For Resident #3, the facility failed to follow the plan of care for falls and toilet transfers to prevent six falls. Resident #3 was admitted to the facility in 9/2012 with [DIAGNOSES REDACTED]. Review of the plan of care for falls and the plan of care for Assist of Daily Living (unclear when first initiated) included the following: - Assist of one for toileting, - Offer snack at bedtime (initiated 4/1/13), - Staff education on ambulation. Physical therapy screen; one assist for all mobility out of room and independent in the bedroom (initiated 5/20/13), - Offer bed at 8:00 P.M., resident may refuse (initiated 7/6/13), - Encourage out of room when in wheelchair (initiated 10/4/13), - Bed alarm (discontinued on 11/21/13), - Floor alarm mats to both sides of the bed at all times and bathroom door alarm(initiated 11/24/13), - Self releasing alarmed seatbelt (initiated 12/8/13), and - Two assist for transfers and ambulation (initiated 2/3/14). Review of the Accident/Incident Report, dated 5/17/13, indicated the resident had an unwitnessed fall in the bedroom at 9:15 P.M. The resident was last seen in the dayroom watching television. At the time of the fall, the resident was assessed as needing one assist for ambulation in the hallway and independent in the bedroom. Based on the facility investigation, no staff person was identified who assisted the resident ambulating to his/her bedroom. Therefore, the conclusion was made that the resident ambulated independently from the dayroom to the bedroom and fell . Education was given to the staff. Review of the Quarterly MDS Assessment, dated 6/10/13, indicated the resident was cognitively impaired, required assist of one for transfers, ambulation and toileting, and had two or more falls since the last assessment. Review of the Accident/Incident Report, dated 7/19/13, indicated the resident had an unwitnessed fall at 6:50 P.M. in the hallway. The resident was not being assisted with ambulation as planned. Review of the Accident/Incident Report, dated 8/8/13, indicated the resident had an unwitnessed fall at 10:00 P.M. in the bathroom. The report indicated the resident was last seen in the dayroom at 10:00 P.M. The resident was not assisted with toileting as planned, nor does the report indicate if the resident was offered to go to bed at 8:00 P.M. as planned. Review of the Annual MDS Assessment, dated 9/10/13, indicated the resident had cognitive impairment, required assist of one for transfers, ambulation and toileting, and had two or more falls since the last assessment. Review of the Accident/Incident Report, dated 11/21/13, indicated the resident had an unwitnessed fall at 1:50 P.M. in the bathroom. The report indicated the resident was in bed and ambulated to the bathroom. The bed alarm did not sound as planned nor was the resident assisted with toileting. Review of the Accident/Incident Report, dated 11/24/13, indicated the resident had an unwitnessed fall in the bathroom. The resident was not assisted with toileting per the plan of care. Review of the Nurse's Note, dated 12/8/13, (the facility unable to locate the Accident/Incident Report) indicated the resident had an unwitnessed fall in the hallway bathroom at 1:50 P.M. The resident was not assisted with ambulation when out of room as planned. During an interview on 3/6/14 at 8:15 A.M. with UM #2, she said the resident was not assisted as planned and said the alarm did not sound when the resident fell on [DATE]. On 3/6/14 at 8:25 A.M. after the interview, the surveyor and UM #2 observed Resident #3's bedroom. There was an alarmed floor mat on the left side of the resident's bed, not both sides as planned. UM #2 said the resident should have alarmed mats to both sides of the bed and was not sure what happened to the second one. Please refer to F323. 3. For Resident #5, the facility failed to apply the resident's Geri Sleeves (protective clothing for the arms) per the physician's orders [REDACTED]. Resident #5 was admitted to the facility in 11/2008 with a [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 9/24/13, indicated the resident had cognitive impairment and was totally dependent for transfers and bed mobility. Review of the physician's orders [REDACTED]. On 3/4/14 at 1:35 P.M., the surveyor observed Resident #5 in bed. The resident was not wearing Geri Sleeves. On 3/4/14 at 5:05 P.M., the surveyor observed the resident in the bedroom sitting in a chair with a lap tray. A CNA entered the bedroom with his/her dinner tray. The resident was not wearing Geri Sleeves. On 3/4/14 at 5:10 P.M., UM #2 entered the resident's room. The surveyor asked if the resident was supposed to be wearing Geri Sleeves. She said "yes, I will get them right away."

Based on observation, staff interview and record review, the facility failed to provide necessary care and services to manage pain for 1 Resident (#8) out of 16 applicable residents with pain in a total sample of 24 residents. Findings include: For Resident #8, the facility failed to administer pain medication prior to providing wound care for burns. Review of the facility policy for Burns, effective date 1/1/2000, indicated that a sign and symptom of a burn is extreme pain at the sight of the injury. Review of the facility policy for Pain Management, revised 10/2012, indicated that each resident shall receive appropriate pain management to relieve acute and chronic pain. Resident #8 was admitted to the facility in 5/2011 and readmitted in 11/2011 with [DIAGNOSES REDACTED]. Review of a Change in Status Minimum Data Set (MDS) Assessment, dated 1/17/14, indicated the resident had severe cognitive impairment. Review of the resident's plan of care for pain, initiated 1/30/14, indicated the following: - Administer medications as ordered. - Give 1/2 hour before treatments/care if needed. -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of a Nurse's Note, dated 2/28/14 at 11:02 P.M., indicated that the resident had spilled hot cocoa on him/herself at dinner in the main dining room. Bilateral upper and inner thighs presented "red with blisters." The resident complained of pain and was medicated with [MEDICATION NAME] (a narcotic pain medication) 20 milligrams (mg.)/1 milliliter (ml), 5 mg. with "positive effect." Review of the 2/2014 Treatment Administration Record indicated a treatment, initiated on 2/28/14, to cleanse bilateral and inner thighs with normal saline and apply Silver [MEDICATION NAME] 1% Cream ([MEDICATION NAME], a topical medication used to debride wounds), cover with [MEDICATION NAME] (a non-adhering dressing) and Kling. Change daily on the 7:00 A.M. to 3:00 P.M shift and as needed. Review of the Physician's Orders, dated 3/2014, indicated an order for [REDACTED]. sublingually (under the tongue) every 4 hours as needed for pain. On 3/5/14 at 1:00 P.M., the surveyor entered Resident #8's room accompanied by Unit Manager (UM) #2 and the Quality Improvement Nurse to observe a dressing change to the resident's bilateral and inner thighs. UM #2 removed the previously applied dressings from the resident's bilateral thighs. Two large open areas on the residents upper and inner thighs were observed. UM #2 said the open areas [MEDICAL CONDITION] by hot cocoa, and had originally been large areas of blisters. UM #2 cleansed the open area on the right inner thigh with normal saline. She then applied [MEDICATION NAME] Cream. The resident became agitated, started to call out and strike UM #2 repeatedly on the lower back. UM #2 then applied a [MEDICATION NAME] dressing to the area and wrapped it with Kling. She then cleansed the area on the left inner thigh with normal saline. When applying the [MEDICATION NAME] Cream, the resident again became agitated, calling out and began to strike UM #2 repeatedly on the lower back. The surveyor asked UM #2 if the resident had been medicated for pain recently. UM #2 said no. Review of the 3/2014 Medication Administration Record [REDACTED].M. on the morning of 3/5/14. Review of a Physician's progress note, dated 3/6/14, indicated the resident had areas of second [MEDICAL CONDITION] the right and left femoral and medial areas (bilateral upper and inner thighs). During an interview with the Director of Nurses on 3/5/14 at 2:15 P.M., she said the resident should have been medicated for pain prior to the dressing change. Please refer to F323.

Based on observation, record review and interviews the facility failed to ensure the environment was free of accidents and hazards for 1 (#8) Resident with a burn and failed to provide adequate supervision and assistive devices for 2 (#3 and #8) Residents out of 13 applicable residents with falls out of a total sample of 24 residents. Findings include: 1. Resident #8 was admitted to the facility in 5/2011 with a [DIAGNOSES REDACTED]. a. The facility failed to provide adequate supervision to prevent a burn. Review of the Occupational Therapy Discharge Summary, dated 10/15/13, indicated; - Patient requires set up and supervision for self feeding. Review of the Change in Status Minimum Data Set (MDS) Assessment, dated 1/17/14, indicated the resident had severe cognitive impairment and was supervised for eating. Review of the Accident/Incident Report, dated 2/28/14, indicated the resident was in the main dining room and was witnessed by two Activity Assistants dropping a cup of hot cocoa on his/her lap. The report indicated the resident sustained [REDACTED]. Further review of the report indicated the "Daily Shift Report", completed by the cook every evening before the meal service, said the coffee/hot water was 180 degrees Fahrenheit. During an interview with the Director of Nurses (DON) on 3/5/14 at 2:45 P.M., she called the Food Service Director (FSD) on the telephone and said the water was set too high and needs to be set at a lower temperature. She said she had not completed her investigation, five days later, and still needed to speak to the staff that were in the dining room at the time of the incident. She said that she had not changed any procedures yet, so the coffee/hot water continued to be served at the 180 degrees Fahrenheit. During an interview on 3/6/14 at 9:45 A.M. with the FSD, she said that when the hot water comes out of the coffee/hot water urn in the kitchen, it is consistently 180 degrees Fahrenheit. The water is poured directly into a carafe. She said that last night (3/5/14) she took temperatures of the water after it had been sitting in the carafe for up to one hour, and the temperature remained at 180 degrees Fahrenheit. During an interview on 3/6/14 at 10:10 A.M. with Activity Assistant #1, she said she had served Resident #8 hot cocoa the night the resident was burned. She poured the hot water from the carafe, mixed the hot cocoa and served it to the resident. She turned her back to speak to Activity Assistant #2 and heard the resident yell. She quickly turned back to the resident and noticed the resident had spilled the hot cocoa. Review of the Physician's Progress note, dated 3/6/10, indicated the resident had spilled hot liquid on him/herself about six days ago. He described the area as a "medial femoral area largely second degree burn with a question of darkened area to the upper portion of the right femoral portion." During observation of the dressing change on 3/6/14 at 1:35 P.M., the surveyor observed Unit Manger (UM) #2 remove the dressing from the resident's left thigh. A second degree burn, measuring 12 centimeters (cm.) in length x 9 cm. in width according to UM #2, was observed. The burn was covered with yellow slough, with two darker areas on the proximal edge. UM #2 removed the dressing on the right thigh. A second degree burn, measuring 19 cm. in length and 14 cm. in width according to UM #2, was observed. The burn was covered with yellow slough with islands of pink tissue. During an interview on 3/6/14 at 3:15 P.M. with Supervisor #1, she said that she always goes to the main dining room for dinner. The dining room is divided into two sections, an independent side and a supervised side. It is her responsibility to assist with the dinner meal and assign staff to the dining room. She said, usually there are three CNAs (Certified Nursing Assistants) and an Activity Assistant to help with dinner. She said that the Activity Assistants help serve drinks and food, and socialize with the residents. One CNA is assigned to the supervised side of the dining room. Two CNAs and Supervisor #1 are assigned to the independent dining room. On the night Resident #8 spilled the hot cocoa, the facility was short staffed, so one CNA was assigned to the middle of the dining room to supervise both the independent and supervised side, and one CNA was on the independent side with Supervisor #1. When the surveyor asked who was supervising Resident #8, she said that CNA #1 should have been because she was assigned to the middle. When the surveyor informed Supervisor #1 that CNA #1 did not see what had happened, Supervisor #1 could not say how the resident was being supervised. During an interview on 3/7/14 at 9:45 A.M. with the Director of Activities, she said that Activity Assistants are not to supervise or assist residents with their meal. Their purpose is more of a social role. She said they are allowed to serve drinks and meals once nursing staff have checked the meal tray. During an interview on 3/7/14 at 10:45 A.M. with the DON, she said that the dining room was short staffed the night the resident sustained [REDACTED].#1 was a capable person. She said that supervision, to her, means that a capable person is overseeing the residents. When the surveyor asked if Activity Assistants are trained to supervise residents during meal times, she said, "no." She said there should have been a CNA assigned to the supervised section of the dining room. b. The facility failed to provide adequate supervision and assistive devices to prevent two out of four falls. Review of the plan of care for falls, dated 10/14/12, included: -Assist of two for transfers and toileting -Encourage proper, well fitting, non-skid footwear, -Pressure Alarm at all times, and -Common area for monitoring when out of bed. Review of the Annual MDS Assessment, dated 9/17/13, indicated the resident had severe cognitive impairment, required assist of two for transfers and toileting, and had one fall without injury. Review of the Nurse's Note, dated 12/9/14, (facility unable to locate the Accident/Incident Report) indicated the resident had an unwitnessed fall (unclear what time, but was on the 3:00 P.M. - 11:00 P.M. shift). A CNA observed the resident sitting on the floor in the hallway with the wheelchair behind her. The alarm was attached to the chair, but was not functioning. Review of the Quarterly MDS Assessment, dated 12/17/13, indicated the resident had severe cognitive impairment, required assist of two for transfers and toileting, and had two or more falls without injury since the last assessment. Review of the Accident/Incident Report, dated 2/19/14, indicated the resident had an unwitnessed fall at 1:30 A.M. The resident was not wearing non-skid socks. On 3/5/14 at 8:55 A.M. the surveyor observed the resident sitting in a wheelchair with anti-rollback breaks and anti-tippers. The resident was eating breakfast. During an interview on 3/6/14 at 9:00 A.M. with UM #2, she said she was not sure what else she could do to prevent the resident from falling, but accidents happen sometimes. 2. For Resident #3, the facility failed to provide adequate supervision and assistive devices to prevent six out of nine falls. Resident #3 was admitted to the facility in 9/2012 with [DIAGNOSES REDACTED]. Review of the Accident/Incident Report, dated 5/17/13, indicated the resident had an unwitnessed fall in the bedroom at 9:15 P.M. The resident was last seen in the dayroom watching television. At the time of the fall, the resident required one assist for ambulation in the hallway and was independent in the bedroom. Based on the facilities investigation, no staff were identified who had walked the resident to his/her bedroom. The conclusion was that the resident ambulated independently from the dayroom to the bedroom and fell . Education was given to the staff. Review of the Quarterly MDS Assessment, dated 6/10/13, indicated the resident was cognitively impaired, required assist of one for transfer, ambulation and toileting, and had two or more falls since the last assessment. Review of the Accident/Incident Report, dated 7/19/13, indicated the resident had an unwitnessed fall at 6:50 P.M. in the hallway. The facility investigation indicated the resident ambulated from the dining room into the hallway, attempted to sit in a chair and missed. The resident was not being assisted with ambulation when out of his/her room. Review of the Accident/Incident Report, dated 8/8/13, indicated the resident had an unwitnessed fall at 10:00 P.M. in the bathroom. The report indicated the resident was last seen in the dayroom at 10:00 P.M. The resident was not assisted with toileting, nor does the report indicate if the resident was offered bedtime at 8:00 P.M. Review of the Annual MDS Assessment, dated 9/10/13, indicated the resident had cognitive impairment, required assist of one for transfers, ambulation and toileting, and had two or more falls since the last assessment. Review of the Accident/Incident Report, dated 11/21/13, indicated the resident had an unwitnessed fall at 1:50 P.M. in the bathroom. The report indicated the resident was in bed and ambulated to the bathroom. The bed alarm did not sound, nor was the resident assisted with toileting. Review of the Accident/Incident Report, dated 11/24/13, indicated the resident had an unwitnessed fall in the bathroom. The resident was not assisted with toileting. Review of the Nurse's Note, dated 12/8/13, (the facility unable to locate the Accident/Incident Report) indicated the resident had an unwitnessed fall in the hallway bathroom at 1:50 P.M. The resident was not assisted with ambulating when out of his/her room. During an interview on 3/6/14 at 8:15 A.M. the surveyor asked UM #2 how the facility is providing supervision and assistance to prevent Resident #3 from falling. UM #2 said "that's a good question," and was unable to answer. On 3/6/14 at 8:25 A.M., the surveyor and UM #2 went to observe Resident #3's bedroom. There was an alarmed floor mat to the left side of the resident's bed, not both sides per the care plan. UM #2 said that the resident should have alarmed mats to both sides of the bed and was not sure what happened to the second one.