Every finding on record at Southwood at Norwell Nursing CTR

Based on observation, record review, and interviews, the facility failed to ensure for one Resident (#12), out of a sample of 25 residents, that respiratory care was provided consistently with professional standards of practice. Specifically, the facility failed to ensure oxygen liter flow was being administered as ordered and to record the date and time of as needed (PRN) oxygen administration.Findings include:Review of the facility's policy titled Oxygen Administration, last revised October 2010, included but was not limited to:Preparation- Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Procedure-Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.DocumentationAfter completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record:-The date and time that the procedure was performed.-The name and title of the individual who performed the procedure.-The rate of oxygen flow, route, and rationale.-The frequency and duration of treatment.-The reason for PRN administration-The signature and title of the person recording the dataLIPPINCOTT NURSING PROCEDURES, 8th editionoxygen .all oxygen delivery systems should be checked at least once each day-verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribedDOCUMENTATION record the date and time of oxygen administration, the type of delivery device, the oxygen flow rate, the patient's vital signs, skin color, respiratory effort and breath sounds.Resident #12 was admitted to the facility in October 2023 with diagnoses including congestive heart failure (CHF-a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply).Review of the comprehensive Minimum Data Set (MDS) assessment, dated 9/9/25, indicated Resident #12 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 9 out of 15, and received oxygen therapy.Review of the medical record indicated Resident #12 was admitted to the hospital in July 2025 for altered mental status, lethargy and low oxygen levels.Review of Physician's Orders included but was not limited to:-Oxygen continuously at 2 liters (L) per minute via nasal cannula (NC- small, flexible tube that contains two open prongs intended to sit just inside your nostrils), as needed (7/14/25)-Oxygen at 2L/min NC to maintain SATs above 90% as needed for shortness of breath (7/14/25)-Monitor Oxygen Saturation and Respirations, Document total amount of minutes used during respiratory assessment every shift (7/14/25)Review of comprehensive care plans indicated but was not limited to:-Focus: Resident has oxygen therapy related to CHF, Respiratory failure (7/12/24; last revised 7/28/25)-Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness; Oxygen settings: O2 via nasal prongs at 2L continuous (7/28/25)-Goal: Resident will have no signs/symptoms of poor oxygen absorption through the review date (7/28/25; Target Date: 2/23/26) During an observation with interview on 12/30/25 at 9:46 A.M., the surveyor observed Resident #12 lying in bed asleep. An oxygen concentrator was at the bedside, was on, and set to a liter flow of 1.5 L/min per minute and not 2 L according to physician's orders. Oxygen tubing was attached to the concentrator and was connected to a nasal cannula that was in place in the Resident's nose.On 12/31/25 at 8:56 A.M., the surveyor observed Resident #12 sitting upright in bed eating breakfast. The oxygen concentrator was at the bedside, was on, and set to a liter flow of 1.5 L/min and not 2 L according to physician's orders. Oxygen tubing was attached to the concentrator and was connected to a nasal cannula that was in place in the Resident's nose.During an interview on 12/31/25 at 1:35 P.M., Resident #12's family member said the Resident has utilized oxygen continuously for quite a while. She said Resident #12 has a history of having pneumonia and the physician ordered oxygen so he/she can be more comfortable. Resident #12 was present during the interview and was observed sitting upright in bed. An oxygen concentrator was at the bedside, was on, and set to a liter flow of 1.5 L/min and not 2 L according to physician's orders.Review of the December 2025 Medication/Treatment Administration Records (MAR/TAR) failed to indicate nursing staff verified Resident #12 was receiving oxygen at 2 L/min according to physician's orders on the dates and times the surveyor observed the oxygen concentrator set at 1.5 L/min.During an interview with observation on 12/31/25 at 2:00 P.M., Nurse #1 and the surveyor observed Resident #12 sitting upright in bed. An oxygen concentrator was at the bedside, was on, oxygen tubing was attached to the concentrator and connected to a nasal cannula that was in place in the Resident's nose. Nurse #1 looked at the oxygen concentrator setting and said the liter flow was set to 1.5 L and should be set to 2 L. The nurse reviewed the MAR/TARs from July 2025 to December 2025 and said nursing staff did not document confirmation that the oxygen liter flow was set according to physician's orders and did not document its use.During an interview on 12/31/25 at 2:20 P.M., Unit Manager #1 said the nurses are supposed to confirm the liter flow and document the oxygen flow rate is set according to physician's orders as well as when it is in use. She said Resident #12 is supposed to be on 2 L/min and not 1.5 L/min.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with professional standards of practice. Specifically, the facility failed to:1. Ensure the medications were administered under direct supervision of a licensed nurse and not left at the bedside for Resident #6; and2. Ensure a medication cart remained locked when not in view/proximity of the nurse. Findings include:Review of the facility's policy titled Medication Administration-General Guidelines, dated January 2024, indicated but was not limited to the following:-Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.-When medications are administered by mobile cart taken to the resident's location, medications are administered at the time they are prepared.-The resident is always observed after administration to ensure that the dose was completely ingested.-When administering as needed (PRN) medications at times other than the medication pass, the dose may be prepared in the medications cart storage area and taken to the resident's bedside, leaving the cart locked and secured.-During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse.1. Resident #6 was admitted to the facility in March 2021 with diagnoses which include major depressive disorder, osteoarthritis, and fibromyalgia.Review of the medical record indicated Resident #6 was advised of their right to self-administer medication on 8/22/21 and indicated he/she wished for the nursing staff to administer their medications.During an interview with observation on 12/30/25 at 9:51 A.M., the surveyor observed Resident #6 in bed and on the overbed table there was a medication cup containing least twelve (12) medications (one round green tablet, one blue and white capsule, one yellow capsule, two oval white tablets, one red oval tablet, one red round tablet, one pink round tablet, one peach round tablet, one beige round tablet, one white capsule, and one white round tablet). Resident #6 said, new nurses stay and make sure I take my medications, but some nurses just leave them. The x-ray technician just left my room, so I still need to take my medications.During an interview with observation on 12/30/25 at 3:08 P.M., the surveyor observed Resident #6 sitting in bed and on the overbed table there was a medication cup containing four medications (one yellow capsule, 2 white oval tablets, one small white oval tablet). Resident #6 said he/she takes one Gabapentin, two Tylenol, and one Tramadol in the afternoon for pain. Resident #6 said some nurses just leave the medications and some will stay and watch to be sure he/she takes all the medications.Review of the December 2025 Medication Administration Record (MAR) indicated Resident #6 had an order to administer the following medications at 8:00 A.M.:-Bupropion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG (antidepressant) Give 1 tablet by mouth two times a day-Docusate Sodium Oral Capsule 100 MG (stool softener) Give 100 mg by mouth two times a day-Duloxetine HCl Oral Capsule Delayed Release Sprinkle 60 MG (antidepressant) Give 1 capsule by mouth two times a day for depression-Gabapentin Oral Capsule 300 MG (anticonvulsant) Give 1 capsule by mouth two times a day Review of the December 2025 MAR indicated Resident #6 had an order to administer the following medications at 9:00 A.M.:-Acidophilus Oral Capsule (Lactobacillus probiotic) Give 1 capsule by mouth in the morning for supplement-Aspirin Oral Tablet Chewable 81 MG (pain reliever) Give 1 tablet by mouth one time a day-Cholecalciferol Oral Tablet 25 MCG (1000UT) (Vitamin D3) Give 1 tablet by mouth one time a day-Clopidogrel Bisulfate Oral Tablet 75 MG (antiplatelet) Give 1 tablet by mouth one time a day-Cranberry Oral Tablet 400 MG (supplement) Give 1 tablet by mouth one time a day-Multivitamin Oral Tablet Give 1 tablet by mouth-Entresto Oral Tablet 24-26 MG (treats heart disease) Give 50 mg by mouth two times a day for hypertension-Tramadol HCl Tablet 50 MG (pain reliever) Give 1 tablet by mouth three times a day for back pain Review of the December 2025 MAR indicated Resident #6 had an order to be administered the following medications at 2:00 P.M.:-Acetaminophen Oral Capsule 500MG (pain reliever), Give two capsules by mouth three times a day for pain. Review of the December 2025 MAR indicated Resident #6 had an order to administer the following medications at 3:00 P.M.:-Gabapentin Oral Capsule 300 MG Give 1 capsule by mouth two times a day-Tramadol HCl Tablet 50 MG Give 1 tablet by mouth three times a day for back pain Review of the December 2025 MAR indicated Nurse #2 administered all medications to Resident #6 at times indicated as ordered.During an interview on 12/30/25 at 3:23 P.M., Nurse #2 said she left the medications at the bedside and was not aware the Resident had not taken his/her morning medications right away. Nurse #2 said the Resident needed to use the restroom during afternoon medications so she left the medication at the bedside and told the Resident she would be back. Nurse #2 said Resident did not have an order for self-administration.During an interview on 12/30/25 at 3:43 P.M., Unit Manager #2 said medications should not have been left at the Resident's bedside.During an interview on 12/31/25 at 9:09 A.M., the Director of Nursing said medications should not have been left at the bedside.2. On 12/30/25 at 3:05 P.M., 3:20 P.M., 3:47 P.M., and 4:10 P.M., the surveyor observed the medication cart on Hall N of the Rosewood Unit to be unlocked and out of Nurse #2's line of sight.The medication cart had remained unlocked for a total of 1 hour and 5 minutes before it was secured by Nurse #2. During an interview on 1/2/26 at 12:34 P.M., Unit Manager #2 said the expectation is the medication cart will always be locked when not in use.During an interview on 1/2/26 at 12:44 P.M., the Assistant Director of Nursing said the facility's expectation is that the medication cart should always be locked.

Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for two Residents (#29 and #71), out of a total sample of 23 residents, and for one Resident (#368) out of three closed records. Specifically, the facility failed: 1. For Resident #29, to ensure physician's orders were in place for the use and management of an implanted continuous glucose monitoring device; 2. For Resident #368, to accurately reconcile and administer medication according to physician's orders; and 3. For Resident #71, to follow a physician's order to check the Resident's apical pulse (AP) (pulse point on your chest at the bottom tip of your heart) to ensure it was greater than 56 prior to administering his/her Atenolol (beta blocker, treats high blood pressure, works by slowing down your heart rate making it easier for your heart to pump blood around your body) medication. Findings include: 1. Resident #29 was admitted to the facility in July 2023 with diagnoses including diabetes mellitus, type 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #29 is cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, requires extensive assistance from staff for activity of daily living and receives insulin injections. During an interview on 9/26/23 at 9:25 A.M., Resident #29 said he/she has a Libre sensor device on his/her left arm and uses an electronic device to check his/her blood sugar level. The Resident said the sensor is changed every two weeks and alternates arms. Resident #29 said he/she is unable to remove and insert the new sensor on his/her own, and he/she had taught Unit Manager #1 and Nurse #2 to insert the new sensor every 14 days. Review of [NAME] Freestyle Libre Continuous Glucose Monitoring (CGM- https://www.freestyle.[NAME]/us-en/home.html), included but was not limited to: -the Libre CGM is a small sensor-based system that provides real-time glucose readings day and night, without fingersticks; -The sensor is applied to the back of the upper arm with a simple, disposable device called an applicator. When the sensor is applied, a small (5 millimeter) filament is inserted just under the skin and held in place with a small adhesive pad; -There is a needle (sharp) in the applicator to insert the filament in the back of your upper arm so the sensor can monitor your glucose; -The sensor lasts up to 14 days and it is recommended to rotate application site of the sensor between arms. Review of the Physician's Orders included but was not limited to: -Insulin Lispro Injection Solution, 100 unit/milliliters (mL), inject as per sliding scale subcutaneously before meals (7/7/23): -if 100 - 139= no insulin required; -140 - 180=2 units; -181 - 220=4 units; -221 - 260=6 units; -261 - 300=8 units; -301 - 350=10 units; -above 351, call Physician Further review of the Physician's Orders failed to indicate orders for the use of the Libre continuous glucose monitoring device to implement the sliding scale, and orders to remove and reinsert the sensor device, alternating arms, every 14 days. Review of July, August, and September 2023 Medication Administration/Treatment Administration Records (MAR/TAR), indicated sliding scale insulin was administered on 166 occasions without an order to obtain blood glucose levels. Further review of the medical record failed to indicate any Physician or Nurse Practitioner notes to acknowledge Resident #29's use of the Libre continuous glucose monitoring device and instructions for its use. During an interview on 9/28/23 at 8:23 A.M., Unit Manager #1 said Resident #29's family brought in the Libre device two or three days after he/she was admitted to the facility and has inserted it into the Resident's arm several times herself. The Unit Manager reviewed the medical record and said there was no physician's order to insert the sensor device to the Resident's arm every 14 days, and no order for use of the device to obtain glucose levels to implement the insulin sliding scale. During an interview on 9/28/23 at 11:50 A.M., Nurse #2 said Resident #29 taught her how to change the Libre monitoring sensor. She said she changed it only once about a week ago, and did not document it in the medical record. During an interview on 9/29/23 at 9:15 A.M., Nurse Practitioner #1 said she was not aware Resident #29 had a Libre continuous glucose monitoring device until last week when the Resident told her about it. The NP said the sensor device has a prong that gets placed through the skin and remains in place for two weeks, then needs to be changed. She said she did not write any orders for Nursing to change the device or use the device to obtain glucose levels to implement the insulin sliding scale. 2. Resident #368 was admitted to the facility in August 2023 for a 9-day respite stay (8/17-8/26) with diagnoses that included hyperlipidemia (high cholesterol), anxiety, hypothyroidism (low thyroid hormone), and dementia. Review of the facility's policy titled Reconciliation of Medications on Admission (Revised July 2017), indicated but was not limited to the following: Purpose: The purpose of this procedure is to ensure medication safety by accurately accounting for medications, routes, and dosages upon admission to the facility. Preparation: -Gather the information needed to reconcile the medication list: *All prescription and supplement information from the resident/family during the medication history. *Most recent medication administration record (MAR), if this is a readmission. General Guidelines: -Medication reconciliation is the process of comparing pre-discharge medications to post discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency route and indication for use for the purpose of preventing unintended changes or omissions at transition points in care -Medication reconciliation reduces medication error and enhances resident safety by ensuring that the medications the resident needs and has been taking continues to be administered without interruptions, in the correct dosage and routes, during the admission/ transfer process. -Medication reconciliation helps ensure that all medications, routes, and dosages have been accurately communicated to the attending Physician and care team. -Documentation: Document the medication discrepancy on the medication reconciliation form (assessment). During an interview on 9/29/23 at 12:44 P.M., Nurse #7 said that when Resident #368 was admitted to the facility (from the community), she called the Resident's Health Care Proxy (HCP) to review and verify the accuracy of the medication list provided by the Resident's community Physician. She said she verified the medications to be administered by placing/writing a checkmark next to each medication during the review with the HCP of the Resident's current medications. The Nurse said she reviewed the medications with the Physician, who then ordered the medications to be administered by the facility. Nurse #7 further said that when the Resident was admitted , the HCP had provided the facility with the Resident's home medications. The home medications were separated into two pre-filled blister packages (packs), one blister pack for the A.M. medications and another blister package for the P.M. medications. Within each bubble of the blister pack, there were multiple medications. Nurse #7 said the top of each blister pack indicated which medications (the names) were contained in each bubble with a corresponding picture of each medication in the bubble. Review of the medical record indicated a home medication list from the Resident's community provider (dated 8/2/23) which included but was not limited to the following medications: -Zoloft (antidepressant) 100 milligrams (mg), take 1.5 tablets (150 mg total) daily. -Synthroid (synthetic hormone) 50 micrograms (mcg), take one tablet daily. -Crestor (used to lower cholesterol) 40 mg tablet, take one tablet daily. -Abilify (antipsychotic) 2 mg tablet, take 1 tablet daily. Also noted on the medication list was a handwritten checkmark next to each medication, which Nurse #7 indicated she had done while reviewing the medications with the HCP. Review of the August 2023 Physician's Orders included, but was not limited to: -Zoloft 100 mg, give 100 mg by daily at 8:00 A.M. -Crestor 40 mg, give 1 tablet daily at 8:00 A.M. -Abilify 2 mg, give 1 tablet daily at 8:00 A.M. The order for Zoloft was inaccurately transcribed as 100 mg daily and not 150 mg daily as indicated on the home medication list. Although the order for Synthroid was verified with the Resident's HCP and approved by the Physician, it was not included on the physician's orders. Review of the August 2023 Medication Administration Record indicated Zoloft 100 mg was administered to Resident #368 from 8/18/23 to 8/22/23 instead of 150 mg, and Abilify 2 mg was not administered on three occasions and noted as being unavailable. During an interview on 9/29/23 at 1:32 P.M., the Director of Nursing (DON) said she became aware of the medication discrepancies after Resident #368 was discharged from the facility and she received a telephone call from his/her HCP with a concern that the Resident had not received all of his/her medications while at the facility. The DON said she initiated an investigation. She said not all of the nurses were comfortable using the Resident's blister cards brought in from home, and some nurses used the electronic medication dispensing device to retrieve the medication. She said she was not told that Abilify was not available in the electronic medication dispensing device, and three doses were not administered as ordered. The DON said the Zoloft in the blister pack from home was 100 mg and not 150 mg according to the home medication list, and it should have been discovered upon medication reconciliation at the time of admission and each time medications were administered. She said although the Synthroid order was not transcribed onto the physician's orders, it was in the blister card and was administered on all days except when the nurses retrieved medications from the electronic medication dispensing device on 8/18/23 and 8/20/23. 42742 3. Resident #71 was admitted to the facility in July 2023 with diagnoses including essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition). Review of the manufacturer's instructions for use (IFUs), revised September 2015, indicated but was not limited to the following: -Atenolol tablets USP are indicated for the treatment of hypertension, to lower blood pressure. Adverse Reactions: -Bradycardia (slowed heart rate), dizziness, light-headedness Review of [NAME] Nursing Procedures, eighth edition, 2019, indicated but was not limited to the following: Safe Medication Administration Practices Verifying the medication order: -Follow a written or typed order or an order entered into a computer order-entry system. -Explain the name and purpose of each medication. Discuss important and common adverse effects for each medication and what to do if the patient experiences any symptoms. Review of the facility's policy titled Medication Administration-General Guidelines, dated February 2019, indicated but was not limited to the following: -Medications are administered in accordance with written orders of the prescriber. On 9/28/23 at 8:53 A.M., the surveyor observed Nurse #3 prepare and administer 9:00 A.M. morning medications to Resident #71 in his/her room. Nurse #3 administered the Resident's Atenolol and did not check vital signs including a heart rate prior to the administration and did not explain the medication including any potential adverse effects to the Resident. After administration, the surveyor asked Nurse #3 if there were parameters (specific instructions that you can measure) for the medication. Nurse #3 said no and said the last time vital signs were taken was on 9/23/23, five days prior. Review of the current Physician's Orders on 9/28/23 at 9:55 A.M. indicated the following: -Atenolol Oral Tablet, give 12.5 milligrams (mg) by mouth one time a day related to essential (primary) hypertension, hold if AP <56, 7/8/23 Review of the September 2023 Medication Administration Record (MAR) failed to indicate documentation of the Resident's AP by Nurse #3 along with the entry that she had administered the Atenolol per her initials on 9/28/23. Further review of the medical record failed to indicate the Resident's heart rate had been assessed since 9/23/23. During an interview on 9/28/23 at 10:40 A.M., the surveyor reviewed the medical record with Nurse #3 who said there was an order to hold the Atenolol if the Resident's AP was less than 56, but she did not do it and should have. The surveyor asked to review the electronic MAR system with Nurse #3 who, when she clicked on the Atenolol medication, said it indicated a pop-up display with special instructions to hold the medication if the AP was less than 56. Nurse #3 said she did not see it previously. She said administering the medication if the heart rate is too low can be potentially harmful as it could lower the heart rate further. During an interview on 9/28/23 at 10:58 A.M., the Director of Nursing (DON) said parameters should have been documented in supplementary documentation on the electronic MAR, but there was no separate order attached to do so which would be where nursing staff would document it along with the administration. The DON said the AP should have been checked as the medication could decrease the heart rate. The DON said the last vital signs documented for Resident #71 were on 9/23/23.

Based on policy review, record review, and interview, the facility failed to provide behavioral health services for two Residents (#102 and #24), out of a sample of 23 residents. Specifically, the facility failed to ensure collaboration with psychiatric (psych) services as deemed necessary according to the behavioral health psychiatric provider and the Residents' plan of care. Findings include: 1. Review of the facility's policy titled Behavioral Health Services, dated as revised on ,d+[DATE], indicated but was not limited to the following: - The facility will provide behavioral health services as needed to residents to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the plan of care - Behavioral health services are provided to residents, as needed, as part of the interdisciplinary, person-centered approach Resident #102 was admitted to the facility in [DATE] with diagnoses including dementia, psychosis, anxiety, and major depressive disorder. The Resident is currently receiving hospice services. Review of the current care plans for Resident #102, included but were not limited to the following: Focus: Altered mood pattern related to anxiety, depression, forgetful, sleep pattern [sic] Goal: Will have improved mood through review date and will have improved sleep pattern through review date Interventions: Behavioral health consults as needed (psych) Review of the medical record for Resident #102 indicated the Resident received behavioral health services through the facility contracted psych group. Further review of the progress notes indicated the last psych progress note, dated [DATE], indicated the following: - Resident is seen for follow up and medical management of dementia and behavioral disturbance - Return for follow up in 12 weeks or earlier if needed There were no psych progress notes available following the [DATE] note, approximately 22 weeks prior to the record review by the survey team. During an interview on [DATE] at 3:47 P.M., Unit Manager (UM) #2 said the Resident is followed by the facility psych team regardless of his/her being on hospice services. She said the Resident can be verbally aggressive and paranoid and was last seen by behavioral health services on [DATE]. She said the Resident was supposed to be seen 12 weeks following the last visit and was not. During an interview on [DATE] at 4:55 P.M., the Assistant Director of Nurses (ADON) said the expectation is that psych would track and maintain the schedule of visits for each resident as they determine it to be necessary. She said the Resident should have been seen sometime in July and was not. She said the Resident did not receive behavioral health services in accordance with the plan of care. 2. Resident #24 was admitted to the facility in [DATE] with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Review of the current care plans for Resident #24, included but were not limited to the following: Focus: Altered mood problem related to anxiety and confusion Goal: Will have improved mood state with happier calmer appearance through review date Interventions: Behavioral health consults as needed (psych) Review of the medical record for Resident #24 indicated the Resident received behavioral health services through the facility contracted psych group. Further review of the progress notes indicated the last psych progress note, dated [DATE], indicated the following: - Resident is seen today ([DATE]) for increased depression, increased crying episodes and looking for his/her deceased spouse. - Resident exhibits symptoms of anxiety and symptoms of depressive disorder with increase in weepy episodes - Behaviors Resident is being seen for are new - Recommendations/Plan: start Trazodone (an antidepressant) 25 milligrams (mg) twice a day and 75 mg at bedtime to target crying episodes - call for worsening mood or behavior - follow up return in ,d+[DATE] weeks or earlier, if needed There were no psych progress notes available following the [DATE] note, approximately 17 weeks prior to the record review by the survey team. Further record review indicated the Resident had been started on Ativan (an anti-anxiety medication) by his/her attending physician in an effort to decrease episodes of anxiety, with the current order started [DATE], without notification or collaboration with behavioral health services. During an interview on [DATE] at 9:45 A.M., UM #2 said the Resident's last visit with psych services was on [DATE] and the Resident should have had a follow up visit three to four weeks after. She said the Resident was not seen by the behavioral health services team as they should have been. During an interview on [DATE] at 10:05 A.M., the Director of Nurses said neither Resident received behavioral health services as he/she should have according to the last available note from psych services and the facility struggles to monitor the visits and frequency of behavioral health services since they are always getting new providers. She said the system of ensuring the services were rendered as deemed necessary needed some work and the expectation was not met to ensure the Residents were seen as deemed necessary by the behavioral health services team. During an interview on [DATE] at 10:21 A.M., the Social Worker said the facility has experienced some difficulty with change over on the psych services team and the expectation is that they are providing services as needed to each individual resident. She said these two Resident (#102 & #24) have not received the necessary behavioral health services as they should have according to the documentation in their medical records and the expectations have not been met.

Based on observation, interview, and policy review, the facility failed to ensure five Residents (#15, #96, #32, #40, and #8), out of a total sample of 23 residents, had their call lights accessible in accordance with the facility policy. Findings include: Review of the facility's policy titled Answering the Call Light, dated as revised 9/2023, indicated but was not limited to the following: - The purpose of the call light is to ensure timely responses to resident's requests and needs - ensure the call light is accessible to the resident when in bed and from the floor Resident #8 was admitted to the facility in June 2021. Review of the most recent Minimum data set (MDS) indicated a Brief interview for Mental Status (BIMS) score of 14 out of 15, indicating the Resident is cognitively intact. Resident #32 was admitted to the facility in November 2012. Review of the most recent MDS indicated a BIMS score of 4 out of 15 indicating the Resident is severely cognitively impaired. Resident #40 was admitted to the facility in July 2023. Review of the most recent MDS indicated a BIMS score of 5 out of 15 indicating the Resident is severely cognitively impaired. Resident #96 was admitted to the facility in March 2022. Review of the most recent MDS indicated a BIMS score of 13 out of 15 indicating the Resident is cognitively intact. Resident #15 was admitted to the facility in February 2022. Review of the most recent MDS indicated a BIMS score of 3 out of 15 indicating the Resident is severely cognitively impaired. During the following days and times the surveyor made the following observations and interviews: 9/26/23: - 8:29 A.M., Resident #8's call light was clipped to itself at the plug by the wall and out of reach of the Resident who was in the bed. Resident #8 said the call light falls on the floor sometimes and the staff keep it up there so it will not fall; he/she was observed to try to reach for the call light and said he/she could not reach it and would have to call out if they needed the staff. - 8:36 A.M., Resident #32's call light was clipped to itself up on the wall behind the bed out of reach of the Resident who was in bed. Resident #32 said he/she does not know how to call for help but would yell if he/she needed something. - 8:39 A.M., Resident #40's call light was clipped to itself up by the plug on the wall behind the Resident's bed out of reach of the Resident who was sitting on the edge of the bed. Resident #40 said if he/she needed something or someone he/she would have to walk down the hall to find someone and said he/she was unaware there was a way to do so from inside his/her room. - 8:44 A.M., Resident #96's call light was clipped to itself up by the wall plug in, out of reach of the Resident who was sitting on his/her bed. Resident #96 said he/she was told the call light was for emergencies only and not to use it unless it was an emergency, which is why the call light is clipped up against the wall and not in reach. He/she said they would walk down the hall and look for a staff member if he/she needed something that was not urgent. - 8:58 A.M., Resident #15's call light was on the floor underneath his/her roommate's bed, out of reach of the Resident who was lying in bed. Resident #15 said if he/she needed help he/she would use the telephone to call their daughter or try to go look down the hall for someone. - 1:44 P.M., Resident #96's call light was not in reach of the Resident, who was sitting in his/her room chair by the window. The call light was clipped to itself up on the wall by the plug. - 1:49 P.M., Resident #32 was in bed with the call light not in reach; the call light was clipped to itself up against the wall behind the Resident's bed. - 1:51 P.M., Resident #8 was in his/her room sitting on the edge of the bed; the call light was not in reach and observed to be clipped to itself up against the wall by the plug in. - 2:03 P.M., Resident #15 was in his/her room chair with a family member present. The call light was on the floor in between the two beds and out of reach of the Resident. The family member for Resident #15 said the Resident does not always remember to use the call light for assistance, especially if it is out of reach or out of sight. She said if the call bell is very close to the Resident and can be visualized the Resident is more likely to use it to call for assistance. She said the Resident is a fall risk and she should inquire about alternate devices for the Resident to notify the staff when he/she needs assistance. 9/27/23: - 8:09 A.M., Resident #15's call light was placed on the roommate's bed and out of reach of the Resident who was lying in bed. - 8:13 A.M., Resident #40's call light was clipped up by the plug in portion of the cord at the wall behind the bed, out of reach of the Resident who was lying in bed. - 8:14 A.M., Resident #32's call light was clipped to itself behind the Resident's bed up against the wall, out of reach of the Resident who was lying in bed. - 8:23 A.M., Resident #96's call light was clipped to itself behind the Resident's bed up by the wall plug, out of reach of the Resident who was lying in bed. Resident #96 told the surveyor to not touch the call light because it is for emergencies only and they can only use it in the event of an emergency. During a tour of the Laurelwood unit on 9/27/23 at 9:40 A.M., the surveyor observed the call lights to be out of reach of Residents #8, #32, #40, #15 and #96. During an interview with observation on 9/27/23 at 9:47 A.M., Certified Nurse Assistant (CNA) #3 said she was assigned to Residents #8, #32, #40 #15, and #96 for the day shift. She walked the unit with the surveyor and observed Resident #8's call light not in reach. She said she forgot to give it to the Resident after making the bed. Resident #32's call light was observed clipped behind the Resident's bed and she said she did not notice that the Resident didn't have his/her call light. She observed both Resident #96 and #40 without their call lights in reach and said these Residents are care planned to not have their call lights in reach and they do not like them attached to or draped across their beds. She said she was unaware that Resident #96 believed he/she was not to use their call light unless there was an emergency. She observed Resident #15 without his/her call light in reach and said the call light is frequently on the floor and should be clipped to the bed but is not. She said CNAs are supposed to do one hour safety checks on the residents on the Laurelwood unit throughout the day and that includes ensuring call lights are in reach. She said she must not have been paying attention, but regardless of their cognitive ability all the residents are required to have a call light in reach at all times and they obviously did not. Review of the current care plans for Residents #96 and #40 failed to indicate the Resident's preference was to not have a call light in reach or the use of any alternative method for calling for assistance. During an observation with interview on 9/27/23 at 9:58 A.M., Nurse #4 said she is unaware of any resident that declines to have a call light in reach or available. She said if a resident had a preference for an alternative call method or not to use a traditional call bell on the call light system that would be documented in the care plans and she was not aware of any resident who had that intervention or provision. She said for all residents call lights should be in reach at all times regardless of their cognitive ability. She observed Residents #8, #32, #40, #15 and #96 with the surveyor, none of the five observed Residents had their call lights in reach or accessible to them. She said all five Residents should have had access to their call lights and they should have been in reach. During an interview on 9/27/23 at 3:56 P.M., Unit Manager #2 said she was made aware of the call light concerns earlier in the day and the call lights are required to be in reach of all residents regardless of their cognitive abilities. She said there are no residents on the unit who are care planned to not have their call bells in reach. During an interview on 9/28/23 at 12:21 P.M., the Director of Nurses said the policy and expectation is that all residents have their call bells in reach and accessible at all times and the expectation was not met as it should have been.

Based on record review, policy review, and interview, the facility failed to ensure that staff developed and implemented a baseline care plan within 48 hours of the resident's admission to address the Resident's constipation management identified in the hospital discharge summary, for one Resident (#63), in a total sample of 23 residents. Findings include: Review of the facility's policy titled Care Plans-Baseline, undated, included but was not limited to: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Resident #63 was admitted to the facility in February 2020 with diagnoses which included muscle weakness and transient cerebral ischemic attack. Review of the Hospital Discharge Summary, dated 7/21/23, indicated due to constipation found on Computed Tomography (CT), we increased his/her laxative, increased Colace from daily to twice daily. Continued MiraLAX and Senna. Added as needed laxative and suppository. Please follow progress and adjust as needed. Review of the medical record indicated no baseline care plan was developed to address the Resident's constipation care needs. The baseline/comprehensive care plan failed to include any person-centered care instructions or interventions to address the Resident's constipation management. During an interview on 9/29/23 at 4:30 P.M., Unit Manager #3 reviewed Resident #63's medical record. She said a baseline care plan or comprehensive care plan should have been developed with individualized, person-centered interventions to address the Resident's constipation within 48 hours of the Resident's admission. She said it was not done.

Based on policy review, observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#29), out of 23 sampled residents. Specifically, the facility failed to develop a care plan to address the Resident's use of a continuous glucose monitoring device. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated but was not limited to the following: - comprehensive care plans include measurable objectives and timetables to meet a resident's psychosocial needs - the comprehensive care plan should reflect currently recognized standards of practice for problem areas Resident #29 was admitted to the facility in July 2023 with diagnoses including diabetes mellitus, type 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #29 is cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15, requires extensive assistance from staff for activity of daily living and receives insulin injections. During an interview on 9/26/23 at 9:25 A.M., Resident #29 said he/she has a Libre sensor device that continuously monitors his/her blood glucose and is implanted in his/her left arm. The Resident said he/she uses an electronic device to check his/her blood sugar level. The Resident said the sensor is changed every two weeks and is alternated between the right and left arm. Resident #29 said he/she is unable to remove and insert the new sensor on his/her own and must have it inserted by Nursing staff. Review of [NAME] Freestyle Libre Continuous Glucose Monitoring (CGM- https://www.freestyle.[NAME]/us-en/home.html), included but was not limited to: -the Libre CGM is a small sensor-based system that provides real-time glucose readings day and night, without fingersticks; -The sensor is applied to the back of the upper arm with a simple, disposable device called an applicator. When the sensor is applied, a small (5 millimeter) filament is inserted just under the skin and held in place with a small adhesive pad; -There is a needle (sharp) in the applicator to insert the filament in the back of your upper arm so the sensor can monitor your glucose. Review of Resident #29's comprehensive care plans failed to indicate a care plan had been developed to address the Resident's use of the Freestyle Libre Continuous Glucose Monitoring system. During an interview on 9/28/23 at 8:23 A.M., Unit Manager #1 reviewed Resident #29's medical record. She said there was no care plan for the Resident's use of the continuous glucose monitoring system, but a care plan should have been developed for its use.

Based on observation, record review, and interview, the facility failed to ensure staff provided respiratory care consistent with professional standards for one Resident (#29), out of a total sample of 28 residents. Specifically, the facility failed to ensure proper care and storage of the Resident's CPAP (Continuous Positive Airway Pressure) machine to reduce risk of infection. Findings include: Review of the facility's policy titled CPAP/BIPAP Support, undated, included but was not limited to: - Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed humidifier use clean distilled water only in the humidifier chamber. -Clean humidifier weekly and air-dry. -Filter cleaning: Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. -Mask, Nasal Pillows and Tubing: Clean daily by placing in warm soapy water and soaking agitating for 5 minutes mild dish detergent is recommended. Rinse with warm water and allow to air dry between uses. -Headgear Strap: Wash in warm water and mild detergent as needed. Allow to air dry. According to the U.S. Food and Drug Administration (fda.gov), CPAP Machine Cleaning: Ozone, UV Light Products Are Not FDA Approved, included but was not limited to: - All types of CPAP machines need to be cleaned regularly so that these germs and contaminants do not grow inside of your equipment and make you sick. - Germs from your lungs, throat, or mouth can get into the CPAP mask or hose as you breathe in and out during sleep, or germs on your skin may get transferred to the CPAP mask or hose. Dust, mold, or other allergens may also get into the CPAP mask or hose. - All types of CPAP machines need to be cleaned regularly so that these germs and contaminants do not grow inside of your equipment and make you sick. Resident #29 was admitted to the facility in July 2023 with diagnoses including sleep apnea and legal blindness. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/11/23, indicated Resident #29 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15, has highly impaired vision, has a diagnosis of sleep apnea and uses non-invasive mechanical ventilation (CPAP). On 9/26/23 at 9:25 A.M., the surveyor observed Resident #29's CPAP machine on top of the Resident's nightstand. The headgear strap, nasal piece and tubing were lying on top of the machine. The nasal piece had droplets of condensation on all surfaces. The Resident said he/she uses the machine every night and replaces the nasal piece weekly his/herself. The Resident said neither he/she nor the staff clean the nasal piece daily or the CPAP unit weekly. On 9/27/23 at 8:17 A.M., the surveyor observed Resident #29's CPAP machine on top of the Resident's nightstand. The headgear strap and nasal piece were lying on top of the machine. The nasal piece had droplets of condensation on all surfaces. On 9/28/23 at 8:00 A.M., the surveyor observed Resident #29's CPAP machine on top of the Resident's nightstand. The headgear and nasal piece were lying on top of the machine. The nasal piece had droplets of condensation on all surfaces. Review of the medical record indicated the following Physician's Order: -CPAP nose piece at hour of sleep. Fill with distilled water. Settings 9cmH20, every evening shift (8/2/23) There were no orders for cleaning the CPAP headgear, nasal piece, tubing and machine according to facility policy and accepted standards of practice. Review of the August 2023 and September 2023 Medication Administration Record/Treatment Administration Records (MAR/TAR) indicated he/she wore the CPAP nose piece every evening from 11:00 P.M. to 7:00 A.M. during the month of August and September. During an interview on 9/28/23 at 8:47 A.M., Unit Manager #1 and the surveyor observed Resident #29's CPAP machine, headgear strap and nasal piece lying on top of the machine. She reviewed the medical record and said there are no orders in place for cleaning and storing the CPAP machine and equipment. The Unit Manager said they should be cleaned according to facility policy and stored in a plastic bag to prevent potential environmental contaminants.

Based on policy review, record review, and interview, the facility failed to ensure one Resident (#368) was free from a significant medication error, out of three closed records. Specifically, the facility failed to ensure three medications were administered to the Resident as ordered by the Physician. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. A nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. A nurse licensed by the Board shall document the handling, administration, and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of practice. Review of the facility's policy titled Medications Acquired or Brought to the Facility by a Resident or Responsible Party From an Outside Source, February 2019, indicated but was not limited to: -Medications acquired or brought into the facility by a resident or responsible party from an outside source are used only upon written order of the resident's attending practitioner; after the contents are verified, and if the packaging meets the facility's guidelines. -Use of medications acquired from an outside source is allowed only when the medication was ordered by the resident's practitioner, and was entered in the resident's Medication Administration Record (MAR) by the facility. Review of the facility's policy titled Unavailable Medications, February 2019, indicated but was not limited to: -The facility must make every effort to ensure that medications are available to meet the needs of each resident. -Nursing staff shall: -Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. -Obtain a new order and cancel/discontinue the order for the non-available medication. Resident #368 was admitted to the facility in August 2023 for a 9-day respite stay. The Resident had diagnoses including hyperlipidemia (high cholesterol), anxiety, and hypothyroidism (low thyroid hormone). During an interview on 9/29/23 at 12:44 P.M., Nurse #7 said when Resident #368 was admitted to the facility, she called the Resident's Health Care Proxy (HCP) to review and verify the medication list provided by the Resident's community Physician. She said she placed a checkmark next to each medication on the list after reviewing it with the HCP to indicate it was accurate. The Nurse said she then reviewed the medications with the Physician, who approved them. Nurse #7 said the Resident brought his/her medications from home in two pre-packaged multidose blister cards. She said the blister cards were filled with medications in two blisters labeled as either A.M. and P.M. Nurse #7 said the top of the blister cards listed each medication and dose packaged in the blisters as well as a picture of each pill. Review of the medical record indicated an 8/2/23 home medication list from the Resident's community provider including the following medications with handwritten checkmarks next to each medication: -Zoloft (antidepressant) 100 milligrams (mg), take 1.5 tablets (150 mg total) daily. -Synthroid (synthetic hormone) 50 micrograms (mcg), take one tablet daily. -Abilify (antipsychotic) 2 mg tablet, take 1 tablet daily. Review of the August 2023 Physician's Orders included but was not limited to: -Zoloft 100 mg, give 100 mg by daily at 8:00 A.M. -Abilify 2 mg, give 1 tablet daily at 8:00 A.M. The order for Zoloft was inaccurately transcribed as 100 mg daily and not 150 mg daily as indicated on the home medication list. Although the order for Synthroid was verified with the Resident's HCP and approved by the Physician, it was not included in the Physician's orders and therefore was not on the Medication Administration Record (MAR) and not administered. Review of August 2023 MAR indicated Zoloft 100 mg was administered to Resident #368 from 8/18/23 to 8/22/23 instead of 150 mg, and Abilify 2 mg was not administered on one occasion (8/22/23) and was noted as being unavailable. During an interview on 9/29/23 at 12:26 P.M., Nurse #10 said on 8/22/23 she did not see a blister pack of medications and retrieved Resident #368's medications from the electronic medication dispensing system. She said she did not administer Abilify because it was not available in the electronic medication dispensing system. Nurse #10 said she notified the Nurse Practitioner, but was not given any direction to either obtain a new order and cancel/discontinue the order for the non-available medication. During an interview on 9/29/23 at 1:32 P.M., the Director of Nursing (DON) said she was contacted by Resident #368's HCP three days after he/she was discharged from the facility with a concern that the Resident had not received all of his/her medications while at the facility. The DON said she initiated an investigation. She said not all of the nurses were comfortable using the Resident's blister cards brought in from home, and some nurses used the electronic medication dispensing system to retrieve the medication. She said her investigation revealed that during medication reconciliation upon admission, the Synthroid order was omitted from the Physician's orders. However, the Synthroid was in the blister cards and administered daily by nursing staff except for two occasions when nursing did not use the blister card. She said on two occasions where the medications were retrieved from the electronic medication dispensing system, it was noted that two doses of Synthroid were not retrieved, therefore assumed omitted, and on three instances, staff documented that Abilify was not available to administer, therefore assumed omitted. She said there was also a discrepancy with the dose of Zoloft. The Zoloft in the blister pack were 100 mg tablets and the home medication list indicated the Resident was to receive 150 mg and the discrepancy should have been discovered upon medication reconciliation at the time of admission and each time the medication was administered. She said the order was changed on 8/23/23 to 150 mg, but staff continued to administer Zoloft 100 mg. She said multiple medication errors occurred and it is her expectation that nursing staff accurately reconcile medications upon admission and administer medications according to physician's orders to ensure no medication errors occur, and that was not done. 48695

Based on record review, Hospice contract review, and staff interview, the facility failed to ensure for one Resident (#102), out of a total sample of 23 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to provide ongoing documentation of hospice staff visits to ensure prompt and effective communication and continuity of care for the Resident, in accordance with the hospice agreement. Findings include: Review of the facility's agreement with Hospice, dated February 2023, indicated but was not limited to the following: - the facility will identify space in the medical record of the hospice patient for ongoing documentation and communication by hospice personnel - the hospice will provide all hospice services in compliance with all federal, state, and local laws, rules and regulations - hospice responsibilities include, but are not limited to, providing medical direction and management of the patient, nursing, spiritual counseling, and social work for the palliation of symptoms associated with terminal illnesses and related conditions - the facility will prepare and maintain medical records for each hospice patient receiving services Resident #102 was admitted to the facility in July 2022 with diagnoses including dementia, psychosis, anxiety, and major depressive disorder. Review of the facility hospice integrated medical record for Resident #102 failed to indicate any schedule of hospice services or visit notes from any discipline after 9/6/23. During an interview on 9/27/23 at 3:23 P.M., Nurse #4 said she was unsure about how the facility receives hospice documentation of visits or where the hospice schedules of visits are kept and deferred the surveyor to the Unit Manager. During an interview on 9/27/23 at 3:24 P.M., Unit Manager (UM) #2 reviewed the hospice schedules with the surveyor and said there was no schedule for visits available for Resident #102 since 9/8/23. She said when hospice comes in, they stop and notify someone on staff, but she is unsure when that is and the schedules are sent to the Director of Nurses (DON) by e-mail and she does not have any since 9/8/23. She said hospice staff bring in the printed out hospice notes about once a week and the facility staff do not otherwise have access to the visit notes or any part of the hospice electronic system. She reviewed the hospice integrated medical record and said there were no notes available to communicate what services the hospice provided since 9/6/23. During an interview on 9/27/23 at 4:55 P.M., the Assistance Director of Nurses said she contacted the hospice and has received Resident #102's hospice visit notes from 9/6/23 to current. She said the notes are usually brought in by the hospice and placed in the medical record about weekly and she couldn't explain why the notes weren't available for the staff or survey team to review as they should have been. During an interview on 9/28/23 at 8:25 A.M. Hospice staff #1 said the hospice visit and communication notes are printed and brought into the facility every week or two and the staff are expected to verbally communicate with the facility if anything significant is occurring. She said she is aware the facility hospice integrated record did not have any documentation of hospice visits or communication for the last three weeks and just provided the facility with the notes on 9/27/23 after they were requested by the surveyor. She said there were some issues on the hospice end and the records were not complete until 9/27/23 as they should have been. During an interview on 9/28/23 at 1:47 P.M., the Director of Nurses said she was made aware that the communication of hospice visits and the visit schedules were not available on the nursing unit for Resident #102. She said the schedules should be printed and supplied to the units weekly to ensure they are aware of upcoming hospice visits with each discipline. She said the expectation for the visit documentation and communication is that the notes are printed out every week or so to ensure collaboration and communication between the hospice and facility staff regarding the Resident's care. She said sometimes getting documentation from outside services is a struggle.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), as well as other residents residing on his/her unit at the time of Resident #1's discharge, the Facility failed to ensure they maintained each residents' right to privacy and confidentiality of their personal and protected health information in a secure manner. When on 10/26/21, Resident #1 was discharged home from the Facility, and included in his/her discharge paperwork was a document that listed the names of other residents that resided on his/her unit, along with the names it listed the residents' clinical information including psychiatric and medical diagnoses, code status, current medical status, vital signs, laboratory results, infection control precautions and medications, all which violated the residents' right to privacy. Findings include: Review of the Facility's Policy titled, Confidentiality of Information and Personal Privacy, dated as revised October 2017, indicated that the Facility will protect and safeguard resident confidentiality and privacy regarding their medical treatment and written communications. Resident #1 was admitted to the Facility in October 2021, medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Health Care Facility Reporting System (HCFRS) Report, dated 12/07/21, indicated that Resident #1 was discharged home on 10/26/21 and his/her discharge folder included a list of other resident names with clinical information. Review of the document sent home with Resident #1 indicated it was dated 10/26/21, identified Resident #1's unit by name, listed other residents (by name) residing on the unit, and included their medical and psychiatric diagnoses, code status, current clinical and medical status, vital signs, laboratory results, infection control precautions and medications. During an interview on 01/04/22 at 10:36 A.M., Resident #1's Family Member said that included with Resident #1's discharge documents, there was a list of other resident names with their personal and medical information on it. The Family Member said that document was a violation of privacy and confidentiality of those residents and said the document should not have been included with Resident #1's discharge documents. During an interview on 01/04/22 at 1:08 P.M., Nurse #1 said that she uses a report sheet with multiple resident's names and medical information to document the condition of the residents in her care. Nurse #1 identified the document that was included in the HCFRS Report, dated 10/26/21, as the document she used to obtain and give report on 10/26/21. Nurse #1 said the document was in her writing and included resident names, medical and psychiatric diagnoses, code status, current medical status, vital signs, laboratory results, infection control precautions and medications. Nurse #1 said that the report sheet contained confidential resident information and said she could not explain how her report sheet ended up in Resident #1's discharge documents. During an interview on 01/04/22 at 1:50 P.M., the Director of Nurses (DON) identified the document that was in the HCFRS Report, dated 10/26/21, as a document that the Facility's nurses use to obtain and give report on resident conditions. The DON said that the document included names of residents who were residents of the Facility and included confidential resident information. The DON said the document should not have been included in Resident #1's discharge documents and said she could not explain how the document was included with Resident #1's discharge documents.

Based on observation, interview, and record review, the facility failed to implement the plan of care to check the placement and function of a wander guard for one Resident (#50) in a total sample of 19 residents. Findings include: Resident #50 was admitted to the facility in March 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/13/21 at 3:05 P.M., the surveyor observed Resident #50 in the unit dining room. The Resident was wearing a wander guard on his/her right ankle. Review of the medical record for Resident #50 included a wander assessment, dated 3/4/21, which indicated the Resident was at high risk to wander. Review of the care plans for Resident #50 indicated he/she was at risk for elopement with an intervention of wearing a wander guard at all times, for staff to check the placement every shift and for the staff to check the function every week on Wednesdays. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/14/21 at 2:33 P.M., Nurse #1 said staff document wander guard placement and function on the TAR. During an interview on 4/15/21 at 10:35 A.M., Unit Manager #2 said an order had not been written to check the function and placement of the wander guard, therefore, the wander guard was not added to the TAR, and was not checked for placement and function per the care plan for Resident #50.

Based on observations, record review and staff interviews, the facility staff failed to identify and document the clinical rationale for the use of an antipsychotic medication for one sampled Resident (#22), out of a total sample of 19 residents. Findings include: Resident #22 was admitted [DATE] with diagnoses that included dementia and depression. Review of the medical record indicated the Resident had a fall in January 2021 and was sent to the hospital. At the hospital, he/she was diagnosed with a right intertrochanteric femur fracture and underwent surgery of a ORIF (Open Reduction Internal Fixation). Review of the hospital discharge information, dated 2/2/21, indicated that the Resident had a physician's order for [MEDICATION(S)] 25 milligrams (mg) every 6 hours as needed and was discharged from the hospital on this medication. [MEDICATION(S)] is an antipsychotic medication. The Nurse Practitioner (NP) saw the Resident on 2/2/21 when the Resident returned to the facility and noted the Resident complained of mild right leg pain and was calm and cooperative. The NP documented to continue the [MEDICATION(S)] 25 mg, as needed for agitation for 14 days. The medical record indicated on 2/3/21, the [MEDICATION(S)] was ordered to change to 25 mg at bed time. A nurse's note, dated 2/3/21 at 2:10 P.M., indicated the Resident when unsupervised, would yell out for help, several times and tried to get out of bed. The nurse wrote the Resident complained of pain of 10 out of 10 on the pain scale (severe) of the right hip and was medicated with pain medication at 7:30 A.M. The note also documented to start the [MEDICATION(S)] 25 mg, to be given at bedtime. A review of the quarterly Minimum Data Set (MDS) assessments dated 11/27/20 and the 2/8/21 Significant Change in Status MDS assessment, both indicated Resident #22 had no behaviors, no delusions, and no hallucinations. The 11/27/20 MDS assessed the Resident's cognitive status by the Brief Interview of Mental Status (BIMS) score of 3 out of 15 and the 2/8/21 assessment at 2 out of 15, both indicating severe cognitive impairment. Review of Resident #22's plan of care, dated 2/9/21, indicated the Resident has a behavior of yelling out for help, and when reminded to wear a mask, will often remove it. One of the interventions was to monitor for pain every shift. Another plan lists the Resident's antidepressant and antipsychotic medications and to monitor for side effects from the two medications. The psychiatry service had seen the Resident on 2/9/21 and added diagnoses of anxiety, adjustment disorder with depressed mood and unspecified dementia with no behaviors. The service made no documentation of the Resident receiving an antipsychotic medication. The surveyor observed the Resident on the following dates and times with no behaviors: - 4/13/21 at 10:10 A.M. sitting in a wheelchair, well-groomed, and when spoken to he/she repeatedly asked what the surveyor was saying. The Resident does have hearing loss and uses no devices. - 4/13/21 at 2:24 P.M. lying in bed with eyes closed. - 4/14/21 at 8:10 A.M. eating in the dining area on the unit, his/her wheelchair positioned at the table, ate all his/her breakfast, needed no assistance from staff to eat. The Resident was smiling at staff when they approached. - 4/14/21 at 10:40 A.M. sitting in activity area with assistant. Greeted other residents with a nod. - 4/15/21 at 7:47 A.M., sitting in wheelchair watching television, awaiting breakfast. - 4/15/21 at 10:45 A.M., sitting with activity assistant with an old movie playing, he/she was smiling and the activity assistant said we are waiting for the other residents to join us. During an interview on 4/15/21 at 10:20 A.M., Unit Manager #1 was asked about the [MEDICATION(S)] usage and what behaviors the Resident exhibited. She informed the surveyor that she was new here as of 4/1/21 and needed to review the record. During interview and record review on 4/15/21 at 3:12 P.M., Unit Manager #1 could not elaborate on the behaviors of Resident #22. She said there were no behavior records and had no other information. Reviewed with Unit Manager #1, that the Resident after having ORIF surgery was assessed using the MDS to have no behaviors, hallucinations or delusions. The Resident is deaf and has no appliances or aids. When the Resident has called out on two occasions for help the nurse's note indicated he/she was medicated for pain. Unit Manager #1 went on to say the Resident has put him/herself on the floor twice from the wheelchair. The surveyor asked the Manager if this was related to his/her pain and she could not answer. During an interview on 4/15/21 at 3:56 P.M., the Director of Nurses (DON) said they had been looking at [CONDITION(S)] medications and she said she could find no information of why the [MEDICATION(S)] was used and said she had called the pharmacist to see if he had information. The DON presented on 4/16/21 at 8:30 A.M. a communication from the Pharmacist that was sent to the DON. Review of the Pharmacist note indicated he reviewed the medications of Resident #22 on 2/15/21 and noted the Resident was receiving [MEDICATION(S)] since 2/3/21. The pharmacist had made a recommendation for the diagnosis of Adjustment Disorder with depressed mood be added to the diagnosis list of Resident #22. The DON went on to say Resident #22 was not on the list of residents receiving [CONDITION(S)] medications and had not been reviewed as part of the dose reduction project. The facility could offer no further documentation to substantiate for the continued use of the antipsychotic medication daily after having surgical repair of the hip, diagnosed with dementia, and having a hearing loss.

Based on observation, record review and staff interview, the facility staff failed to maintain complete, accurate and systemically organized medical records within accepted professional standards and practice. Specifically, the facility failed to: transcribe physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] (a) for laboratory services, and (b) to transport the resident out of the facility for an acute medical evaluation, for one Resident (#96) out of three closed records. Findings include: Review of the medical record indicated Resident #96 experienced two falls on 2/24/21 (found sitting on the floor/chair) with no documented injuries or bruises. The physician was notified and ordered orthostatic vital signs (have patient lie down for 5 minutes, measure blood pressure and pulse. Have patient stand, repeat blood pressure and pulse after 1 and 3 minutes) twice a day for three days and a psychological evaluation of medications. Review of the physician's progress note, dated 2/25/21, indicated that nursing had reported that the Resident was in his/her usual state of health with weakness and had questioned low hematocrit (measurement of the amount of red blood cells) and hemoglobin (protein found in red blood cells that carries oxygen to the body) levels. Review of a nursing progress note, dated 2/25/21, indicated the physician requested, and the Resident's health care agent agreed, a complete blood count (CBC) and comprehensive metabolic panel (CMP) be obtained on 3/2/21. Review of the medical record on 4/16/21 failed to indicate an interim order for the Resident's laboratory blood tests. Although the blood test was obtained, facility staff failed to transcribe the order to obtain the laboratory blood test. Review of a nursing progress note, dated 3/2/21, indicated the Resident's laboratory results identified a critical hemoglobin (hgb) of 6.6 (normal range 12.1-15.7 g/dL). The nurse practitioner and nurse supervisor were notified and an ambulance was called to transfer the Resident to the hospital. Review of the medical record on 4/16/21, failed to indicate an interim physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 4/16/21 at 10:05 A.M., Unit Manager #2 said all physician orders, including interim orders were hand written and not electronic. Unit Manager #2 said the orders for lab work and the order to transfer the Resident to the emergency room should have been included in the medical record and were not.

Based on observations, interviews and record review the Facility staff failed to implement care plan interventions for 5 Residents (#3, #15, #50, #58 and 78), 1 of which resulted in injury, in a total sample of 24 Residents. Findings include: 1. For Resident #15, Facility staff failed to ensure the care plan for fall risk was implemented consistently. Resident #15 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS, with a reference date of 8/20/18, indicated that Resident #15 had significant cognitive impairment as evidenced by a Brief Interview for Mental Status score of 1 out of 15 and required extensive assistance with all activities of daily living. Review of Fall Assessments dated 8/19/18, 11/19/18, and 2/6/19 indicated Resident #15 as a high fall risk. Review of the care plan for falls indicated that Resident #15 was a high fall risk due to a history of falls, gait/balance problems, and unaware of safety needs. Review of the interventions included place call light within reach, ensure bed alarm is in place, and bed in low position while Resident is in bed. On 2/28/18 at 10:07 A.M., Resident #15 was observed lying in bed sleeping. The bed was not in the low position, the call light cord was wound and fastened to the wall and out of the Resident's reach, and bed alarm cord was on the floor and unattached from the unit. On 3/1/18 at 10:03 A.M., Resident #15 was again observed lying in bed sleeping. The bed was not in the low position, the call light cord was wound and fastened to the wall and out of the Resident's reach, and bed alarm cord was on the floor and unattached from the unit. 2. For Resident #50, Facility staff failed to ensure the care plan for falls was consistently implemented. Resident #50 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS with a reference date of 12/11/18, indicated that Resident #50 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and required extensive assistance from staff for activities of daily living. Review of the care plans for Resident #50 indicated the Resident was a high risk for falls related to dementia, and spinal stenosis. Review of the interventions included to place call light within reach and encourage Resident to use it for assistance as needed (12/8/17), nonskid mat on left side of the bed near bathroom door. On 2/26/19 at approximately 8:30 A.M., Resident #50 was observed lying in bed sleeping. The call light was observed secured to the wall and out of the Resident's reach, and there was no nonskid mat on the left side of the Resident's bed. 3. For Resident #58, Facility staff failed to ensure the care plan for fall risk was implemented consistently. Resident #58 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the most recent annual MDS, with a reference date of 12/21/18, indicated that Resident #58 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 4 out of 15, had 2 or more falls since admission or the prior assessment, and used a bed alarm daily. Review of the care plans for Resident #58 indicated the Resident was a high risk for falls related to history of falls, incontinence, gait/balance problems, unaware of safety needs, and wandering. Review of the interventions included a bed alarm and check proper function (initiated 5/29/18), place call light within reach and encourage Resident to use it for assistance as needed (4/12/17), bed in low position while in bed (initiated 4/12/17). On 2/26/19 at 10:27 A.M., Resident # 58 was observed lying in bed resting. The bed was observed to not be in a low position, the call light was underneath the bed and out of reach, and the bed alarm was disconnected from the unit and the cord was underneath the bed. At 10:35 A.M., CNA #3 entered the room to deliver water to the Resident and did not notice the Resident's bed was not in the low position, the call light was out of the Resident's reach, and the bed alarm was disconnected. On 3/1/18 at 10:15 A.M., the Surveyor alerted the Director of Nursing (DON) of observations of fall interventions not in place for Residents #15, #50, and #58. The DON, Unit Manager #2 and the Surveyor conducted a tour of the unit and confirmed the Surveyor's observations that fall interventions were not in place. 4. For Resident #3, Facility staff failed to ensure the care plan addressed the resident's personal urinary catheter needs. Resident #3 was admitted to the Facility in 11/2018, with [DIAGNOSES REDACTED].>[MEDICAL CONDITION], hypertension and dementia without behavioral disturbances. Review of the most recent quarterly Minimum Data Set, with a reference date of 2/11/19, indicated that Resident #3 was able to communicate and understand as evidenced by a Brief Interview for Mental Status score of 7 out of 15. For activities of daily living, the assessment indicated the Resident required supervision and use of a walker device for mobility, independent to eat, and extensive assistance for dressing, toilet and hygiene needs. A catheter device was identified in use to collect urine. Record review of medical progress notes dated 11/17/18, indicated an initial care plan meeting focus included to remove the Resident's Foley catheter. As recommended by the urologist, voiding trials of urine were conducted without the use of the Foley catheter but failed, resulting in a urinary tract infection. Review of the care plan (dated 11/2018 and 2/2019), and current physician orders [REDACTED]. The plan of care also included to position the catheter bag, below level of bladder and to hang on the side of the bed, away from the doorway (for visual privacy). During the survey visit on 2/26/19, Resident #3 was observed ambulating with a walker device, dressed to leave the facility with visitors. On 2/27/19 at 3:30 P.M., Resident #3 was observed ambulating in the corridor on the resident unit fully dressed. On 3/01/19 at 8:29 A.M., the Resident was lying on the bed fully dressed with coat on and had just finished eating breakfast. Throughout the survey visit (2/26/19 to 3/5/19), Resident #3 was seen at activites or in the unit dining room for meals. For all observations, there was no visible Foley catheter bag. Review of the Resident #3's care plan failed to include the personal preference and services specific for the care and use of a catheter leg bag. During interview on 3/05/19 at 9:55 A.M., Unit Manager #3 had no explanantion why the use of the leg bag was not included on the care plan. Unit Manager #3 said that when it is used, the nurse aides have to monitor and check it every hour and assist the Resident with emptying often to avoid leaks. Further interview on 3/6/19 at 10:00 A.M., the Unit Manager said that the Resident uses the leg bag daily, and agreed that the care plan only addressed the full Foley catheter bag and to it place on the window side of bed out of view. Unit Manager #3 said she was uncertain whether to identify the leg bag as a behavioral concern, as the Resident frequently asks staff to change or check it, or to include and add under the catheter care plan. 5. For Resident #78, the Facilitystaff failed to ensure the Resident's safety by not implementing the care plan for a bed alarm. Resident #78 was admitted in 7/2017 with [DIAGNOSES REDACTED]. Record review indicated that the resident had a history of [REDACTED]. Further review of the record revealed that the Resident experienced a fall in 11/2018. On 11/12/18, at the time of the fall, the Resident was supposed to have a bed alarm in place and functioning. According to the Accident/Incident Report Investigation completed by the DON (Director of Nursing), on 11/12/18 at 10:00 P.M., the Resident was heard by staff yelling help. A loud bang was reportedly heard from the nurses station. The Report indicated that the nurse observed the Resident lying on his/her back with knees bent. The Resident was in the bathroom, unsupervised, at the time of the fall. According to the investigation, the Resident reported to the nurse that he/she experienced dizziness at the time of the fall. The nurse observed a laceration on the back of the scalp that the nurse questioned whether or not sutures were indicated. The Resident was sent to the Hospital for evaluation and treatment. The Resident was admitted to the hospital on [DATE] at 2:00 P.M. with a posterior [MEDICAL CONDITION] for which three sutures were applied. The Investigation report indicated that preventative measure were not being carried out and, Bed alarm not plugged in.

Based on observation, record/document review, and staff interviews, the Facility staff failed to provide adequate supervision and accident prevention measures to ensure the safety of 2 Residents (#78, and #46), of a total sample of 24 residents. Additionally, the Facility failed to ensure that Residents were provided an environment that was free from accident hazards on 1 of 3 units. Findings include: Review of the facility's Falls Management Policy (last revised 3/15/16), included the following: -Residents will be assessed for falls risk as part of the nursing assessment process -those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury -Individualized careplans will be developed, reviewed and revised regularly -If the Resident falls, document the accident/incident, and update the care plan to reflect new interventions 1. For Resident #78, the Facility failed to ensure that the Resident's safety alarm was in working order, which contributed to two falls, one with major injury. Resident #78 was admitted in 7/2017 with [DIAGNOSES REDACTED]. Record review indicated that the resident had a history of [REDACTED]. According to the incident investigation for a fall that the Resident experienced on 11/12/18, at the time of the fall, the Resident was care planned to have a bed alarm in place and functioning. According to the Accident/Incident Report Investigation completed by the DON (Director of Nursing), on 11/12/18 at 10:00 P.M., the Resident was heard by staff yelling help. A loud bang was reportedly heard from the nurses station. The Report indicated that the nurse observed the Resident lying on his/her back with knees bent. The Resident was in the bathroom, unsupervised, at the time of the fall. According to the investigation, the Resident reported to the nurse that he/she experienced dizziness at the time of the fall. The nurse observed a laceration on the back of the scalp that the nurse questioned whether or not sutures were indicated. The Resident was sent to the Hospital for evaluation and treatment. The Resident was admitted to the hospital on [DATE] at 2:00 P.M. with a posterior [MEDICAL CONDITION] that required three sutures. The Investigation report indicated that preventative measure were not being carried out and, Bed alarm not plugged in. Additionally, the investigation report-Recommendations for preventive measures not already in place and/or additional corrective measures taken, indicated: -Maintain bed alarm at all times -Check every 15-30 minutes during safety rounds. The Facility failed to investigate why the bed alarm was not plugged in at the time of the fall, or whether the alarm was an effective intervention in the future to maintain the Resident's safety. The Care Plan for Falls was reviewed by the Surveyor. There was no change to the Care Plan for falls that addressed the effectiveness and/or reliability of the Resident's safety alarm. The Facility continued to utilize the safety alarm for the Resident's safety. Record Review on 2/28/19, indicated that on 2/11/19 at 7:10 A.M., the CNA reported to the nurse that the Resident was found lying on the floor on the right side of the bed. According to the Accident/Incident Investigation Report, the resident sustained [REDACTED]. An ice pack was reportedly applied to the forehead and a small amount of blood was cleaned from the Resident's nose. The Investigation Report indicated that the Resident was responding to bladder urgency. Additionally, the nurse completing the Investigation Report indicated that a plan of care with preventative measures was in place-bed alarm, and preventative measures were being carried out-bed alarm/bed in low position. Recommendation for preventive measures not already in place, and/or additional corrective measure taken included: -30 minute checks -offer toileting at each interval -offer bedside commode The Director of Nursing Section, Summary of Investigation indicated: Sent to ER (emergency room ) for evaluation. Alarm did not sound at time of occurrence. His/Her P[NAME] (Plan of Care) was followed. Alarm checked not working, not sounding consistently, wiring to box ? faulty secondary to pushes in and box sounds, replaced. The DON indicated that a new P[NAME] (plan of care) in place when returns from hospital.' Further record review indicated that the fall was reported to the Nurse Practitioner who ordered to monitor the Resident's neurological signs which were reportedly negative. However the Resident complained of neck and knee pain at 3:00 P.M. on 2/11/19. At 11:39 P.M., a nurses note indicated pt (patient) OOB (out of bed) to wheelchair alert and at baseline mental status. Cont (continue) on neuros. (neurological checks) Tylenol 650 mg administered for discomfort (s/p) status [REDACTED]. NP (Nurse Practitioner) present to evaluate pt. New order to send pt out for further eval. (evaluation). A progress note by the DON on 2/12/19 at 8:49 A.M., indicated that the Resident had been assessed to have sustained a [MEDICAL CONDITION]-1 (cervical vertebrae) and was admitted to the Hospital for evaluation and treatment. The Plan of Care for Falls was reviewed by the Surveyor on 2/28/19. Following the Resident's fall with a C-1 cervical fracture the following new interventions were made to the Resident's Plan of Care for Falls: -15 minute safety checks -offer toileting every 2 hours -ensure environment is free from obstructions and lighting is adequate -keep frequently used items within reach The Plan of Care for falls included: The Resident uses a bed alarm at all time. Ensure the device is in place at all time. Although the use of the bed alarm was determined to be ineffective in preventing falls with injury, on 11/12/18 and 2/11/19, the Facility continued to use the device without investigating the cause of the alarm's failure to function properly at the time of each of the Resident's falls. On 3/1/19 at 10:50 A.M., the Surveyor requested UM #1 (Buttonwood Unit Manager) to conduct a random inspection of Resident safety alarms (Including Resident #78) to evaluate their function. He provided the Surveyor with a list of 15 residents who used alarms to maintain their safety. The following was observed: -Resident #78's bed alarm was positioned under the left hand, top corner of the bed. UM#1 activated the alarm which was observed to give off a faint beeping sound. The Surveyor and UM#1 walked down to the nurses station approximately 40-50 feet away from the Resident's room. The alarm was barely audible at the nurses station. UM #1 said that the alarm had to be positioned under the bed so the Resident wouldn't tamper, disconnect, or disable it, -UM #1 checked Resident #123's bed alarm. It was noted to be barely audible. The Unit Manager acknowledged that the alarm would not be heard by staff if the Resident tried to get out of bed unassisted. He said that the night shift checks them and maintenance makes sure they work. Additionally, UM #1 said that when the safety alarm doesn't work he lets maintenance know so they will change the battery. -Resident #124's bed alarm was checked with UM #1. The alarm control box was attached to the bottom left side of the bed under the mattress. The wire from the bed alarm pad was observed by both the Surveyor and UM #1 to be separated from the connecting clip where it attaches to the control box, wires were exposed, rendering the alarm inoperable. UM #1 said he was not aware that the Resident's safety alarm was broken. On 3/1/19, at 11:40 A.M. the Surveyors met with the DON, the Administrator, and the Maintenance Director to discuss concerns over the number of residents with a history of falls on both the Laurelwood and Buttonwood Units, who required safety alarms as an intervention to maintain the residents' safety. The observations and findings by the Surveyor and UM #1 of the broken or ineffective alarms on the Buttonwood Unit were shared with the Administrator, the DON, and the Maintenance Director. The Maintenance Director said that he does not check alarm batteries, or replace them, and that he was not responsible for the overall functioning of the alarms. He acknowledged that the alarms must work properly at all times in order for them to be effective in maintaining the safety of each resident who uses one. The DON explained that nurses are responsible for ensuring the alarm is in place on their shift and that it works. The DON said that there was no ongoing Facility policy or procedure for inspecting the alarm pads, cords, or alarm boxes, for overall condition, or for changing alarm batteries before they become too weak and fail. The DON also said, that at that time, there were approximately 20 alarm pads, and/or alarm control boxes, discovered during an inspection with a different Surveyor on the Laurelwood Unit (Dementia Specialty Care Unit) that needed to be replaced due to being faulty and not functioning properly. The Administrator acknowledged the Surveyors' concerns regarding Residents such as Resident #78, who had fallen multiple times and sustained serious injury due to safety alarms not working properly. The Administrator, DON, and Director of Maintenance offered no information to Surveyors on a Facility-wide plan that had addressed problems in the past with safety alarms not working properly following multiple falls by residents who used alarms. The Administrator, DON, and Director of Maintenance said they would be addressing Surveyor concerns immediately over the Facility's failure to develop an effective plan to identify and maintain safety alarms used to maintain the safety of residents assessed to be at risk for falls and injury. On 3/1/19 at 2:20 P.M., Resident #78 was observed in bed on the Buttonwood Unit. The Resident was observed lying in bed in his/her room on the Buttonwood Unit with the bed alarm positioned under the Resident. The Resident's eyes were closed and he/she appeared to be resting comfortably. CNA #1 accompanied the Surveyor into the Resident's room to check on the status of the bed alarm. CNA #1 checked the Resident's bed alarm by unplugging it from the control box. The alarm sounded softly due to it being positioned under the mattress. CNA #1 said that nursing attaches the alarm box under the mattress so that the Resident can't disconnect it. CNA #1 said that the alarm sounded softly because of where it was positioned. On 3/6/19 at 10:13 AM, the Surveyor interviewed the DON about the Resident's falls with injury in 11/18 and 2/19. The DON acknowledged that the Resident could unplug the alarm and that it was unplugged at the time of the fall in 11/18. She also acknowledged that both falls resulted in injury, (scalp laceration in 11/18 and fractured neck (C-2 vertebrae) in 2/19). The DON said both injuries occurred when the Resident's alarm failed to sound, to alert staff that the Resident was getting out of bed. Although, the Resident was noted to unplug the alarm (unplugged on 11/12/18 fall) rendering it ineffective, the Facility continued to rely on the alarm as a safety measure to keep the Resident from getting out of bed without staff assistance. The Facility failed to ensure that it developed and implemented an ongoing plan/process to prevent accidents and hazards, that evaluated the effectiveness of interventions used in the Resident's Plan of Care. 2. For Resident #46, the facility staff failed to ensure that the Resident received adequate supervision and assistance devices to prevent an accident (fall) which resulted in a left arm femur fracture. Resident #46 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with a reference date of 9/10/18, indicated that Resident #46 required physical assistance of one person to walk in the corridor, and walk on the unit. The MDS also indicated that Resident #46 had 2 falls in the assessment period, 1 of which resulted in an injury. Review of the medical record indicated the following care plan for fall risk and included: -Monitor safety awareness, intervene and counsel if Resident exhibits poor safety awareness behaviors (4/10/17) -Ambulate with assist of one (initiated 9/6/18) The Health Care Facility Reporting System (HCFRS) Report, dated 11/12/18, indicated that on 11/7/18 at 11:40 A.M., Resident #46 was observed by nursing staff walking in front of the nursing desk, and was then observed to trip and fall onto the floor. Resident #46 sustained a fracture to his/her left arm. An Incident Report, dated 11/7/18 at 11:00 A.M., indicated that Resident #46 was observed by nursing staff walking in front of the nursing station without his/her walker, tripped and fell to the floor. The investigation indicated that preventative measures were not being carried out at the time of the fall because the Resident did not have his/her walker with him/her. The walker was found two hours later in another Resident's room. A Nurse Progress Note, dated 10/28/17, indicated Resident #46 was observed walking in front of the nursing station without his/her walker, tripped and fell on to his/her face on the hardwood floor. The Resident's nose was bleeding, was face down on the floor, and complained of pain at a level of 10 out of 10. The Resident fell out of bed during morning care, sustained a one inch by half inch wide laceration to his/her right elbow which was unable to be closed and was transferred to the hospital for wound closure. During interview on 3/4/18 at 1:35 P.M., the Surveyor reviewed Resident #46's 11/7/18 fall and care plan with Nurse #2. Nurse #2 said that the Resident should have had his/her walker and been assisted by staff for ambulation. 3. Review of the Matrix for Providers completed by the Director of Nursing and provided to the survey team on the first day of survey (2/26/19), indicated that 36 of 37 Residents residing on the DSCU had [DIAGNOSES REDACTED]. During the survey period from 2/26/19 to 3/6/19, the following items were observed unsecured in Resident's rooms on the Laurelwood unit/ Dementia Special Care Unit (DSCU): -room [ROOM NUMBER]- 1 tube of Cortisone 10 for [MEDICAL CONDITION] cream in basket on bureau, 1 pump bottle of skin cleanser (Equate), 1 bottle of moisture lotion (Purpose) on bureau -room [ROOM NUMBER]- 1 small clear plastic jar contained push pins on bedside table -room [ROOM NUMBER]- 1 container of lemon disinfectant wipes on the windowsill -room [ROOM NUMBER]- 1 can of hairspray on bureau -room [ROOM NUMBER]- 1 bottle of foaming facial cleanser (Equate) on table -room [ROOM NUMBER]- Selan Zinc Oxide formula diaper rash and pressure ulcer barrier cream on bedside table, 1 spray bottle of Tilex bathroom cleaner, 1 bottle of Scrubbing Bubbles bathroom cleaner on a shelf in the bathroom On 2/28/19 at 10:30 A.M. in the common area of the Laurelwood unit/DSCU, housekeeping staff was observed to repeatedly spray a liquid substance from a bottle onto a dark, solid floor surface, and then go over the area with a cleaning machine. The floor surface was shiny and appeared wet. During Surveyor observation, 2 Residents walked across the shiny floor that the housecleaning staff had just sprayed the liquid. During environmental tour with the Director of Nursing (DON) and Unit Manager #1 on 3/01/19 at 10:28 A.M., the Surveyor shared the observations during the survey. The DON said that housekeeping staff should not be cleaning the floors where Residents are walking, and the items identified in the Resident's rooms should not be unsecured.

Based on observation, documentation review and interviews, the Facility staff failed to ensure there was a system by which the maintenance department conducted inspections of all 142 beds in the facility for the possibility of entrapment besides the zones for the functioning of the bed rails, including when there was a change in the mattress or bed frame to avoid potential risk of entrapment for 3 Residents (#58, #78, and #176) out of a total sample of 24 Residents. Findings include: 1. For Resident #176, the Facility failed to complete a comprehensive safety inspection of the bed when a mattress was replaced and side rails in use to assure no entrapment risks. Resident #176 was admitted ,[DATE] with [DIAGNOSES REDACTED]. Record review indicated the Resident consented to use 1/2 bed rails as enablers on 2/14/19. The Maintenance Director provide documentation of bed safety evaluations completed by room number, model of bed and mattresses types. Review of information provided by the Maintenance Director for the bed in Resident #176's room, included a Bed System Measurement Device Test Results Worksheet dated 8/15/18, which indicated Zone 2 and Zone 4 areas were tested and included BED ID SW BED 7 model ECS with natural care mattress that has side rail, head and foot board area. The bed safety evaluation was noted as passed. Record review indicated a nurses' note dated 2/16/19, that Resident #176's mattress was changed due to discomfort. During observation on 2/26/19 at 10:43 A.M., the Resident stated that the bed is comfortable now, since they changed the mattress. The mattress was an air type mattress and the resident said he/she used the 1/2 rails to assist movement in bed. Review of Facility's bed and safety inspection documentation for the room and bed in Resident #176's room did not include the latest (air) mattress in use, as the mattress in place is no longer the same as when inspected on 8/15/18. 2. For Resident #58 the Facility staff failed to ensure mattresses properly fit the bed frame to reduce the risk of entrapment Resident #58 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. During initial tour of the Laurelwood Unit on 2/26/19 at 10:27 A.M., Resident #58 was observed lying in bed resting with his/her feet dangling off of the foot of his/her bed. A large space between the mattress and footboard was observed on Resident #58's bed. During interview on 3/1/19 at 12:31 P.M., the Maintenance Director said that he conducted inspections of all the beds in the facility (142) where the bed rails are located (Zone 2 and Zone 4) only. He said that he does not conduct an inspection for risk of entrapment between the mattress and headboard or footboard. He said that there are a few different models of beds, but all the mattresses are interchangeable. The Surveyor alerted him to the large gap between Resident #58's mattress and footboard. On 3/1/19 at 1:40 P.M., the Surveyor accompanied the Maintenance Director to Resident #58's room. Upon inspection, the Maintenance Director said that Resident #58's mattress was 78 (inches) long and should be 80 long. He then measured the space between the mattress and footboard and said it was a 5 1/2 inches space and would need a spacer to close the gap. Review of the most recent annual MDS, with a reference date of 12/21/18, indicated that Resident #58 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 4 out of 15, had 2 or more falls since admission or the prior assessment, and used a bed alarm daily. 3. For Resident #58 the Facility staff failed to ensure mattresses properly fit the bed frame to reduce the risk of entrapment Resident #78 was admitted in 7/2017 with [DIAGNOSES REDACTED]. Record review indicated that the resident had a history of [REDACTED]. During initial tour of the Laurelwood Unit on 2/26/19 at 10:27 A.M., Resident #58 was observed lying in bed resting with his/her feet dangling off of the foot of his/her bed. A large space between the mattress and footboard was observed on Resident #58's bed. On 3/1/19 at 2:20 P.M., the Resident was observed lying in bed in #130A, eyes closed, resting quietly. The Resident's bed was observed to have a large space of approximately 4 inches, at the foot of the bed, between the end of the mattress and the foot board. . Interview with the Director of Maintenance on 3/1/19, indicated that all of the beds in the Facility had been assessed for entrapment risk and each potential entrapment zone had been found to be without safety risk. However, he had not assessed the head of the bed or the foot of the bed for potential entrapment risks.

Based on interview, the Facility failed to establish a Resident smoking policy, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents to ensure the safety of all Residents. Findings include: During entrance interview on 2/26/19 at 8 :30 A.M., the Administrator and Director of Nursing said that the Facility does not have a Resident smoking policy in accordance with Federal, State, and local laws and regulations. They said that they currently do not have any smokers in the Facility. However, if a smoker is admitted to the facility, they would develop a policy.

Based on observation and interview the Facility stafff failed to ensure housekeeping and maintenancy services to maintain a sanitary, orderly and comfortable interior on 1 of 3 Resident units. Findings include: During the survey period from 2/26/19 to 3/6/19 the Surveyor observed the following on the Laurelwood Unit/Dementia Special Care Unit: room [ROOM NUMBER] -Container of lemon disinfectant wipes on the windowsill. room [ROOM NUMBER] -Wallpaper on the wall across from bed was ripped away from the wall exposing drywall. room [ROOM NUMBER] -Wallpaper behind the Resident's bed was ripped away from the wall exposing drywall. room [ROOM NUMBER] -Wallpaper under window peeling. - Wall across from the Resident's bed was stained and gouged exposing drywall. room [ROOM NUMBER] -Soiled sheets and towels on over bed table. room [ROOM NUMBER] -Selan Zinc Oxide formula diaper rash and pressure ulcer barrier cream on bedside table. -1 spray bottle of Tilex bathroom cleaner, 1 bottle of Scrubbing Bubbles bathroom cleaner on a shelf in the bathroom room [ROOM NUMBER] -A large section of wallpaper, approximately 3 feet by 1 foot area, behind the A bed was ripped off the wall exposing drywall -Dove body wash on the A bed nightstand -Wall paper under the windowsill was peeling at the seams and a large area was ripped away from the wall exposing drywall. room [ROOM NUMBER] -Wallpaper behind the B bed ripped away from the wall exposing drywall, and the wall was gouged. room [ROOM NUMBER] -Wallpaper behind the A bed ripped away from the wall exposing drywall. room [ROOM NUMBER] -Wall paper under the windowsill was peeling at the seams and a large area was ripped away from the wall exposing drywall. room [ROOM NUMBER] -Wall paper under the windowsill was peeling at the seams and a large area was ripped away from the wall exposing drywall. On 3/1/19 at 10:17 A.M., the Surveyor conducted an environmental tour with the Administrator and Unit Manager #1 on the Laurelwood Unit/ Dementia Special Care Unit and confirmed the observations. Additionally, the DON and Surveyor observed the B bed in room [ROOM NUMBER] neatly made with a blanket that had a large, brown, circular shaped stain on it that the DON identified as feces.

Based on record review and staff interview, the Facility failed to ensure that medical records were complete, and accurately documented in accordance with professional standards of practice for 4 Residents (#62, #94, #126 and #127) from a total sample of 24 Residents. Findings include: 1. For Resident #126, the Facility failed to ensure a physicians order for discharge was obtained and included in the medical record. Resident #126 was admitted to the Facility in ,[DATE], with [DIAGNOSES REDACTED]. The Resident was admitted for short term stay, respite care. Although there was written documentation from social services of a planned discharge on [DATE] to return to the community, including notices for discharge, and referral information sent (faxed) to the community service programs, there was no physician order (or interim order from MD/NP ) for Resident #126 to be discharged home with medications/services according to standards of practice and to ensure complete medical record information. This information was discussed with the Director of Nurses on [DATE]. 2 For Resident #94 the facility failed to ensure the Resident had a physician's order to discharge the Resident from Hospice services. Resident #94 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Clinical record review indicated that the Resident had begun Hospice Services in ,[DATE]. Review of a nurses note, dated [DATE], indicated that the Resident would be discharged for m Hospice services on [DATE]. Review of the physician orders from through ,[DATE] through [DATE] indicated that there was not physician's order to discontinue Hospice Services. On [DATE] at 2:24 P.M. Unit Manager #1 said that the facility failed to obtain a physician's order to discontinue Hospice Services. 3. For Resident #127 the facility failed to document a final nurses note when the Resident expired at the facility that included the observation and assessment that the Resident had ceased vital body functions per professional standards. Determination of Death means observation and assessment that a person has ceased vital bodily functions irreversibly including, but not limited to, the following: pulse, respiration, heartbeat, and pupil reaction. Resident #127 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Clinical record review indicated that on [DATE] at approximately 4:02 P.M., the Resident expired and was pronounced at the facility by the Registered Nurse. Review of the final nurses note indicated that there was no assessment made that included, at a minimum, the above determination of death information. On [DATE] at 1:08 PM the Surveyor spoke with the Director of Nursing and indicated that the final nurses note did not include the minimal determination of Death information as per professional standards. 4. For Resident #62 the facility failed to ensure that the content of the psychiatric Nurse Practioner (NP) notes were correct. Resident #62 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Clinical record review indicated that the Resident was evaluated initially by the psychiatric NP on [DATE] who indicated that the Resident was receiving the following antipsychotic medications: [REDACTED] [MEDICATION NAME] 1.25 milligrams (mg) three times a day [MEDICATION NAME] 2.5 mg. at bedtime Further clinical record review indicated that the NP had seen the Resident on [DATE], [DATE], [DATE] and [DATE] . On each of these visits the NP documented the current medications the Resident was receiving, any medications that she would recommend be initiated, which medications would be continued, which medications would be changed and which medications would be discontinued. The Residents dose of [MEDICATION NAME] of 1.25 mg had been decreased from three times a day to once daily and the NP's notes reflected the changes in the dose and the correct current dose. The Resident had remained on the [MEDICATION NAME] 2.5 mg at bedtime and no changes had been made to this dose since [DATE], however the notes on the above dates did not reflect that the Residents was receiving the dose of [MEDICATION NAME] 2.5 mg. On [DATE] at approximately 11:00 A.M. Unit Manager #1 said that the [MEDICATION NAME] 2.5 mg was the correct dose of medication that the Resident was currently receiving and indicated that the NP notes were incorrect as they had omitted the medication. UM#1 indicated that she would call the NP and alert her to the error/omission in documentation. The Facility failed to maintain Resident #62's medical record that was complete, accurate and systemically organized within accepted professional standards and practice.

Based on records reviewed, interviews and observations, for one of three sampled residents (Resident #1), the facility failed to; - ensure that an exit stairwell door alarm was audible to all staff to prevent resident elopement and/or injury; - to ensure staff thoroughly checked an exit stairwell after an alarm sounded, which included multiple flights of stairs before reaching the bottom and an alcove area adjacent to the stairwell. - At approximately 11:10 A.M. on [DATE], an exit stairwell door alarm on Resident #1's unit was activated, and there was a delay in locating and responding to Resident #1, a cognitively impaired resident who was known to wander. Resident #1 was later found at the bottom of the exit stairwell with traumatic injuries, including multiple fractures of his/her facial bones, brain hemorrhages (bleeding), and a facial laceration. Resident #1 died 8 days after the incident. Findings include: Resident #1 was admitted to the Facility in (MONTH) (YEAR), review of his/her medical record indicated the following; - [DIAGNOSES REDACTED]. -Wandering Risk Assessment, dated [DATE], indicated that he/she was at high risk for wandering. - Care Plan interventions, dated [DATE] and [DATE], indicated that Resident #1 required supervision when ambulating and that he/she preferred to walk with his/her family throughout the Facility; - Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 had severe cognitive impairment, and had balance issues. - Resident #1's Treatment Record, dated for (MONTH) (YEAR), indicated that he/she had a Wanderguard device in place. On [DATE], during tour of Resident #1's unit with the Director of Nurses (DON) and the Administrator, the Surveyor made the following observations of the exit stairwell where Resident #1 was found: - The exit stairwell door through which Resident #1 reportedly gained access to the stairwell, was equipped with a keypad alarm; - Signage on the exit stairwell door indicated that it was alarmed, but could be opened if the push bar was held down for 15 seconds; - The stairwell consisted of an approximately three foot square landing, which lead to 10 stairs down to another landing before a 180 degree turn to the left, which lead to another 9 stairs to the bottom of the stairwell; - The landings, railings and stairs appeared to be constructed of metal and concrete-type materials; - There was an approximate three foot square alcove area to the right of the bottom of the stairwell, with a door leading to an interior corridor of the Facility; - Visualization of the alcove when descending the stairwell was limited until approaching the bottom of the stairwell; and, - The Surveyor was unable to see where the DON indicated Resident #1's head was in the alcove where he/she was found until approximately three stairs from the bottom of the stairwell. The Surveyor interviewed the DON at 7:21 A.M. and at multiple times throughout the date of survey. The DON said Resident #1 resided on a secured unit and all of the exit doors on the unit were equipped with a keypad alarm, which required a code to deactivate. The DON said the Wanderguard system (a system designed to sound an alarm when a resident wearing a device comes within close proximity to a corresponding device, usually on a door or elevator) was only in place for the elevator servicing Resident #1's unit, and the stairwell and elevator located off of Resident #1's unit. The DON said the exit stairwell door accessed by Resident #1 on his/her unit was not equipped with the Wanderguard system. The Surveyor interviewed Unit Manager #1 at 12:46 P.M. on [DATE]. Unit Manager #1 said Resident #1 was known to wander throughout the unit and would follow staff to the exit doors. The Surveyor interviewed Nurse #2 at 1:06 P.M. on [DATE]. Nurse #2 said Resident #1 was known to pace throughout the unit, had tried to exit the unit previously, and had been found off of the unit in the past. The Surveyor interviewed Nurse #3 at 1:20 P.M. on [DATE]. Nurse #3 said Resident #1 was known to walk and try to exit the unit all of the time, or words to that effect. The Surveyor interviewed Nurse #1 at 9:16 A.M. and at multiple times on [DATE]. Nurse #1 said she had seen Resident #1 push on the door to the exit stairwell a couple of times, but said it was never long enough to activate the alarm on the door. Nurse #1 said Resident #1 had a Wanderguard device in place, but said that the door he/she went through on [DATE] was not equipped with a corresponding Wanderguard device. The Surveyor interviewed the Medical Director at 12:45 P.M. on [DATE]. The Medical Director said he was Resident #1's attending physician. The Medical Director said that Resident #1 was known to wander, but said he was not aware of any attempts by Resident #1 to exit his/her unit. Unit Manager #1 said she heard the exit stairwell door alarm sound at approximately 11:10 A.M., which was shortly after she had completed a progress note in a residents record, and the progress note was electronically timed stamped at 11:08 A.M., as completed. Nurse #1 said that on the morning of [DATE], exact time unknown, she was in a dining area on Resident #1's unit administering medications when she heard an alarm sound. Nurse #1 said she finished administering the medications and then went to the door where the alarm was sounding. Nurse #1 said she opened the door, which lead to an exit stairwell, and did not see anyone. Nurse #1 said she entered the exit stairwell and proceeded down a few stairs, and then stopped to lean over the railing to look down to the bottom of the stairwell. Nurse #1 said she did not see anyone and the exterior exit door was closed, and so she went back to the unit. Nurse #1 said she was unable to recall the code to deactivate and reset the door alarm, and went to get CNA #1 to assist her. - Observations of Resident #1's unit indicated that the dining area Nurse #1 said she was in at the time the exit stairwell door alarm sounded placed Nurse #1 a minimum of 50 feet away from the stairwell door. The Surveyor interviewed CNA #1 at 9:06 A.M. on [DATE]. CNA #1 said she was behind a closed door in a resident's room two doors away from the exit stairwell door when the alarm reportedly sounded, and said she did not hear the alarm sound. The Surveyor interviewed CNA #3 at 1:51 P.M. on [DATE]. CNA #3 said she was providing care behind a closed door in a resident's bathroom three rooms away from the exit stairwell door when the alarm reportedly sounded. CNA #3 said she could not hear the alarm sound from behind closed doors. CNA #1 said Nurse #1 came to the room she was in, exact time unknown, and asked for help to deactivate and reset the exit stairwell door alarm. CNA #1 said she assisted Nurse #1 with the deactivating the alarm and then went back to providing care. CNA #1 said she did not check the exit stairwell, and said she did not know if other staff had checked the stairwell when the alarm sounded. CNA #1 said sometime time later, exact time unknown, she left Resident #1's unit for her break, using the same exit stairwell door that the alarm had sounded in earlier. CNA #1 said she went to get Nurse #1 for assistance after seeing an unidentified person at the bottom of the stairs. Nurse #1 said that after the exit stairwell door alarmed, exact time unknown, she saw CNA #1 leave the unit using the same exit stairwell door that had alarmed previously. Nurse #1 said CNA #1 quickly returned to the unit and appeared panicked. Nurse #1 said CNA #1 asked her for assistance in the exit stairwell because there was an unidentified person on the floor. Nurse #1 and CNA #1 said that when they got to the bottom of the exit stairwell, they were able to identify the person as Resident #1. Nurse #1 and CNA #1 said Resident #1 was lying on the floor in a small area to the side of the stairwell, with blood on his/her head, face and on the floor from an unknown source, and said Resident #1's cheek was swelling. Nurse #1 and CNA #1 said Resident #1 was saying help me, help me, or words to that effect. Nurse #1 and CNA #1 said CNA #1 ran back up the stairs to Resident #1's unit for assistance and to alert staff to call 911 while Nurse #1 stayed with Resident #1. Nurse #2 said during her shift on the day of the incident, exact time unknown, she saw CNA #1 come through the exit stairwell door, gesture at Nurse #1 and say that someone was in the stairwell. Nurse #2 said that Nurse #1 and CNA #1 went into the stairwell, and CNA #1 came back onto the unit, saying to call 911 and that Resident #1 was in the floor in the stairwell and that there was a lot of blood. Nurse #2 said she called the ambulance provider directly to find out if an ALS (Advanced Life Support) ambulance was available, instead of calling 911. Unit Manager #1 said that a few minutes after the exit stairwell door alarmed, CNA #1 came running down the hallway saying to call 911 because Resident #1 had gone down the stairs and there was blood everywhere. Unit Manager #1 said she grabbed the code cart (a set of trays/drawers/shelves on wheels used for the transportation and dispensing of emergency medication/equipment at the site of a medical emergency), and brought it to the stairwell door. Unit Manager #1 said she could not see Resident #1 until she got to the bottom of two flights of stairs as Resident #1 was lying in an alcove to the right of the bottom of the stairs. Unit Manager #1 said Resident #1 had blood under his/her head, a visible bruise to the right side of his/her face, and a bleeding laceration to the right side of his/her face. Unit Manager #1 said Resident #1 was responsive to staff, and kept saying help me, help me, or words to that effect. Unit Manager #1 said she went to retrieve first aid supplies from the code cart, and said Nurse #3 and Nurse #4 responded to the exit stairwell to assist. The Surveyor interviewed Nurse #4 at 1:32 P.M. on [DATE]. Nurse #3 and Nurse #4 said they responded to an overhead page for help on Resident #1's unit, exact time unknown. Nurse #4 said she called Resident #1's unit, and was told that someone had gone down the stairwell. Nurse #3 and Nurse #4 said they responded to Resident #1's unit, and were directed by Unit Manager #1 to go down the exit stairwell because Resident #1 had fallen. Nurse #3 and Nurse #4 said that as they proceeded down the exit stairwell, they did not see Resident #1 until they were near the bottom of the stairs because Resident #1 was lying in an alcove to the right of the bottom of the stairs. Nurse #3 and Nurse #4 said Resident #1's right eye was bruised and swollen shut, and there was blood to the majority of the right side of Resident #1's face. Nurse #3 said that after cleaning Resident #1's face, they realized he/she had a laceration to the right side of his/her head. Nurse #3 said that staff had to apply pressure dressings (dressings which exert pressure to stop bleeding) and ice packs to try to stop the bleeding. Nurse #4 said Resident #1 was lying on the floor in a pool of blood, and had a wound to his/her right temporal area (side of the head towards the eye area). The DON said the area where Resident #1 was found in the stairwell, in addition to the position he/she was found in, would have prevented staff from seeing him/her unless they descended almost all of the way down the stairs. The DON said staff was not able to assess Resident #1's pupils (altered pupil response could indicate possible head injury) because of facial swelling, particularly around his/her right eye. The DON said the Medical Director was in the Facility at the time of the incident and was able to assist in the assessment of Resident #1. The Medical Director said he was at the Facility on the morning of [DATE] when he heard a call for assistance on Resident #1's unit. The Medical Director said he went to Resident #1's unit and was told that a resident was down in the stairwell. The Medical Director said that when he saw Resident #1, it was obvious that he/she had a significant head injury. The Medical Director said Resident #1 was semi-conscious but was able to speak, had dense (localized) swelling of the right side of his/her face, diffuse ecchymosis (widespread bruising) of the right eye, and had a lot of blood coming from a right frontal-temporal (side of the head closer to the temple) laceration. The Medical Director said Resident #1's right eye was swollen shut, and he had to pry his/her eye open to check pupil response. The Medical Director said that given the location where Resident #1 was found and how he/she was positioned, staff would not have seen him/her unless they went all of the way down the stairwell. The Medical Director said he was not surprised to hear about the extent of Resident #1's documented injuries based on his observations of Resident #1's injuries at the Facility. Review of the Ambulance Provider's Patient Care Report, dated [DATE], indicated that a request for services was received at 11:16 A.M. on [DATE] and that an ambulance was on scene 15 minutes later. The Report indicated Resident #1 would have benefited from a 911 response, as the responding ambulance had been two towns away. The Report also indicated that Resident #1's injuries included: complaints of head pain, a ,[DATE] centimeter laceration beside the right eye, the right eye was blackened and swollen shut, a ping-pong ball sized hematoma (a collection of blood outside of the blood vessels, most commonly caused by injury) to the top of the head, and a small skin tear to the right knee with some swelling and minimal bleeding. The Report indicated that Resident #1 vomited en route to the Hospital, and had to be rolled to the side to prevent aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airways). Review of Resident #1's Hospital Discharge Summaries, dated [DATE], indicated that Resident #1 presented to the Hospital as a level II trauma. The Division of Trauma and Surgical Critical Care define level II trauma criteria, for patients aged 16 and older, to include: facial trauma or suspected fractures with no airway compromise; and, minimal external bleeding with stable vital signs. The Division's recommendations included upgrading the emergency response to a level I trauma (most critical) for patients aged [AGE] years and older. The Hospital Discharge Summaries also indicated that Resident #1's injuries and conditions included: - In the emergency department: Resident #1 was suctioned for emesis (vomit) in his/her mouth, placed on oxygen due to a low blood saturation level in the 80%'s (normal range is 94% to 99%), and had an episode of [MEDICAL CONDITION] (low blood pressure) with a systolic blood pressure in the 80s (normal is ,[DATE]); - Observed injuries included: large lateral right orbital (eye socket area) hematoma; vertical laceration adjacent to the right orbital hematoma with clotting and slight oozing; his/her right eyelids were ecchymotic (bruised) and swollen shut; infraorbital right sided swelling (swelling in the tissues around the eyes) with bruising and tenderness; a right shoulder bruise; and, right knee bruising and a superficial abrasion; and, - Computed Tomography scans (CTs; multiple X-ray measurements taken from different angles to produce cross-sectional images of specific areas) indicated: a traumatic right subarachnoid hemorrhage (SAH; bleeding in the area between the brain and the tissue covering the brain); a traumatic right subdural hemorrhage (SDH; a collection of blood between the brain and the tissue covering the brain); a possible right [MEDICATION NAME] hemorrhage (EDH; a collection between the tissue covering the brain and the skull); midline shift (occurs when the pressure exerted by the buildup of blood and swelling around the damaged brain tissues is powerful enough to push the entire brain off center); a right orbit fracture; a right maxillary sinus (bone near the sinus cavities) fracture; a right sphenoid (one of the bones that make up the back of the eye sockets) fracture; a right zygomatic arch (cheekbone) fracture; an iliac wing fracture (outer portion of the pelvic bone); a possible L1 (first vertebra of the lumbar (lower spine) fracture; and, fractures of the right 4th, 5th, 6th, 7th and & 9th ribs. The DON said Resident #1 was discharged from the Hospital to hospice care on [DATE], and died approximately four days later. On [DATE], the Facility provided the Surveyor with a Plan of Correction which indicated that the Facility addressed the concerns as of [DATE], as evidenced by: A. Resident #1 was discharged from the Facility on [DATE]. B. The Facility provided the Surveyor with documentation, dated [DATE] through [DATE], which indicated that staff from all departments were educated on the Facility's elopement policy; expected response to alarms, including a physical check of the area near where the alarm sounded, and a head count if no one was found; and, that exit stairwells were to be used in the event of an emergency only. C. The Facility provided the Surveyor with documentation, dated [DATE] and ongoing, which indicated that 15 minute checks were instituted to check all doors and to verify the location of all residents. D. The Facility provided the Surveyor with documentation, dated [DATE] through [DATE], which indicated that all residents were reassessed for elopement/wandering risk. E. The Director of Nursing (DON) conducted chart audits to ensure that residents determined to be at risk for elopement/wandering had care plans in place. F. The Facility provided the Surveyor with documentation, dated [DATE], which indicated that the Facility's Elopement Books were updated, including new resident photographs as needed, on all nursing units, laundry department, dietary department, and the front desk. G. The Facility provided the Surveyor with documentation, dated [DATE], which indicated that all door alarms were assessed for proper functioning. H. The Facility provided the Surveyor with documentation, dated [DATE], which indicated that an ad-hoc QAPI (Quality assurance and Performance Improvement) meeting was held to discuss corrective actions in relation to Resident #1's incident on [DATE]. The DON said the corrective actions put forth would be discussed at Facility QAPI meetings through at least (MONTH) (YEAR). As part of the Facility's ongoing QAPI Plan, the Facility provided the Surveyor with documentation that velcro across-the-door stop signs were placed on all stairwell doors by maintenance and administration on [DATE]; an upgraded Wanderguard system was ordered on [DATE]; and, random Elopement/Missing Resident drills were started on [DATE], and would be conducted for 3 months to test employee response to alarms, the checking of stairwells and exit doors.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent Resident #1 from being verbally abused by Certified Nurse Aide (CNA) #1, who was witnessed by visitors and staff to be yelling at Resident #1, stomping her foot forcefully in front of Resident #1, and continued to yell at Resident #1 despite being asked to stop, which resulted in Resident #1 becoming frightened and observed to be crying, after the incident. - On 10/20/17, CNA #1 was observed standing in front of Resident #1, then stomping her foot on the floor in front of Resident #1 forcefully enough to shake the floor, and heard yelling in a loud voice words to the effect, Jesus Christ! Jesus Christ is the only Lord! Go! Go! CNA #1 said she could see, feel and hear evil spirits that were attacking Resident #1 and she was trying to rid the evil spirits from Resident #1. Resident #1 told CNA #1 to stop yelling at him/her and said that CNA #1 was scaring him/her. Despite being asked by Resident #1 to stop, CNA #1 kept yelling at Resident #1 and stomping her foot at Resident #1. CNA #1 did not stop this behavior until staff intervened. Resident #1 was observed by several witnesses to be frightened and crying after CNA #1 after the incident. The witnesses were consistent with their account of the incident and validated that Resident #1 was upset and scared by CNA #1's actions towards him/her. Findings include: The Facility's Abuse Prevention Program Policy, revised 12/2016, indicated that the residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat a resident's symptoms. As part of the resident abuse prevention, the Administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The Quarterly Minimum Data Set (MDS) Assessment, completed 9/22/17, indicated that Resident #1 had severe cognitive impairment and had a [DIAGNOSES REDACTED]. The Internal Investigation, dated 10/20/17, indicated that, at approximately 6:10 P.M. on 10/20/17, Visitor #1 told Nurse #1 that Certified Nurse Aide (CNA) #1 was yelling and scaring Resident #1 in the Activity room. The Investigation indicated that Nurse #1 immediately responded and heard someone yelling Jesus Christ, and heard a stomping noise and, upon entering the activity room, Nurse #1 observed CNA #1 standing to the right of Resident #1, leaning towards him/her, and she heard no further yelling or stomping when she entered the room. The Investigation indicated Nurse Supervisor #1 also entered the Activity room and escorted CNA #1 out of the area and that Nurse Supervisor #1 notified the supervisor on-call, and that the Director of Nurses (DON), the Administrator and the local police were notified. The Investigation indicated that Visitor #1 told the DON that CNA #1 was stomping her foot and was screaming Jesus Christ and Resident #1 was getting upset and said to CNA #1 words to the effect, You are scaring me, I want to go home and stop yelling at me. Visitor #1 said CNA #1 continued stomping her foot and yelled Jesus Christ at Resident #1, approximately a half dozen times. The Investigation indicated Visitor #1 said Resident #1 stated that he/she loved God and everyone, and that CNA #1 seemed angry. The Investigation indicated that Visitor #2 told the DON that CNA #1 stomped her foot and pointed her hand over Resident #1 and yelled, Go! Go! and that Resident #1 said to CNA #1, what are you - a crazy person? The Investigation indicated CNA #1 kept saying Jesus Christ at Resident #1 and loudly stomped her foot repeatedly. The Investigation indicated CNA #2 said she went to the activity room as she heard Visitor #1 report to Nurse #1 that something was going on and, upon entering the activity room, CNA #2 said she heard Resident #1 yelling back at CNA #1 saying that he/she was scared. The Investigation indicated Patrol Officer #1 and the DON interviewed CNA #1 who said that she was a preacher and she was trying to release Resident #1 of his/her demons. The Surveyor interviewed Visitor #1 at 3:29 P.M. on 2/2/18 and Visitor #2 at 1:24 P.M. on 2/2/18. Visitor #1 and Visitor #2 said they observed CNA #1 stomp her right foot on the floor in the activity room, approximately six times near Resident #1 and so forcefully that you could feel the vibrations in the floor from the stomping, and then CNA #1 yelled at Resident #1, Jesus Christ, approximately six times. Visitor #1 and Visitor #2 said that these actions by CNA #1 also upset Resident #2, who they were visiting. Visitor #1 and Visitor #2 said that Resident #1 was getting nervous and upset and asked, What is going on over there? Why is she (CNA #1) yelling? Visitor #1 said she heard CNA #1 yell at Resident #1 Jesus Christ is the only Lord. Visitor #1 said she heard Resident #1 tell CNA #1, in response to being yelled at, words to the effect, I love God, you are scaring me, I want to go home, and stop shouting at me! Visitor #1 said CNA #1 did not stop, so she left the activity room and reported this incident to Nurse #1. Visitor #2 said that she heard CNA #1 also say, Go! Go! to Resident #1, and Resident #1 clutched at his/her own shirt and said to CNA #1, in response to being yelled at, words to the effect, Get away from me! You are crazy! Leave me alone! The Surveyor interviewed Nurse #1 at 11:31 A.M. on 2/2/18. Nurse #1 said she was at the nurses' station and she heard a stomping noise and, while on her way to the activity room to check out the noise, she heard CNA #1 yell Jesus Christ! one to two times. Nurse #1 said, after she entered the activity room, she observed CNA #1 lean towards Resident #1 and yell Jesus Christ! another two times and CNA #1 stomped her right foot loudly on the floor. Nurse #1 said Resident #1 cried in response to being yelled at, and said, She (CNA #1) is crazy! Nurse #1 said the Nurse Supervisor #1 happened to be walking down the corridor at the time and she called Nurse Supervisor #1 over for assistance. Nurse #1 said that after she entered the activity room, then CNA #1 then stopped her actions towards Resident #1. The Surveyor interviewed Nurse Supervisor #1 at 12:35 P.M. on 2/2/18. Nurse Supervisor #1 said she was in the hallway and heard a loud banging sound coming from the activity room. Nurse Supervisor #1 said before she entered the activity room, she heard a loud bang and bang and could feel the vibrations on the floor under her foot. Nurse Supervisor #1 said Nurse #1 told her that CNA #1 started stomping her foot and screaming about Jesus Christ to Resident #1. Nurse Supervisor #1 said she heard CNA #1 yell Jesus Christ and when she entered the room, Resident #1 looked frightened and he/she said CNA #1 was stomping her foot and screaming about Jesus. Nurse Supervisor #1 said she told CNA #2 to help take care of Resident #1 and CNA #2 escorted Resident #1 to the day room while Nurse Supervisor #1 took CNA #1 to the Nurses' station and then to the chart room for questioning and she informed the DON about this incident. The Surveyor interviewed CNA #2 at 11:02 A.M. on 2/2/18. CNA #2 said that she was in the hallway at the time and Visitor #1 told Nurse #1 saying something was going on in the activity room so she went to the room with Nurse #1 and she observed CNA #1 stomp her foot at Resident #1 and yell the words Jesus Christ! CNA #2 said Resident #1 said, in response to being yelled at by CNA #1, words to the effect, I am scared of her (CNA #1)! I am scared of her (CNA #1). CNA #2 said that Resident #1 was crying in response to this incident. The Surveyor interviewed Patrol Officer #1 at 2:07 P.M. on 2/2/18. Patrol Officer #1 said, and the Police Report, dated 10/20/17 indicated, Visitor #1 told him that CNA #1 stomped her feet loudly at Resident #1 and yelled extremely loud, Jesus Christ. Patrol Officer #1 said Resident #1 told him that CNA #1 had, yelled at him/her, something about religion. Patrol Officer #1 said that CNA #1 told him that she was trying to rid the Resident #1 of demons that she (CNA #1) saw in Resident #1, and to do so, she had to yell at Resident #1 and stomp her feet loudly. The Surveyor interviewed the Director of Nurses (DON) at 2:55 P.M. on 2/2/18. The DON said CNA #1 told her that she was a preacher, that there were demons in Resident #1, and that she (CNA #1) was trying to release the demons from Resident #1. The DON said that CNA #1 told her that the resident was saying things about her own sister, who did not work at the Facility. The Surveyor interviewed CNA #1 at 11:52 A.M. on 2/5/18. CNA #1 told the Surveyor that, at approximately 6:00 P.M. on 10/20/17, she could see that Resident #1 was being attacked by demons, and that she was trying to take the demons out of Resident #1. CNA #1 said she heard the evil spirit who told her things about her own sister and that this was a warning. CNA #1 said she called on Jesus Christ for help and stomped her foot and said to Resident #1, Jesus Christ! Go! Leave! When the Surveyor asked CNA #1 what the demons looked like, CNA #1 said she saw the evil spirit, but she could not describe it, but the evil spirit had no form, color, or shape. CNA #1 said she couldn't explain it, but said she could feel and hear the evil spirit. CNA #1 said she did not get permission from Resident #1 ahead of time to try and rid him/her of the evil spirits because it came on all of a sudden. CNA #1 said she was trying to take the evil spirit out of Resident #1 and the Facility because it did not belong there. Resident #1 was unable to be interviewed by the Surveyor because he/she was no longer at the Facility. The DON said when she spoke with Resident #1 on the evening of the incident, that he/she did not have any recall of of what had happened. Although Resident #1 was unable to recall the incident to the DON due to his/her cognitive impairment, the Reasonable Person Concept presumes that an unimpaired individual would experience pain and mental anguish from having someone stomp their feet loudly multiple times, while standing in front of them, with enough force to cause the floor to vibrate, and at the same time being yelled at loudly.