Every finding on record at St Francis Rehabilitation & Nursing Center

Based on observations and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infection for three Residents (#33, #89, #78) out of a total sample of 24 residents.Specifically,1) for Resident #33, the facility failed to ensure that nursing staff performed hand hygiene as required during glove changes while providing wound care.2) for Resident #89, the facility failed to ensure that appropriate Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn as required when nursing staff failed to don gowns while providing high-contact care for the Resident with a Physician's order for Enhanced Barrier Precautions (EBP).3) for Resident #78, the facility failed to: -perform hand hygiene as required upon entering and exiting the room of the Resident on Droplet Precautions (precautions used to prevent transmission of infectious agents spread through respiratory droplets), and -ensure a gown was worn by staff as required to enter the room, and a face mask was changed after exiting the room of the Resident who was on Droplet Precautions, placing other residents and staff at risk for the spread of infection. Findings include: Review of CDC Guidelines for Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revised 6/28/24, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html indicated: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. -Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gowns and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. -Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Review of the facility policy titled Enhanced Barrier Precautions, revised 3/31/25, indicated: -High-contact Resident care activities requiring gown and glove use for Enhanced Barrier are defined as: dressing, bathing/showing, transferring, providing hygiene care, changing linens, changing briefs, or assisting with toileting, and device care that includes Central Venous Access Devices, Urinary catheters, gastrostomy tubes, and wound care that requires dressing. -Wounds generally include chronic wounds. -Use gowns and gloves while providing high contact care activities. Review of the facility policy titled Enhanced Barrier Precautions, revised 4/29/20, indicated: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a) After removing gloves. b) After handling used dressings, contaminated equipment, etc. 1) Resident #33 was admitted to the facility in October 2025 with diagnoses including Malignant Neoplasm of Bone. Review of Resident #33's November 2025 Physician orders indicated: -Coccyx: wash with warm wound cleanser, pat dry, apply Calcium Alginate to wound bed followed by dry clean dressing every day shift, start date 11/3/25. -Enhanced Barrier Precautions secondary to history of ESBL (Extended-Spectrum Beta-Lactamase bacteria) in urine, start date 11/3/25. On 11/20/25 at 1:00 P.M., the surveyor observed the following while Nurse #1 was providing wound care for Resident #33: -Nurse #1 washed her hands with soap and water and donned a gown and gloves. -Nurse #1 repositioned the Resident to his/her side, then removed the Resident's old dressing from his/her wound. -Nurse #1 doffed her gloves then donned new gloves without performing hand hygiene. -Nurse #1 cleansed the wound bed, doffed her gloves and donned new gloves without performing hand hygiene. -Nurse #1 applied the new treatment to the Resident's wound, reached into her pocket while still wearing soiled gloves, removed a pen and dated the wound dressing. -Nurse #1 doffed her gloves and donned new gloves without performing hand hygiene. -Nurse #1 repositioned Resident #33 in bed. During an interview on 11/20/25 at 1:30 P.M., Nurse #1 said she performed hand hygiene before beginning the dressing change for Resident #33 and did not perform hand hygiene between doffing and donning new gloves. Nurse #1 said she should have performed hand hygiene before donning new gloves, but she did not. 2) Resident #89 was admitted to the facility in July 2025 with diagnoses including Crohn's disease. Review of Resident #89's November 2025 Physician's orders indicated: -Enhanced Barrier Precautions (EBP) secondary to ESBL in urine, start date 7/16/25. On 11/19/25 at 9:25 A.M., the surveyor observed an EBP sign at Resident #89's door. The surveyor observed CNA (Certified Nurse's Aide) #1 and CNA #2 transferring Resident #89 from bed to chair with a Hoyer lift (mechanical device that helps people with mobility issues transfer safely between surfaces). The surveyor further observed that neither CNA #1 nor CNA #2 was wearing a protective gown while transferring Resident #89 from the bed to the chair. During an interview on 11/19/25 at 9:43 A.M., CNA #1 said she had removed her gown to look for a Hoyer lift and did not don a new gown to transfer Resident #89 from the bed to the chair but should have. During an interview on 11/19/25 at 9:45 A.M., CNA #2 said she should have worn a gown to transfer Resident #89, but she did not. During an interview on 11/19/25 at 9:50 A.M., Nurse #1 said Resident #89 was on EBP for ESBL in the urine. Nurse #1 said CNA #1 and CNA #2 should have a gown on during the Hoyer lift transfer of the Resident, but they did not. Review of the facility policy titled, Transmission Based Precautions, revised 5/5/23, indicated: -Droplet Precautions: used for diseases or germs that are spread into tiny droplets caused by coughing and sneezing (examples: respiratory MRSA pneumonia, influenza, whooping cough, bacterial meningitis, RSV, Covid-19) -When Transmission Based Precautions (TBP- second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) are implemented, the Infection Preventionist (or designee): >Clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used. >Determines the appropriate notification on the room entrance door so that personnel and visitors are aware of the need for and type of precautions. -Source control: put a mask on the patient. -Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space. 3) Resident #78 was admitted to the facility in September 2025 with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA) of the nares. Review of the Resident #78's November 2025 Physician Orders indicated: -Maintain Droplet Precautions for +(positive) MRSA nasal every shift, initiated 9/24/25. On 11/20/25 at 10:29 A.M., the surveyor observed the following: -Signage outside Resident #78's room that indicated: *Droplet Precautions: >Perform hand hygiene before entering room and exiting room >Mask while in room >Apply a new gown before entering room and remove it when leaving room -CNA #3 was wearing a mask, did not perform hand hygiene, and did not don a gown prior to entering Resident #78's room. -CNA #3 stood at Resident #78's bedside and then removed the Resident's breakfast tray and exited the room. -CNA #3 did not perform hand hygiene upon exiting the Resident's room. -CNA #3 did not remove her mask or don a new mask upon exiting the room. During an interview on 11/20/25 at 10:29 A.M., CNA #3 said she did not know why Resident #78 was on Droplet Precautions, but according to the signage outside of the Resident's room, she should have performed hand hygiene, donned gloves, and donned a gown before entering the room, CNA #3 said she should have performed hand hygiene when exiting the room but did not because she was picking up a breakfast tray. During an interview on 11/20/25 at 10:33 A.M., Unit Manager (UM) #1 said CNA #3 should have performed hand hygiene and donned PPE according to the signage outside of Resident #78's room, even if the CNA was just picking up a breakfast tray. During an interview on 11/21/25 at 1:18 P.M., the Infection Preventionist (IP) said staff should be donning and doffing PPE according to the signage outside Resident #78's room. The IP said that CNA #3 should have washed her hands prior to entering and exiting the room and should have changed her mask when leaving the room to prevent spreading the infection to another person.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#74) of two applicable residents who require hemodialysis, and have a Central Venous Catheter (CVC - a flexible tube inserted into a large vein in the chest for exchanging blood between a patient and a hemodialysis machine), out of a total sample of 24 residents.Specifically, for Resident #74, the facility failed to ensure that an emergency kit including a non-toothed clamp was always available at the Resident's bedside as ordered by the Physician, when a CVC catheter was in use, for the management of dialysis emergencies related to the CVC catheter. Findings include: Resident #74 was admitted to the facility in April 2025, with diagnoses including dependence on renal dialysis, End Stage Renal Disease (ESRD), and Anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #74:-was cognitively intact as evidenced by a Brief Mental Status (BIMS) score of 13 out of a possible score of 15.-was receiving Dialysis treatment. Review of Resident #74's November 2025 Physician's orders indicated:-Dialysis on Monday, Tuesday, Wednesday, Thursday, and Friday, start date 4/25/25.-Non-toothed clamp at bedside at all times when dialysis catheter is in use, start date 4/25/25. Review of the November 2025 Medication Administration Record (MAR) indicated that Resident #74 received dialysis every Monday, Tuesday, Wednesday, Thursday, and Friday. On 11/19/25 at 10:18 A.M., the surveyor observed Resident #74 sitting in a wheelchair in his/her room. The surveyor observed a Central Venous Catheter (CVC) with a dressing on the Resident's right chest wall. The surveyor did not observe an emergency non-toothed clamp or any other emergency supplies in Resident #74's bedroom. During an interview at the time, Resident #74 said he/she went to dialysis at 7:00 A.M on Mondays, Tuesdays, Wednesdays, Thursdays and Fridays. Resident #74 further said he/she was unsure of what an emergency non-toothed clamp was. On 11/20/25 at 10:45 A.M., the surveyor failed to observe an emergency non-toothed clamp in Resident #74's bedroom. During an interview at the time with Unit Manager (UM) #2, the surveyor asked if there were any emergency supplies available in the event of any bleeding emergency related to the Resident #74's dialysis CVC site. UM #2 said that there should be a non-toothed clamp available and mounted on the back of the Resident's headboard. The surveyor and UM #2 were unable to locate an emergency non-toothed clamp or any other supplies for use in the event of a bleeding emergency related to the Resident's CVC, mounted on the Resident's headboard or anywhere else in the Resident's bedroom. UM #2 said the emergency supplies including a non-toothed clamp should be available in the Resident's bedroom and unit but there was none. During an interview on 11/20/25 at 12:58 P.M., the Director of Nursing (DON) said that there should be emergency supplies including a non-toothed clamp mounted on the back of the headboard for any Resident with dialysis access ports.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and had a history of wandering in his/her wheelchair, the Facility failed to ensure he/she was free from physical abuse by a staff member, when on 07/19/25, Certified Nurse Aide (CNA) #1, after seeing Resident #1 exiting another resident's room with an object in his/her hands, that did not belong to him/her, CNA #1 slapped his/her hand and grabbed the object away from him/her, all of which was captured on video by a visitor.Findings include:Review of the Facility's Policy titled Abuse Prohibition Guideline, dated as revised 10/24/22, indicated the policy was to maintain a zero tolerance for any form of abuse or neglect of a resident. The Policy indicated the Facility would assure that staff uses caring, ethical, and professional behavior in all relationships with residents.Further review of the Policy indicated the definition of Physical Abuse included but was not limited to hitting, slapping, pinching, and kicking.Review of the Facility's Internal Investigation Summary, undated, indicated that on 07/19/25, a visitor video recorded their family member (a resident) during a meal, with their phone. The Summary indicated that a few days later, the Visitor discovered the video had captured an altercation between a resident and a staff member. The Summary indicated the Visitor shared the video footage of the altercation with the Director of Social Services during a meeting on 07/24/25 at approximately 1:02 P.M. The Summary indicated the video footage showed the following:- Resident #1 was sitting in his/her wheelchair in another resident's bedroom doorway, across from where the Visitor was recording with her phone. - CNA #1 approached Resident #1 and made contact with the top of his/her (Resident #1) left hand, using her right hand, and repeatedly told him/her Stop, stop, stop. - CNA #1 took a glass cross from Resident #1's hands. - Resident #1 did not appear to react and instead self-propelled his/her wheelchair away from CNA #1. The Summary indicated that Resident #1 did not have any bruises, marks or pain following the incident, and had full range of motion in his/her hand.The Summary further indicated that CNA #1 told the Director of Nursing (DON) that she tapped Resident #1's hand and then grabbed the glass cross from his/her hands, because he/she had been in another resident's room going through their belongings and she thought the glass cross did not belong to him/her. The Summary indicated CNA #1 was suspended pending investigation on 07/24/25 and later terminated on 07/31/25. Resident #1 was admitted to the Facility in September 2020, diagnoses included moderate unspecified dementia and osteoarthritis of the left hand. Resident #1 resided in the Memory Care Unit.Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 06/26/25, indicated Resident #1 was severely cognitively impaired with a score of 1 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). The Assessment indicated Resident #1 exhibited wandering behavior 1 to 3 days per week, during the assessment period.Review of Resident #1's Behavior Care Plan, dated as reviewed 07/10/25, indicated Resident #1 had episodes of wandering the halls looking for a new room. Interventions identified for Resident #1 included redirection using a diversional activity when he/she was agitated about his/her room and offering prayer books, visits and musical programs of interest. During an interview on 08/05/25 at 12:58 P.M., Certified Nurse Aide #2 said that she worked full time in the Memory Care Unit and often provided care to Resident #1. CNA #2 said that Resident #1 sometimes wandered into other resident rooms and took their belongings. CNA #2 further said that Resident #1 generally responded well to redirection and would often release objects in his/her hands when engaged or reapproached. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 07/24/25, indicated that CNA #1 stated she tapped Resident #1's hand and grabbed the cross from him/her. The Surveyor was unable to interview CNA #1 as she did not respond to the Department of Public Health's telephone or letter requests for an interview. During a telephone interview on 08/05/25 at 2:25 P.M., the Director of Social Services said that during a meeting on 07/24/25, a Visitor showed her a video that unknowingly captured an incident that occurred between a staff member and a resident. The Director of Social Services said that when she watched the video, she was able to identify the staff member as CNA #1 and the resident as Resident #1. The Director of Social Services said the video showed Resident #1 sitting in the doorway of another resident's room, holding a glass cross in his/her hands. The Director of Social Services said that CNA #1 came into view, slapped the top of Resident #1's hand and said repeatedly Stop, stop, stop. The Director of Social Services said that CNA #1 then pulled the glass cross from Resident #1's hands. The Director of Social Services said the incident was immediately reported, and the video was shared with the Director of Nursing, the Administrator and Law Enforcement. The Director of Social Services said she subsequently requested that the Visitor delete the video to preserve Resident #1's privacy. During an interview on 08/05/25 at 3:06 P.M., the Administrator said that she was notified of the incident by the Director of Social Services on 07/24/25 and observed in the video that CNA #1 struck Resident #1's hand and took a glass cross from him/her. During an interview on 08/05/25 at 2:45 P.M., the Director of Nurses (DON) said that on 07/24/25 the Director of Social Services informed her of an altercation between CNA #1 and Resident #1 which had been captured on video by a visitor. The DON said she reviewed the footage and observed CNA #1 strike Resident #1's hand before removing a glass cross from him/her. The DON said that Resident #1 did not appear to react to the incident and showed no signs of injury or distress at the time or in the days that followed. The DON said that during the Facility's Internal Investigation it was determined that there were no direct witnesses to the 07/19/24 incident, and the only evidence was the video footage that was provided by the Visitor. The DON said that based on the review of this footage, the Facility substantiated the allegation of physical abuse, and CNA #1's employment was terminated on 07/31/25.

Based on interview, record and policy review, the facility failed to develop a comprehensive care plan for the use of anticoagulant (also known as blood thinner: used to prevent or treat blood clots in blood vessels and the heart) and antiplatelet (prevents platelets from sticking together and decreasing the body's ability to form blood clots) medications for two Residents (#8 and #78), out of a total sample of 24 residents. Specifically, the facility failed to: 1) develop a care plan for Resident #8 for Clopidogrel Bisulfate (Plavix: antiplatelet medication) that addressed the risks, potential side effects, and monitoring associated with the use of the medication. 2) develop a care plan for Resident #78 for Apixaban (Eliquis: anticoagulant medication) that addressed the risks, potential side effects, and monitoring associated with the use of the medication. Findings include: Review of the facility policy titled Anticoagulation Use Guideline revised 7/28/22, indicated the following: -the staff and Physician will monitor for possible complications in individuals who are being anticoagulated (being administered anticoagulant medications) and will manage related problems. -if an individual on anticoagulant therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (blood in sputum) or other evidence of bleeding, the Nurse will discuss the situation with the Physician before giving the next scheduled dose of anticoagulant. -the Physician will order measures to address any complications, including holding or discontinuing the anticoagulant (medication) as indicated 1) Resident #8 was admitted to the facility in May 2016, with diagnoses including Peripheral Vascular Disease (PVD: a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and Cerebral Vascular Accident (CVA/Stroke: interruption of blood flow to part of the brain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #8 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of a total score of 15. Review of the August 2024 Physician's orders indicated the following: -Clopidogrel Bisulfate 75 mg (milligrams), give one tablet by mouth one time a day related to Peripheral Vascular Disease, start date 6/18/18. Review of the August 2024 Medication Administration Record (MAR) indicated that Clopidogrel Bisulfate had been administered as ordered from 8/1/24 through 8/5/24. Review of Resident #8's clinical record indicated no evidence that a plan of care which included the risks, potential complications and monitoring for the medication use was developed for the Clopidogrel Bisulfate medication. 2) Resident #78 was admitted to the facility in March 2024 with a diagnosis of Cerebral Infarction (Stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #78 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15. Review of the August 2024 Physician orders indicated the following: -Apixaban Oral Tablet 5 mg, give one tablet by mouth two times a day, start date 6/19/24. Review of the August 2024 Medication Administration Record (MAR) indicated that Apixaban had been administered as ordered from 8/1/24 through 8/5/24. Review of Resident #78's clinical record indicated no evidence that a plan of care was developed for the Apixaban medication which included the risks, potential complications and monitoring for the medication use. During an interview on 8/06/24 at 7:30 A.M., the Director of Nurses (DON) said that every resident who was prescribed an anticoagulant medication should have a care plan in place for monitoring complications and side effects of the medication. The DON said that Resident #8 and Resident #78 did not have a care plan in place that included monitoring for potential complications and risks associated with the use of the anticoagulant medication, but they should have had a care plan in place.

Based on observation and interview, the facility failed to ensure a clean, safe, comfortable, and homelike environment for one Resident (#21) out of a total sample of 24 residents. Specifically, the facility failed to ensure that Resident #21's wheelchair was provided with preventative and routine maintenance and maintained in a clean, safe and homelike condition. Findings include: Resident #21 was admitted to the facility in June 2012, with diagnoses including Dementia (a group of conditions characterized by the impaired ability to remember, think, or make decisions that interferes with everyday activities), Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area), and need for assistance with personal care. Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a severe cognitive impairment as he/she was unable to complete the Brief Interview for Mental Status (BIMS) assement. Further review of the MDS indicated that he/she was dependent onstaff for Activities of Daily Living (ADLs- an individual's daily self-care activities). On 8/1/24 at 9:09 A.M., the surveyor observed Resident #21 sitting in a tilt and space (allows the seated person to maintain the correct posture while being tilted so pressure is distributed evenly across the body) wheelchair in the day room. The surveyor observed that Resident #21's wheelchair had areas that were covered in food debris, the left arm pad was worn enough to view the exposed padding underneath, the right-side pad next to his/her leg was torn exposing a large area of blue foam and the footrest extender was ripped with exposed white padding. On 8/5/24 at 8:14 A.M., the surveyor observed Resident #21 sitting in a tilt and space wheelchair in the day room. The surveyor observed that Resident #21 was sitting in the wheelchair that still had areas covered in food debris, the left arm pad with the exposed padding underneath, the right-side pad that was torn and exposing a large area of blue foam next to his/her leg and the footrest extender that was ripped with exposed white padding. The facility was unable to provide a preventative maintenance policy or cleaning policy for wheelchairs when the surveyor requested this information. The facility was also unable to provide a routine maintenance schedule for wheelchairs during the duration of the recertification survey. During an interview on 8/5/24 at 8:16 A.M., Unit Manager (UM) #1 said that depending on the type of concern, the Rehabilitation or Maintenance staff will manage the repair of wheelchairs in the facility. UM #1 also said that staff are expected to report a wheelchair concern into an electronic work order computer system called Tels after they see it. During an interview of 8/5/24 at 9:56 A.M., the Director of Nursing (DON) said that the facility staff are taught during their general new employee orientation training to put a wheelchair concern into the Tels system to generate a work order. Review of the facility's work orders summary dated 6/1/24 to 8/4/24, did not indicate that any facility staff had reported that Resident #21's wheelchair had been dirty and in a state of disrepair. During an interview on 8/5/24 at 1:08 P.M., the surveyor and Maintenance Staff #2 observed Resident #21's wheelchair in his/her bedroom. Maintenance Staff #2 said that he had not been made aware of the damage to Resident #21's chair and that it should have been repaired. During an interview on 8/5/24 at 1:15 P.M., Rehabilitation Staff #1 said that the wheelchair should have been cleaned and repaired, however Resident #21 was not receiving rehabilitation services at the time so the Rehabilitation staff had been unaware of the damage to the wheelchair.

Based on observation, interview, policy and record review, the facility failed to provide ongoing review of residents rights and services to residents during the residents stay, for six Residents who attended Resident Council. Specifically, the facility failed to conduct ongoing review of resident's rights and services with six Residents who attended monthly Resident Council meetings in the facility. Findings include: Review of the facility policy titled Resident Rights and Responsibilities Guideline, revised 5/25/22, indicated that the facility informs the Resident both orally and in writing, in a language that the Resident understands, of his/her rights and rules and regulation governing Resident conduct and responsibilities during their stay in the facility. Review of the Resident Council Meeting minutes for 2023 - 2024 failed to indicate that any resident rights had been reviewed during the Resident Council meetings that were held within the time period. On 8/5/24 at 11:02 A.M., the surveyor held a group meeting with six residents who had attended the Resident Council meetings. The Resident group said that the facility held monthly Resident Council meetings on a regular basis. The Resident group also said that no facility staff had reviewed their rights with them during these monthly Resident Council meetings. During observations on 8/5/24 and 8/6/24, on the third floor units where most of the Resident Council attendees reside, the surveyor did not see any written postings of Resident Rights and Services. During an interview on 8/6/24 at 9:23 A.M., the Administrator said that the staff holding Resident Council meetings had not been reviewing resident rights with the Resident Council Residents. The Administrator also said that the facility staff should have been doing this, but could not provide evidence that the staff in the facility had been reviewing residents rights and services with any of the Resident Council Residents.

Based on observation, interview and policy review, the facility failed to provide a dignified dining experience for one Resident (#97) out of total sample of 24 residents. Specifically, the facility staff remained standing while assisting Resident #97 during a breakfast meal. Findings include: Review of the facility policy titled Dining Guideline, last revised November 2017, indicated the following: -the goals of the dining experience are to enhance the individual's quality of life through person centered dining and providing person centered care and attention. -staff will listen, pay attention, and converse with each individual. On 8/5/24 at 8:30 A.M., the surveyor observed Certified Nurses Aide (CNA) #3 assisting Resident #97 with the breakfast meal while standing over the Resident who was seated in his/her wheelchair in the third-floor unit dining room. On 8/5/24 at 8:36 A.M., the surveyor and Nurse #2 observed CNA #3 assisting Resident #97 with the breakfast meal while standing over the Resident who was seated in his/her wheelchair in the third-floor unit dining room. During an interview at the time Nurse #2 said that CNA #3 should not have been standing over Resident #97 while assisting him/her with the breakfast meal. Nurse #2 said staff should be seated when the staff assist residents with their meals. During an interview on 8/5/24 at 8:38 A.M., CNA #3 said that she was standing over Resident #97 assisting him/her with breakfast because she does not like to sit down. CNA #3 said that she was supposed to be seated next to Resident #97 while assisting him/her with breakfast so that she could have eye contact and converse with the Resident. During an interview on 8/6/24 at 7:30 A.M., the Director of Nursing (DON) said staff should be seated while assisting residents with meals for dignity purposes. The DON also said that CNA #3 should have been seated next to Resident #97 while she assisted him/her with the breakfast meal.

Based on observation, interview, policy and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#48), out of a total sample of 24 residents. Specifically, the facility failed to ensure that Resident #48's oxygen concentrator (a medical device used to deliver supplemental oxygen) was maintained in a clean and sanitary manner to prevent contamination, the spread of infection and device malfunction when dust and debris was not being approppriately cleaned from the top rear air intake vent of the device. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: >Equipment maintenance and supervision: -All oxygen delivery equipment (concentrators, liquid systems, and cylinders) should be checked at least once daily -Facets to be assessed include proper function of the equipment -should be serviced and maintained in accordance with the manufacturer specifications and consistent with all federal, state, and local laws and regulations. Review of the user manual for Resident #48's oxygen concentrator dated 2017: CAIRE_Companion5 UserManual.pdf (caireinc.com) indicated: -Warning: Do not allow either the air intake or the air outlet vents to become blocked. Do not drop or insert any objects into any openings on the device. This can cause the oxygen concentrator to overheat and impair performance. -Select a location for the device that avoids the intake of smoke, fumes and pollutants. Correct placement of the device should allow intake of air through the three air intake locations at the top rear and underneath the [device]cabinet and allow for exhaust air to freely leave the exhaust vent at the bottom left of the device. -DO NOT block the air intake locations (top rear or underneath) or the exhaust vent (back bottom left and right). Resident #48 was admitted to the facility in January 2024, with diagnoses including COPD (Chronic Obstructive Pulmonary Disease- a chronic inflammatory lung disease that causes restrictive air flow and breathing problems) and Asthma (a condition in which airways narrow and swell [inflammation] making it difficult to breathe). Review of Resident #48's comprehensive care plan, last revised 5/9/24, indicated the Resident: -has altered respiratory status and difficulty breathing due to diagnoses of COPD exacerbation (increase in severity), Asthma and Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs). -an intervention to be maintained at their respiratory baseline with a patent (open) airway and unlabored respiration. -an intervention to provide support to the Resident to mitigate the risks related to aspiration up to including death. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #48 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of a total score of 15. Further review of the MDS assessment indicated that Resident #48 was dependent on staff for Activities of Daily Living (ADLs) and received oxygen therapy. Review of Resident #48's Physician's orders for August 2024, included: -Oxygen at 1.5 Liters via nasal cannula (a thin flexible tube that provides supplemental oxygen to patients through the nose via nasal prongs) continuous (delivered around the clock) every shift, start date 7/7/24 -Clean concentrator filter every day shift, every Thursday AND as needed (PRN), start date 8/21/23 Review of Resident #48's Treatment Administration Record for July 2024, indicated that the Resident's oxygen concentrator filter was cleaned on the following dates: -7/4/24 -7/11/24 -7/18/24 -7/25/24 On 8/1/24 at 9:28 A.M., the surveyor observed Resident #48 lying in bed with oxygen in use via nasal cannula. The surveyor also observed that the Resident's oxygen concentrator was dirty, with a thick layer of grey dust and two dried liquid spill stains with hair stuck to the spills on the top rear intake vent of the device. On 8/5/24 at 8:33 A.M., the surveyor observed that Resident #48's oxygen concentrator remained dirty with the thick layer grey dust and dried liquid spill stains with hair stuck to the spills on the top rear intake vent of the device. On 8/5/24 at 12:59 P.M., the surveyor and Unit Manager (UM) #1 observed Resident #48's oxygen concentrator in the Resident's room. UM #1 said the concentrator should have a filter on it, that the filter appears to be missing and there is a thick grey dusty coating on the area where the filter is supposed to be placed. During an interview on 8/5/24 at 1:48 P.M., the Respiratory Therapist (RT) said that Resident #48's oxygen concentrator did not require a filter and that the concentrator should have been cleaned every Thursday. The RT also said that she did not know the last time the oxygen concentrator had been cleaned and that it did not appear to have been cleaned recently. During an interview on 8/5/24 at 3:00 P.M., the Director of Nursing (DON) said that Resident #48's oxygen concentrator did not require a filter and an error had been made on the Physician's orders. The DON also said that the oxygen concentrators should be cleaned weekly and Resident #48's concentrator had not been cleaned.

Based on record review and interview, the facility failed to ensure that COVID-19 vaccination was offered and administered, according to professional standards, for two Residents (#101 and #100) out of five applicable residents, in a total sample of 24 residents. Specifically, the facility staff failed to: 1. offer the COVID-19 vaccine to Resident #101 when the Resident had received previous doses of the COVID-19 vaccine, the COVID-19 vaccine was not medically contraindicated for the Resident, and the Resident was not up to date with his/her COVID-19 vaccinations. 2. administer the COVID-19 vaccine to Resident #100 when the Resident had received previous doses of the COVID-19 vaccine, was not up to date with the COVID-19 vaccine and the Resident's Healthcare Proxy (HCP: individual identified to make medical decisions for someone who cannot make medical decisions for themselves) signed consent for the Resident to receive the COVID-19 vaccine. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidelines titled Staying Up to Date with COVID-19 Vaccines, dated 7/3/23, indicated the following: -CDC recommends the 2023-2024 updated COVID-19 vaccines-Pfizer-BioNTech, Moderna, or Novavax - to protect against serious illness from COVID-19. -Everyone aged 5 years and older should get 1 dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. -People aged [AGE] years and older who received 1 dose of any updated 2023-2024 COVID-19 vaccine (Pfizer-BioNTech, Moderna or Novavax) should receive 1 additional dose of an updated COVID-19 vaccine at least 4 months after the previous updated dose. -People who are up to date have lower risk of severe illness, hospitalization and death from COVID-19 than people who are unvaccinated or who have not completed the doses recommended for them by CDC. 1. Resident #101 was admitted to the facility in November 2023, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) and personal history of COVID-19 infection. Review of Resident #101's clinical record indicated: -The Resident had been assigned a legal Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions). -The Resident received COVID-19 vaccine doses, prior to his/her admission to the facility, on the following dates: 1/16/21, 2/6/21, 10/14/21, and 4/14/22. -No evidence that Resident #101 had been offered an updated 2023-2024 COVID-19 vaccine. -No evidence that an updated 2023-2024 COVID-19 vaccine was medically contraindicated for the Resident. During an interview on 8/2/24 at 10:48 A.M., the Staff Development Coordinator (SDC) said she oversaw vaccinations for the residents at the facility, that she would meet with residents and would contact Resident Representatives shortly after residents were admitted to the facility to offer COVID-19 vaccines. The SDC said Resident #101 was due for his/her first dose of the updated 2023-2024 COVID-19 vaccine when he/she was admitted to the facility in November 2023. The SDC said she could provide no evidence that an updated COVID-19 vaccine had been offered for Resident #101 because she had not contacted the Resident's Guardian to obtain consent. 44337 2. Resident #100 was admitted the facility in January 2024, with a diagnosis of Cerebral Infarction (Stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area). Review of Resident #100's clinical record indicated: -The Resident had an invoked Health Care Proxy (HCP). -The Resident had received COVID-19 vaccine doses, prior to his/her admission to the facility, on the following dates: 2/26/21, 3/27/21, and 11/9/21. -The Resident's HCP had signed a consent form on 12/1/23 for the administration of the COVID-19 vaccine. -No evidence the Resident had been administered an updated 2023-2024 COVID-19 vaccine. During an interview on 8/6/24 at 10:27 A.M., the Assistant Director of Nurses (ADON) said that Resident #100 should have received the updated 2023-2024 COVID-19 vaccine but he/she had not received the updated vaccine.

Based on observation, interview, policy and record review, the facility failed to ensure that activities of daily living (ADL's- activities related to personal care which include bathing, dressing, grooming, and eating) were provided for one Resident (#316), out of a total sample of 24 residents. Specifically, the facility failed to ensure that personal care relative to grooming was provided for Resident #316 who required the assistance of staff for care. Findings include: Review of the facility policy titled: ADL Support Guideline, last revised 7/18/22, indicated: -Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal oral hygiene. -Appropriate care and services will be provided for residents unable to carry out ADL's independently . including appropriate support and assistance with .Hygiene (bathing, dressing, grooming and oral care). Resident #316 was admitted to the facility in July 2024, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) and Alzheimers disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language), and need for assistance with personal care. Review of the Resident's ADL care plan, last updated on 7/25/24, indicated Resident #316 had an ADL self-care performance deficit and the Resident required substantial/maximum assistance for personal hygiene and mobility. Review of the Resident #316's Certified Nurses Aide (CNA) Kardex (a brief overview of a Resident's care needs) indicated that the Resident required assistance for personal hygiene (grooming). During an interview and observation on 8/1/24 at 10:29 A.M., the surveyor observed Resident #316 with long facial hair and hair above the Resident's upper lip. Resident #316 said that he/she needed the facial hair to be shaved, that no one had offered to assist with this, and he/she needed help with shaving. The surveyor observed that the Resident had long facial hair and hair above the upper lip during the following observations: -8/1/24 at 10:29 A.M. -8/5/24 at 12:22 P.M. -8/6/24 at 1:23 P.M. Review of CNA care documentation for August 2024 indicated that ADL care was provided to Resident #316 with assistance from staff on: -8/1/24. -8/5/24. -8/6/24. Review of the clinical record did not indicate any refusals of ADL care by Resident #316. During an interview on 8/6/24 at 12:37 P.M., Nurse #1 said all residents, male or female should be provided a shave with ADL care daily if they wanted one (shave). During an interview on 8/6/24 at 12:34 P.M., CNA #1 said all residents should be offered to shave as part of ADL care and that shaving is important because it makes residents feel better, look better, and is part of the delivery of care. During an interview on 8/6/24 at 1:21 P.M., the Director of Nursing (DON) said that delivery of shaving care daily, is important to all residents because shaving is part of routine ADL care.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of adaptive equipment (a double handled mug) for beverages due to hand tremors, as well as staff assistance with set-up for meals, the Facility failed to ensure he/she received adequate staff assistance during meal service related to the nurses' inspection of meal trays for appropriateness of the meal, as well as for the inclusion of necessary adaptive equipment per each resident's meal ticket, prior to the meal tray being delivered and served to the resident, in an effort to prevent an incident/accident resulting in an injury. On 03/30/24, Resident #1's dinner tray was not checked by nursing prior to being served as required, the tray did not include his/her required double handled mug and his/her hot beverage was served in a Styrofoam cup. Resident #1 spilled the hot beverage on his/her thigh, which resulted in him/her sustaining a second degree burn (a partial thickness burn that affects the first and second layers of skin), which required treatment. Findings include: Review of the (undated) Facility Policy titled Food Tray Accuracy and Delivery, indicated the following: -A licensed nurse or qualified designee will check each resident tray prior to distributing to the resident to ensure that the name and room number of the resident are accurate and verify that the items on the plate or tray match the meal ticket for accuracy of the ordered diet, allergies and necessary adaptive equipment. -If the meal tray is missing necessary equipment the member of the nursing department or qualified professional will report it to the Food Service Manager so that the missing items can be provided prior to distributing the resident tray. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/05/24, indicated that on 03/30/24, Resident #1 was served his/her dinner, which included hot coffee, with paper products (Styrofoam cups) instead of his/her double handled mug. Resident #1 spilled the hot coffee on his/her left thigh and sustained a (second degree) burn which was deep pink with blisters at the edges. Review of the Investigation Report Form, dated 03/30/24 at 7:47 P.M., indicated that Resident #1 accidentally spilled hot coffee on his/her left thigh when he/she poured coffee from one cup (Styrofoam cup) to another cup and his/her hands were shaking. The Investigation indicated that Resident #1 did not report the incident immediately (instead waited approximately two hours). Resident #1 was admitted to the Facility in July 2023, diagnoses included Parkinsonism (an umbrella term that refers to brain conditions that cause tremors, slow movements, stiffness and rigidity) and diabetes mellitus with polyneuropathy (causes decreased sensation). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/09/24, indicated he/she scored a 15 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS also indicated he/she required staff assistance for meal set-up. Review of Resident #1's meal ticket (in place at time of incident on 03/30/24), indicated it included his/her name, diet, preferences and that he/she required adaptive equipment, a two handled covered mug. Review of Resident #1's Nutrition Care Plan, with goal date of 07/09/24, indicated he/she required a double handled mug with a spout. During an interview on 04/25/24 at 1:20 P.M., Cook #1 said she was on duty on 03/30/24 for the second shift (11:30 A.M. through 8:00 P.M.) and the kitchen was short staffed. Cook #1 said she called the Food Service Director (FSD) for instruction, and said the FSD told her to use paper products for the dinner meal (instead of regular plates, silverware, mugs etc). Cook #1 said that at that time (03/30/24), she was unaware that resident specific adaptive equipment was to be provided even when the Facility implemented the use of paper products instead of regular dishware. Cook #1 said that no resident specific adaptive equipment was provided to the residents during the dinner meal on 03/30/24. During an interview on 04/25/24 at 1:35 P.M., the Food Service Director (FSD) said that he instructed Cook #1 to use paper products for the dinner meal on 03/30/24. The FSD said that resident specific adaptive equipment should still be provided to residents who require it, even when the Facility chooses to use paper products instead of regular dishware. The FSD said Resident #1 required a two handled mug for beverages, however for the dinner meal on 03/30/24, he/she was provided a Styrofoam cup for his/her hot coffee. During an interview on 04/25/24 at 1:58 P.M., Nurse #1 said she was on duty for the 3:00 P.M. to 11:00 P.M. shift on 03/30/24. Nurse #1 said she did not check the resident's dinner meal trays for accuracy of diets, texture, or adaptive equipment, prior to the meals being distributed to the residents that night. Nurse #1 said she had not been trained to do so and at that time (03/30/24) she was unaware that it was nursing's responsibility. Nurse #1 said that Resident #1 reported, a couple hours (exact time unknown) after dinner, that he/she spilled hot coffee on his/her left thigh during dinner. Nurse #1 said she provided first aid, notified the Nurse Practitioner to obtain treatment orders, and also notified the Director of Nurses. Nurse #1 said the skin on Resident #1's left thigh was deep red with blisters forming at the edges. Review of Resident #1's physician's orders indicated he/she had a new order, dated 3/30/24, for Silvadene Cream 1% (topical antibiotic used for burns) to be applied to his/her left thigh burn twice daily. During an interview on 04/25/24 at 2:42 P.M., Certified Nurse Aide (CNA) #1 said Resident #1 was on her assignment on 03/30/24 for the 3:00 P.M. to 11:00 P.M. shift. CNA #1 said she delivered Resident #1's tray to him/her and said although she knew Resident #1 required a two handled mug for beverages, he/she instead was provided a Styrofoam cup for hot coffee. CNA #1 said she had not seen the nurse(s) check the resident dinner trays (for accuracy) on 03/30/24, prior to the CNA's delivering them that night. Review of Resident #1's care Kardex (in place at time of incident on 03/30/24, used by Certified Nurse Aides to determine individual care needs) indicated he/she required a doubled handled mug with spout. During an interview on 04/25/24 at 3:34 P.M., the Director of Nurses (DON) said that the nurse(s) on the unit should have checked each resident's meal tray for accuracy prior to the meal tray being provided to a resident. The DON said that on 03/30/24, the nurse(s) should have notified kitchen staff that Resident #1 did not have his/her double handled mug on his/her dinner meal tray. On 04/25/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by: A) 03/30/24, Resident #1 was assessed by nursing, new orders were obtained for Silvadene Cream 1% (topical antibiotic used for burns) to be applied to his/her left thigh burn twice daily. B) 04/01/24 through 04/07/24, the Assistant Director of Nurses educated all licensed staff that nurses must check meal trays for correct diet consistency and adaptive equipment prior to the trays being given to the residents. C) 04/01/24 through 04/07/24, the Assistant Director of Nurses educated all licensed staff that when delivering residents meal trays, staff must offer to assist residents with setting up their tray such as opening cartons, cutting food, and pouring drinks. D) 04/01/24 through 04/09/24, the Food Service Director and Kitchen Manager educated the dietary staff on providing adaptive equipment to residents even when using Styrofoam and paper products. E) 04/03/24, the Food Service Director and the Administrator began an audit visualizing adaptive equipment against each resident's meal ticket on the resident's meal trays. F) 04/10/24, weekly audits were initiated related to adaptive equipment use and meal tickets, audits will continue times four weeks, then monthly times three weeks, will be conducted by the Administrator, Food Service Director, Food Service Manager, Assistant Director of Therapy, Therapy Assistants, Unit Nurse Managers and Nursing Shift Supervisors. G) The results of the weekly audits will be brought to Quality Assurance Performance Improvement (QAPI) monthly times three months or until substantial compliance is achieved. H) The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure services provided by nursing met professional standards of practice, when nursing initiated life saving measures including performing Cardiopulmonary Resuscitation on a resident who was a DNR. On [DATE], at approximately 8:30 A.M., Resident #1, was found unresponsive, was assessed by nursing to be without a pulse or respirations, and nursing immediately intervened and initiated life saving measures in an attempt to resuscitate him/her, including starting CPR (administering chest compressions) and activating 911, without verifying his/her code status. Resident #1 was resuscitated, transferred to the Hospital Emergency Department for evaluation, was diagnosed with 6th and 7th rib rib fractures, as well as second degree heart block, was admitted to the Hospital for four days, and then returned to the Facility. 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 and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Titled Nursing Practice and Cardiopulmonary Resuscitation, dated as revised ,d+[DATE], indicated that as a Standard of Nursing Practice, the nurse licensed by the Board is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's position that these standards, in the context of practice in all settings where health care is delivered require initiating cardiopulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L. c. 46, S 9, except when the patient has a current, valid Do Not Resuscitate order/status. It further indicated, that for the purpose of this Advisory Ruling, the licensed nurse must, at a minimum, attain and maintain the following competencies through successful completion of entry-level nursing education programs or continuing education experiences, the nurse's role in obtaining accurate information about the DNR status of all assigned patients. The Facility Policy, titled Do Not Resuscitate Guideline, dated ,d+[DATE], indicated the Facility would honor a resident's right to withhold Cardiopulmonary Resuscitation and related emergency measures to maintain life functions when there was a Do Not Resuscitate order in effect. The Facility Policy, titled Cardiopulmonary Resuscitation (CPR) Guideline, dated [DATE], indicated Licensed Nurses and other designated staff were educated to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, malignant neoplasm of the brain, and bone density disorder. Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1 on [DATE], indicated he/she was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to transfer to the Hospital. Review of Resident #1's Advance Directives Care Plan, dated [DATE], indicated he/she had Advanced Directives and they would be honored by staff. Review of Resident #1's Physician's Order, dated [DATE], (related to his/her Advanced Directives) indicated nursing staff were to refer to his/her MOLST. Review of the Nurse Progress Note, dated [DATE], indicated Resident #1 was found to be unresponsive sitting in his/her room in his/her wheelchair, a code blue was called, and he/she was transferred to the Hospital Emergency Department. Review of the Hospital Discharge Summary, dated [DATE], indicated Resident #1 was admitted to the Hospital via the emergency roiagnom on [DATE], was diagnosed with a second-degree heart block and 6th and 7th right rib fractures. Review of Unit Manager #1's Written Witness Statement, undated, indicated she was alerted that Resident #1 was unresponsive, and did not have a palpable pulse. The Statement indicated staff assisted Resident #1 to bed, at which time she (Unit Manager #1) initiated CPR (administered chest compression) while another nurse checked Resident #1's chart for his/her code status, it was discovered that he/she was a DNR/DNI, and she (Unit Manager #1) stopped CPR. During interview on [DATE] at 10:16 A.M., Unit Manager #1 said that on [DATE] at 8:30 A.M., she was alerted by a Certified Nurse Aide that Resident #1 was unresponsive. Unit Manager #1 said she ran to Resident #1's room, saw that he/she was slumped over in his/her wheelchair, was limp, pale, had no observable respirations, and she could not feel a radial (wrist) pulse. Unit Manager #1 said she instructed staff to transfer Resident #1 to his/her bed, to call a code blue, and asked what his/her code status was, to no one in particular. Unit Manager #1 said once Resident #1 was in bed, she checked again for respirations and a radial pulse, and when she assessed that he/she had neither, she administered 30 chest compressions. Unit Manager #1 said that right when she completed the 30 chest compressions, someone yelled out that Resident #1 was a DNR. Unit Manager #1 said she stopped doing chest compressions and that Resident #1 became responsive, pushed her hand away, and was talking in a low voice. Unit Manager #1 said she thought the protocol was to initiate CPR and stop it if it was discovered that a resident was a DNR. During interview on [DATE], Respiratory Therapist (RT) #1 said she was a certified Basic Life Support instructor, and said she conducted training for the staff at the Facility. RT #1 said the current standard of practice in a Long-Term Care Facility that staff were to check the resident's code status before administering any life saving measures including CPR and said that was what she taught facility staff during CPR trainings. RT #1 said nursing staff should not have administered chest compressions to Resident #1, as he/she had a valid MOLST that indicated he/she was a DNR. During interview on [DATE] at 11:56 A.M., the Director of Nurses (DON) said that on [DATE], she responded to the overhead code blue page, and when she arrived at Resident #1's room, he/she was unresponsive in his/her wheelchair, staff transferred him/her to bed, and Unit Manager #1 administered chest compressions. The DON said soon after chest compressions were started, someone yelled that Resident #1 was a DNR, chest compressions were stopped, and Resident #1 was observed to be responsive at that time. The DON said Resident #1 was then transferred to the Hospital Emergency Department via 911. The DON said that at the time of Resident #1's code blue, she misunderstood the current standard of practice and thought that staff were to begin CPR, and to discontinue it if a valid DNR order was discovered. The DON said that since that day, she was re-educated to the current standards of practice and said chest compressions should not have been performed on Resident #1 as he/she had Advance Directives in place and a signed MOLST which indicated he/she was a DNR.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Comprehensive Person Centered Plan of Care indicated staff were to honor his/her Advance Directives, which indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure the staff implemented and followed interventions identified in his/her plan of care related to his/her Advanced Directives, when on [DATE], at approximately 8:30 A.M., after being found unresponsive, and assessed by nursing to be without a pulse or respirations, nursing staff immediately intervened and initiated Cardiopulmonary Resuscitation (CPR) in an attempt to resuscitate him/her, and activated the 911, without first verifying his/her code status. Resident #1 was resuscitated by nursing, was transferred to the Hospital Emergency Department for evaluation, was diagnosed with 6th and 7th right rib fractures, as well as second degree heart block, was admitted to the Hospital for four days, and then returned to the Facility. Findings include: The Facility policy, titled, Care Plan Guideline, dated [DATE], indicated the Facility would develop an individualized plan of care for each resident, and staff were responsible for implementation of the plan. The Facility Policy, titled Advance Directives, dated [DATE], indicated the Facility would honor the advance directives of the resident or their legal representative according to state and federal laws, guidelines, and regulations, and defined the following: -Do Not Resuscitate indicated that, in the case of respiratory or cardiac failure, the resident or representative has directed that no cardiopulmonary resuscitation (CPR) or other life saving methods were to be used. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, malignant neoplasm of the brain, and bone density disorder. Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1 on [DATE], indicated he/she was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to transfer to the Hospital. Review of Resident #1's Advance Directives Care Plan, dated [DATE], indicated he/she had Advanced Directives and they would be honored by staff. Review of Resident #1's Physician's Order, dated [DATE], (related to his/her Advanced Directives) indicated nursing staff were to refer to his/her MOLST. Review of the Nurse Progress Note, dated [DATE], indicated Resident #1 was found to be unresponsive sitting in his/her room in his/her wheelchair, a code blue was called, and he/she was transferred to the Hospital Emergency Department. Review of the Hospital Discharge Summary, dated [DATE], indicated Resident #1 was admitted to the Hospital via the emergency roiagnom on [DATE], was diagnosed with a second-degree heart block and 6th and 7th right rib fractures. Review of Unit Manager #1's Written Witness Statement, undated, indicated she was alerted that Resident #1 was unresponsive, and did not have a palpable pulse. The Statement indicated staff assisted Resident #1 to bed, at which time she (Unit Manager #1) initiated CPR (administered chest compression) while another nurse checked Resident #1's chart for his/her code status, it was discovered that he/she was a DNR/DNI, and she (Unit Manager #1) stopped CPR. During interview on [DATE] at 10:16 A.M., Unit Manager #1 said that on [DATE] at 8:30 A.M., she was alerted by a Certified Nurse Aide that Resident #1 was unresponsive. Unit Manager #1 said she ran to Resident #1's room, saw that he/she was slumped over in his/her wheelchair, was limp, pale, had no observable respirations, and she could not feel a radial (wrist) pulse. Unit Manager #1 said she instructed staff to transfer Resident #1 to his/her bed, to call a code blue, and asked what his/her code status was, to no one in particular. Unit Manager #1 said once Resident #1 was in bed, she checked again for respirations and a radial pulse, and when she assessed that he/she had neither, she administered 30 chest compressions. Unit Manager #1 said that right when she completed the 30 chest compressions, someone yelled out that Resident #1 was a DNR. Unit Manager #1 said she stopped doing chest compressions and that Resident #1 became responsive, pushed her hand away, and was talking in a low voice. During interview on [DATE] at 11:56 A.M., the Director of Nurses (DON) said that on [DATE], she responded to the overhead code blue page, and when she arrived at Resident #1's room, he/she was unresponsive in his/her wheelchair, staff transferred him/her to bed, and Unit Manager #1 began CPR and administered chest compressions. The DON said soon after chest compressions were started, someone yelled that Resident #1 was a DNR, chest compressions were stopped, but that Resident #1 was observed to be responsive. The DON said chest compressions should not have been performed on Resident #1 as his/her plan of care indicated he/she had Advance Directives in place and a signed MOLST which indicated he/she was a DNR.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Order indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation, in the event of cardiac or respiratory arrest) the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of Advanced Directives. On [DATE], at approximately 8:30 A.M., Resident #1 was found unresponsive, was assessed by nursing to be without a pulse or respirations, and without verifying his/her code status, nursing staff immediately intervened and initiated life saving measures including starting chest compressions for CPR and activating the 911. Nursing then determined Resident #1 was a DNR and CPR was stopped, however Resident #1 had been resuscitated. Resident #1 was transferred to the Hospital Emergency Department, was diagnosed with 6th and 7th right rib fractures, as well as a second degree heart block, was admitted to the Hospital for four days, and then returned to the Facility. Findings include: The Facility Policy, titled Resident Rights and Responsibilities Guidelines, dated [DATE], indicated staff would uphold the residents' right to self-determination. The Facility Policy, titled Advance Directives, dated [DATE], indicated the Facility would honor the advance directives of the resident or their legal representative according to state and federal laws, guidelines, and regulations, and defined the following: -Advanced Directive was defined as a written instruction, recognized by State law, relating to the provisions of health care when the individual is incapacitated. -Do Not Resuscitate indicated that, in the case of respiratory or cardiac failure, the resident or representative has directed that no cardiopulmonary resuscitation (CPR) or other life saving methods were to be used. The Facility Policy, titled Do Not Resuscitate Guideline, dated ,d+[DATE], indicated the Facility would honor a resident's right to withhold Cardiopulmonary Resuscitation and related emergency measures to maintain life functions when there was a Do Not Resuscitate order in effect. The Facility Policy, titled Cardiopulmonary Resuscitation (CPR) Guideline, dated [DATE], indicated Licensed Nurses and other designated staff were educated to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, malignant neoplasm of the brain, and bone density disorder. Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) Form, dated and signed by Resident #1 on [DATE], indicated he/she was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to transfer to the Hospital. Review of Resident #1's Advance Directives Care Plan, dated [DATE], indicated he/she had Advanced Directives and they would be honored by staff. Review of Resident #1's Physician's Order, dated [DATE], (related to his/her Advanced Directives) indicated nursing staff were to refer to his/her MOLST. Review of the Nurse Progress Note, dated [DATE], indicated Resident #1 was found to be unresponsive sitting in his/her room in his/her wheelchair, a code blue was called, and he/she was transferred to the Hospital Emergency Department. Review of the Hospital Discharge Summary, dated [DATE], indicated Resident #1 was admitted to the Hospital via the emergency roiagnom on [DATE], was diagnosed with a second-degree heart block and 6th and 7th right rib fractures. Review of Unit Manager #1's Written Witness Statement, undated, indicated she was alerted that Resident #1 was unresponsive, and did not have a palpable pulse. The Statement indicated staff assisted Resident #1 to bed, at which time she (Unit Manager #1) initiated CPR (administered chest compressions) while another nurse checked Resident #1's chart for his/her code status, it was discovered that he/she was a DNR/DNI, and she stopped CPR. During interview on [DATE] at 10:16 A.M., Unit Manager #1 said that on [DATE] at 8:30 A.M., she was alerted by a Certified Nurse Aide that Resident #1 was unresponsive. Unit Manager #1 said she ran to Resident #1's room, saw that he/she was slumped over in his/her wheelchair, was limp, pale, had no observable respirations, and she could not feel a radial (wrist) pulse. Unit Manager #1 said she instructed staff to transfer Resident #1 to his/her bed, to call a code blue, and asked what his/her code status was, to no one in particular. Unit Manager #1 said once Resident #1 was in bed, she checked again for respirations and a radial pulse, and when she assessed that he/she had neither, she administered 30 chest compressions. Unit Manager #1 said that right when she completed the 30 chest compressions, someone yelled out that Resident #1 was a DNR. Unit Manager #1 said she stopped doing chest compressions and that Resident #1 became responsive, pushed her hand away, and was talking in a low voice. Unit Manager #1 said she thought the protocol was to initiate CPR and then stop if it was discovered that a resident was a DNR. Unit Manager #1 said she felt afterwards as though she had not honored Resident #1's wishes to be a DNR, and said she felt bad that he/she had fractured ribs as a result of the chest compressions. During interview on [DATE] at 11:56 A.M., the Director of Nurses (DON) said that on [DATE], she responded to the overhead code blue page, and when she arrived at Resident #1's room, he/she was unresponsive in his/her wheelchair, staff transferred him/her to bed, and Unit Manager #1 administered chest compressions. The DON said soon after chest compressions were started, someone yelled that Resident #1 was a DNR, chest compressions were stopped, and Resident #1 was observed to be responsive at that time. The DON said Resident #1 was then transferred to the Hospital emergency room via 911. The DON said chest compressions should not have been performed on Resident #1 as he/she had Advance Directives in place and a signed MOLST which indicated he/she was a DNR.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who on [DATE] was found unresponsive and for whom nursing staff initiated life saving measures (initiated cardiopulmonary resuscitation by administering chest compressions), the Facility failed to ensure they maintained a complete and accurate medical record when there was no nursing documentation in Resident #1's Medical Record related to the administration of chest compressions. Findings include: The Facility Policy, titled Charting and Documentation Guideline, dated ,d+[DATE], indicated: - All services provided to the resident, or any changes in the resident's medical, physical, functional or psychological condition, would be documented in the resident's medical record. - Documentation would include treatments or services performed and events, incidents or accidents involving the resident. - Documentation would be complete and accurate. Resident #1 was admitted to the Facility in [DATE], diagnoses included dementia, malignant neoplasm of the brain, and bone density disorder. Review of Unit Manager #1's Written Witness Statement, undated, indicated she was alerted that Resident #1 was unresponsive, and did not have a palpable pulse. The Statement indicated staff assisted Resident #1 to bed, at which time she (Unit Manager #1) initiated Cardiopulmonary Resuscitation (CPR). Review of the Nurse Progress Note, dated [DATE], indicated Resident #1 was found to be unresponsive sitting in his/her room in his/her wheelchair, a code blue was called, he/she presented with hypotension (low blood pressure), bradycardia (slower than normal heart rate) and was transferred to the Hospital Emergency Department. Further review of Resident #1's medical record indicated there was no documentation to support Unit Manager #1's assessments that Resident #1 had no radial pulse or observable respirations, or that he/she received CPR (chest compressions) on [DATE], and that Resident #1 had become responsive after she administered CPR to him/her. There was no nurse progress note or incident note related to the event by Unit Manager #1, which included her assessments of Resident #1 or that she initiated and then stopped CPR. During interview on [DATE] at 10:16 A.M., Unit Manager #1 said that on [DATE] at 8:30 A.M., she was alerted by a Certified Nurse Aide that Resident #1 was unresponsive. Unit Manager #1 said she ran to Resident #1's room, saw that he/she was slumped over in his/her wheelchair, was limp, pale, had no observable respirations, and she could not feel a radial (wrist) pulse. Unit Manager #1 said she instructed staff to transfer Resident #1 to his/her bed, said once Resident #1 was in bed, she checked again for respirations and a radial pulse, and when she assessed him/her there was neither, so she administered 30 chest compressions. Unit Manager #1 said that right when she completed the 30 chest compressions, someone yelled out that Resident #1 was a DNR, and she stopped doing chest compressions. Unit Manager #1 said that Resident #1 then became responsive, pushed her hand away, and was talking in a low voice. During interview on [DATE] at 1:07 P.M., Unit Manager #1 said that on [DATE], she should have documented her full assessment of Resident #1 in his/her medical record, including that chest compressions were administered. During interview on [DATE] at 2:07 P.M., the Director of Nurses (DON) said Unit Manager #1's assessment that Resident #1 was without a pulse or respirations and that chest compressions were administered should have been documented in his/her medical record.

Based on record review and interview, the facility failed to ensure one Resident (#4) out of 25 total sampled residents,was free of significant medication errors. Specifically, facility staff failed to implement necessary action when daily administration of Fondaparinux Sodium Solution was: a) ordered by the Physician/NPP, and b) omitted from the Resident's medication administration for three consecutive days in January 2023, two consecutive days and one non-consecutive day in February 2023, when the Resident had a documented history of a DVT and chronic PE, increasing his/her risk for development of blood clots. Findings include: Review of the facility's policy, titled Medication Related Errors, dated January 2022, included the following: - In the event of an administration error, facility staff should follow facility policy relating to medication administration errors. - An example of medication administrations errors included omission errors. - An omission error is when the facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication. - Facility staff were to notify the Physician/Prescriber and obtain further instructions and/or orders. Facility staff were to monitor the resident in accordance with the Physician's/Prescriber's instructions. Resident #4 was admitted to the facility in March 2022 with diagnoses including history of DVT and chronic PE. Review of a Minimum Data Set (MDS) Assessment, dated 3/7/23, included that Resident #4 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible 15 points. Review of an active Physician's order, dated 3/25/22, indicated: Fondaparinux Sodium Solution 2.5 mg/0.5 ml Inject 0.5 ml subcutaneously one time a day for prevention of blood clots. Review of the January 2023 MAR indicated the ordered daily dose of Fondaparinux Sodium Solution was not administered to Resident #4 on the following consecutive dates: 1/29/23, 1/30/23, and 1/31/23. The code charted on the MAR for these dates was 9, which indicated the reason for not administering the ordered dose as Other/See Nurse Notes. Review of the January 2023 Nurse's Notes included the following: - A Nurse's Note, dated 1/29/23 that indicated: med not in cart, awaiting pharmacy. - A Nurse's Note, dated 1/30/23 that indicated: unavailable, pharmacy called. - A Nurse's Note, dated 1/31/23 that indicated: unavailable. Further review of Nurse's Progress Notes between 1/29/23 and 1/31/23 indicated no evidence that the Physician/NPP had been consulted regarding the omitted doses of Fondaparinux Sodium Solution or advice on alternative medication and treatment. Review of the February 2023 MAR indicated the ordered daily dose of Fondaparinux Sodium Solution was not administered to Resident #4 on 2/13/23, 2/17/23, and 2/18/23. The code charted on the MAR for these dates was 9, which indicated the reason for not administering the ordered dose was Other/See Nurse Notes. Review of the February 2023 Nurse's Notes included the following: - A Nurse's Note, dated 2/13/23 that indicated: unavailable, pharmacy called. - A Nurse's Note, dated 2/17/23 that indicated: the Resident did not have his/her doses of Fondaparinux that morning. The Nurse called the pharmacy, the pharmacy said it was too soon to refill and could not be refilled until 2/18/23. - A Nurse's Note, dated 2/18/23 that indicated: unavailable. Further review of the Nurse's Progress Notes for 2/13/23, 2/17/23, and 2/18/23 included no evidence the Physician/NPP had been consulted regarding the omitted doses of Fondaparinux Sodium Solution or advice on alternative medication and treatment. During an interview on 4/7/23 at 8:34 A.M., Resident #4 said there were days in February 2023 that he/she did not receive his/her blood thinning medication because it ran out. He/she said this happened sometimes and he/she just had to wait until the medication was received at the facility for it to be administered. During an interview on 4/7/23 at 10:38 A.M. Nurse #3 said if a resident's medication was unavailable, the Nurse was required to call the pharmacy. If the pharmacy told the Nurse they could not fill the medication because it was too soon, the Nurse would be required to notify the Director Nursing (DON) so the DON could complete an override form. Nurse #3 said once the override form was completed, it would be faxed to the pharmacy so the pharmacy could refill the medication. Nurse #3 said if they were unable to obtain the medication from the pharmacy, the Nurse would be required to contact the Physician/NPP so that instruction for alternative medication or treatment could be implemented. During an interview on 4/7/23 at 10:47 A.M., Unit Manager (UM) #1 said Fondaparinux Sodium Solution was ordered for Resident #4 as a blood thinner to prevent blood clots. UM #1 said missed doses of blood thinning medications could increase the resident's risk for developing blood clots. UM #1 also said if a blood thinning medication was not available for a resident, the Nurse would be required to call the Physician/NPP and obtain alternate care instructions. UM #1 reviewed Resident #4's clinical record at this time and said she could locate no evidence that the Physician/NPP had been consulted for alternate care instructions for the Resident when the medication was unavailable. During an interview on 4/7/23 at 11:09 A.M., the DON said if a medication was unavailable for a resident at the facility, the Nurse was required to notify her and an override form would be completed so the medication could be obtained. She also said if a medication could not be obtained, the Nurse would be required to call the Physician/NPP to obtain alternate care instructions for the Resident. The DON said she had not been made aware that ordered daily doses of Fondaparinux Sodium Solution had not been administered as ordered and were unavailable to Resident #4 between 1/29/23 and 1/31/23, and on 2/13/23, 2/17/23, and 2/18/23. The DON said facility staff should have adhered to the facility's process for obtaining the medication and communicating with the Physician/NPP, but they did not.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#27) out of a total sample of 25 residents, was free from unnecessary medications. Specifically, facility staff administered prophylactic (intended to prevent disease) antibiotic medication treatment to Resident #27 for seven consecutive days to prepare the Resident for a dental procedure that did not occur. Findings include: Resident #27 was admitted to the facility in April 2011. Review of a Dental Consult, dated 11/7/22, included: - The Resident required two tooth extractions (removal of teeth). - Amoxicillin (antibiotic medication) 500 milligrams (mg) TID (three times a day) for seven days prior to extracting teeth was recommended. Review of a Physician Order, dated 11/8/22, indicated: Amoxicillin tablet 500 mg by mouth three times a day for tooth extraction for seven days. Review of the November 2022 Medication Administration Record (MAR) indicated Amoxicillin was administered to the Resident as ordered for seven days. Review of the Consent for Extraction, dated 11/7/22, indicated consent for the tooth extractions was obtained on 11/15/22. Review of the Resident's clinical record included no evidence that the Resident's teeth were extracted. During an interview on 4/6/23 at 1:33 P.M., Unit Manager (UM) #1 reviewed Resident #27's clinical record and said the Dental Consultant recommended treating the Resident with Amoxicillin in November 2022 in preparation for extracting two of the Resident's teeth. UM #1 said the Resident received the Amoxicillin as ordered, but she located no evidence that the dental procedure occurred as planned. UM #1 said she would have to call the Dental Consultant to determine whether the extractions had been completed. During a follow-up interview on 4/6/23 at 1:43 P.M., UM #1 said she spoke with the Dental Consultant office and that the Resident's teeth had not been extracted, as recommended, because the office never received the consent form from the facility and the appointment had not been scheduled. The UM further said the purpose of the Amoxicillin was to treat the Resident prophylactically, to prepare for the dental extractions, but this did not occur. On 4/6/23 at 1:51 P.M., the surveyor observed UM #1 look into Resident #27's mouth. UM #1 said the Resident still had both teeth in his/her mouth that were recommended to be extracted in November 2022. UM #1 said staff should have realized that the Resident was receiving Amoxicillin in preparation for having teeth extracted and should have followed up with the Dental Consultant to schedule the appointment. She further said if the Resident was not going to have his/her teeth extracted, it would not be necessary for the Resident to be treated with Amoxicillin. Please Refer to F791.

Based on observation, record review and interview, the facility failed to ensure its staff provided appropriate care and services for three Residents (#88, #77, and #114), who required an indwelling urinary catheter (a tube placed through the urethra into the bladder to drain urine), out of a total sample of 25 residents. Specifically, the facility staff failed to ensure that the indwelling urinary catheter tubings for Residents #88, #77, and #114 were securely placed as required to prevent possible dislodgement and trauma. Findings include: Review of the facility policy titled Catheter Care, Urinary effective 6/2021 indicated the following: - Assess the need for a leg strap to reduce friction and movement at the insertion site as the resident allows. Note: catheter tubing should be strapped to the resident's inner thigh. 1) Resident #88 was admitted to the facility in July 2021 with a diagnosis of Obstructive and Reflex Uropathy (structural or functional hindrance of normal urine flow). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. During an observation and interview on 4/6/23 at 1:28 P.M., the surveyor observed that there was no device securing the indwelling catheter tubing to the Resident's thigh. The Resident said that a long time ago, when he/she was first admitted , there was a strap on his/her thigh that held the tube but when the strap got dirty the staff took it off and taped the tubing to his/her thigh with an adhesive device. The Resident said the adhesive device fell off quickly and there has not been any other securement device put in place. Review of the current Physician orders for Resident #88 indicated the following: - May have anchored Foley Catheter (indwelling urinary catheter) 18 fr (French) with 10 ml (milliliter) balloon, initiated 1/10/23. - Ensure catheter is secure with securement device every shift, initiated on 12/9/22. - Change indwelling urinary catheter anchor weekly and as needed every night shift every Wednesday, initiated 1/18/23. Review of the current care plan for Resident #88 indicated a care plan focus for Foley Catheter and an intervention to ensure catheter is secure with securement device, created 12/9/22. During an observation and interview on 4/10/23 at 2:17 P.M., the surveyor and Nurse #2 observed that there was no indwelling urinary catheter tubing securement device securing the tubing to the Resident's thigh. Nurse #2 said there should have been a strap securing the tubing to the Resident's thigh as ordered. 44222 2) Resident #77 was admitted to the facility in November 2022 with a diagnosis of retention of urine (when the bladder does not completely empty during urination). Review of the April 2023 Physician's orders included: -Change indwelling urinary catheter anchor weekly and as needed, initiated 1/16/23. -May have anchored Foley Catheter (indwelling) 16F (French) with 10 balloon, initiated 11/8/22. Review of Resident #77's care plan indicated that the Resident had a urinary catheter with an intervention for care and treatment per current MD (Medical Doctor) orders initiated 11/8/22. During an observation and interview on 4/10/23 at 2:02 P.M., with CNA #2, the Resident was observed sitting in a wheelchair with a urinary catheter tube coming out from under his/her clothing attached to a drainage bag which was hooked to the back of the wheelchair. When asked if there was an anchor device on the Resident's leg to secure the catheter tubing, CNA #2 said no there was no anchoring device on the Resident's leg. CNA #2 further said that she could not remember ever seeing an anchoring device securing the catheter tubing to the Resident's leg. During an interview on 4/10/23 at 2:15 P.M., Nurse #1 said that she was not aware that there was an order for an anchor strap for the Resident's catheter tubing. Nurse #1 reviewed the Physician's orders and said that there was actually an order to replace the anchor strap weekly on Wednesdays on the night shift, but she hadn't noticed it because she works during the day. Nurse #1 further said and there was no order in place to check the anchor strap each shift but there should have been. Nurse #1 said that the Resident should have an anchoring device to secure the catheter tubing to his/her leg but there wasn't one. 3) Resident #114 was admitted to the facility in November 2022 with a diagnosis of acute urine retention (when the bladder does not completely empty during urination). Review of the April 2023 Physician's orders included: -change indwelling urinary catheter anchor weekly and as needed -may have anchored Foley Catheter 14Fr (French) with 10cc (cubic centimeter) balloon During an observation and interview on 4/10/23 at 2:05 P.M., with CNA #1, the Resident was observed sitting in a wheelchair with a urinary catheter tube coming out from under his/her clothing attached to a drainage bag which was hooked to the back of the wheelchair. When asked if there was an anchor device on the Resident's leg to secure the catheter tubing, CNA #1 said no there was no anchoring device on the Resident's leg. CNA #1 further said that she could not remember ever seeing an anchoring device to secure the catheter tubing to the Resident's leg. During an interview on 4/10/23 at 2:15 P.M., Nurse #1 said that she was not aware that there was an order for an anchor strap for the Resident's catheter tubing. Nurse #1 reviewed the Physician's orders and said that there was an order to replace the anchor strap weekly on Wednesdays on the night shift, but she didn't notice it because she works during the day. Nurse #1 further said and there was no order in place to check the anchor strap each shift but there should have been, and that the Resident should have an anchoring device to secure the catheter tubing to his/her leg but there wasn't one.

Based on record review and interview, the facility failed to ensure its staff notified the Physician/Non-Physician Practitioner (NPP: a Nurse Practitioner, clinical Nurse Specialist, or Physician Assistant) of the unavailability and multiple missed doses of an ordered medication for one Resident (#4) out of 25 total sampled residents. Specifically, the facility failed to notify the Physician/NPP when ordered doses of Fondaparinux Sodium Solution (injectable blood thinning medication used to treat and prevent blood clots) were unavailable and not administered to Resident #4 as ordered, for a documented history of Deep Vein Thrombosis (DVT- a blood clot located in a deep vein) and chronic Pulmonary Embolism (PE- a condition where one or more arteries in the lungs becomes blocked by a blood clot), increasing his/her risk for development of blood clots. Findings include: Review of the facility's policy, titled Medication Related Errors, dated January 2022, included the following: - In the event of an administration error, facility staff should follow facility policy relating to medication administration errors. - An example of medication administrations errors included omission errors. - An omission error is when the facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication. - Facility staff were to notify the Physician/Prescriber and obtain further instructions and/or orders. Facility staff were to monitor the resident in accordance with the Physician's/Prescriber's instructions. Resident #4 was admitted to the facility in March 2022 with diagnoses including a history of DVT and chronic PE. Review of a Minimum Data Set (MDS) Assessment, dated 3/7/23, included that Resident #4 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15. Review of an active Physician's order, dated 3/25/22, indicated: Fondaparinux Sodium Solution 2.5 milligrams (mg)/0.5 milliliters (ml) Inject 0.5 ml subcutaneously (injected in the fatty tissue, just under the skin) one time a day to prevent blood clots. Review of the January 2023 Medication Administration Record (MAR) indicated the ordered daily dose of Fondaparinux Sodium Solution was not administered to Resident #4 on the following consecutive dates: 1/29/23, 1/30/23, and 1/31/23. The code charted on the MAR for these dates was 9, which indicated the reason for not administering the ordered dose as Other/See Nurse Notes. Review of the Nurse Progress Notes between 1/29/23 and 1/31/23 indicated no evidence that facility staff notified the Physician/NPP that the Fondaparinux Sodium Solution had not been administered to Resident #4 as ordered on 1/29/23, 1/30/23, and 1/31/23. Review of the February 2023 MAR indicated the ordered daily dose of Fondaparinux Sodium Solution was not administered to Resident #4 on 2/13/23, 2/17/23, and 2/18/23. The code charted on the MAR for these dates was 9, which indicated the reason for not administering the ordered dose was Other/See Nurse Notes. Review of the Nurse Progress Notes for 2/13/23, 2/17/23, and 2/18/23 included no evidence that facility staff notified the Physician/NPP that the Fondaparinux Sodium Solution had not been administered to Resident #4 as ordered on 2/13/23, 2/17/23, and 2/18/23. During an interview on 4/7/23 at 8:34 A.M., Resident #4 said there were days in February 2023 that he/she did not receive his/her blood thinning medication and that no alternate treatment interventions were provided. During an interview on 4/7/23 at 10:38 A.M., Nurse #3 said if a resident's blood thinning medication was not administered as ordered, the Nurse was required to notify the Physician/NPP and in the event that the resident's treatment needed to be altered, the Nurse would obtain instructions from the Physician/NPP for alternative medication or treatment. Nurse #3 said if this occurred, the Nurse was required to document this in the resident's clinical record. During an interview on 4/7/23 at 10:47 A.M., Unit Manager (UM) #1 said Fondaparinux Sodium Solution was ordered for Resident #4 as a blood thinner to prevent blood clots. UM #1 said missed doses of blood thinning medications could increase the resident's risk for developing blood clots. UM #1 also said if a blood thinning medication was not administered to a resident as ordered, the Nurse was required to notify the Physician/NPP. UM #1 further said, when notifying the Physician/NPP, the Nurse would be required to obtain alternate care instructions. UM #1 reviewed Resident #4's clinical record at this time and said she could locate no evidence that facility staff notified the Physician/NPP that Fondaparinux Sodium Solution had not been administered to the Resident as ordered from 1/29/23 through 1/31/23, and on 2/13/23, 2/17/23, and 2/18/23, as required. During an interview on 4/7/23 at 11:09 A.M., the DON said if a blood thinning medication was not administered to a resident as ordered, the Nurse would be required to notify the Physician/NPP and to obtain further instructions/orders for care of the Resident. The DON said she had not been made aware that ordered daily doses of Fondaparinux Sodium Solution had not been administered to Resident #4 between 1/29/23 and 1/31/23, and on 2/13/23, 2/17/23, and 2/18/23. The DON said facility staff should have adhered to the facility's process for notifying the Physician/NPP in the event that alternative treatment was required, but they did not. Please Refer to F760.

Based on record review and interview the facility failed to ensure that its staff implemented the plan of care for one Resident (#114) out of a total sample of 25 residents. Specifically, the facility failed to complete weekly weights for the Resident as indicated in the care plan. Findings include: Resident #114 was admitted to the facility in November 2022. Review of the Resident's Minimum Data Set (MDS) assessment, dated 11/16/22, section L indicated that the Resident had no natural teeth or tooth fragment(s) (-edentulous). Review of the Resident's current care plan last reviewed 2/28/23 indicated: - Focus - edentulous with no dentures at the SNF (skilled nursing facility), created 11/28/22. - Goal - patient will be able to tolerate diet ordered and have no significant weight loss x (times) 90 days, created 11/28/22. - Intervention - monitor weights every week, created 11/28/22. Review of the Resident's clinical record documented 11/9/22, indicated that the Resident weighed 173.8 pounds at admission. Further review of the Resident's clinical record indicated that the Resident had only been weighed one time for the month of March 2023. -2/6/23 weight 160.2 pounds -2/13/23 weight 159.4 pounds -2/20/23 weight 158.8 pounds -3/6/23 weight 158.9 pounds -4/3/23 weight 156.2 pounds During an interview on 4/10/23 at 2:15 P.M., Nurse #1 said that the care plan indicated to weigh the Resident weekly, but after reviewing the recorded weights, the Resident was only weighed one time in March 2023. The nurse said that the Resident's name was not on the list for weekly weights but should have been. Nurse #1 said that the Resident should have been weighed weekly but had not been.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure residents were free from verbal abuse or punishment by staff. Certified Nurse Aide (CNA) #1 admitted to and was witnessed yelling at Resident #1 on 03/22/21. In addition, Resident #1 reported that staff, including CNA #1, removed his/her call light from within reach because they said he/she used the call light too often, or words to that effect. Resident #1 said he/she was dependent on staff for care and was fearful of not having his/her needs met, if he/she complained. Findings include: Review of the Facility's Abuse Prohibition Guideline policy, revised 10/25/17, indicated that: - Maintain a work and living environment that is professional and free from threat of and/or occurrence of harassment, abuse (verbal, physical, mental, psychological, or sexual), neglect, corporal punishment, involuntary seclusion, or misappropriation of property; and, - Assure that staff uses caring, ethical and professional behavior in all relationships with residents. Resident #1 was admitted to the Facility in April of 2011, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set, dated dated [DATE], indicated that he/she had adequate hearing, was cognitively intact, and required staff assistance with all Activities of Daily Living (ADLs). 1. During an interview on 04/07/21 at 11:46 A.M., Resident #1 said that on 03/22/21, CNA #1, whom Resident #1 identified by first and last name, came to assist him/her (Resident #1) sometime after the start of the 11:00 P.M. to 7:00 A.M. shift. Resident #1 said CNA #1 yelled at him/her loud enough that staff heard CNA #1 at the nurses' station. Resident #1 said CNA #1 accused him/her in a nasty tone of voice of treating her (CNA #1) like his/her personal aide, and said that CNA #1 said she hated coming to help him/her (Resident #1). Resident #1 said he/she did not report how poorly CNA #1 treated him/her because he/she was fearful of not having his/her care needs met. During an interview on 04/08/21 at 11:46 A.M., Nurse #1 said that shortly after the start of the 11:00 P.M. to 7:00 A.M. shift on 03/22/21, she and Nurse #2 were at the nurses' station. Nurse #1 said Nurse #2 told CNA #1 to go down to Resident #1's room to help him/her because he/she was yelling for help. Nurse #1 said CNA #1 asked Nurse #2 what Resident #1 needed, and Nurse #2 said he did not know, but that she (CNA #1) needed to go check on Resident #1. Nurse #1 said CNA #1 said she was not going to go to Resident #1's room again, but did finally get up and go. Nurse #1 said CNA #1 initially stood in the doorway of Resident #1's room and said words to the effect of, what do you need now? I'm not changing you again! Nurse #1 said CNA #1's tone was irritated and angry, or words to that effect, and said that CNA #1 was speaking very loud. During an interview on 04/7/21 at 12:29 P.M., Nurse #2 said that on 03/22/21 at approximately 11:20 P.M., he and Nurse #1 were at the nurses' station performing narcotic count (a procedure to reconcile the physical number of narcotics on hand with the documented number reported to be on hand) when he heard Resident #1 yelling for help. Nurse #1 said he told CNA #1 that Resident #1 was yelling for help, and when CNA #1 did not initially respond to him, he repeated himself. Nurse #2 said CNA #1 then began arguing with him, but did go to Resident #1's room. Observations of Resident #1's unit on 04/07/21 at 10:38 A.M. indicated that the doorway of Resident #1's room was approximately 40 feet from the nurses' station. Nurse #1 said she checked on Resident #1 after CNA #1 left the room, and said Resident #1 reported that CNA #1 was mean to him/her and that CNA #1 hated him/her. Nurse #1 said Resident #1 reported similar allegations on multiple prior occasions (exact dates unknown) that CNA #1 was mean to him/her and said she hated him/her, which Nurse #1 reported to her (unidentified) supervisors. Nurse #1 said she had also expressed concerns about CNA #1 being burned out, that CNA #1 worked approximately 80 hours per week between different jobs, had expressed hatred of the Facility, that CNA #1 did not have any respect for staff or residents, and that she was a bully. During interview on 04/07/21 at 9:27 A.M. and multiple times during the day of survey, the Director of Nurses (DON) said she attempted to interview CNA #1 by telephone on the night of as well as the morning after the alleged incident, but said that her attempts to reach CNA #1 were unsuccessful. The DON said she was able to reach CNA #1 via text message the morning after the alleged incident. Review of what were identified by the DON as screen shots of text messages between herself and CNA #1 from the night of and the morning after the alleged incident indicated, in response to one of the DON's requests for a statement from CNA #1, CNA #1 wrote that there was nothing to investigate, that she yelled at Resident #1 for taking off his/her diaper and for making a mess of the bed. 2. Resident #1 said that on 03/22/21, CNA #1 removed his/her call light from within reach because she (CNA #1) said he/she (Resident #1) used the call light too much. Resident #1 said CNA #1 had removed his/her (Resident #1's) call light from his/her reach on prior occasions (exact dates unknown), and when CNA #1 did that, he/she would have to yell for help. Resident #1 said he/she did not report staff taking away his/her call light because he/she was fearful of not having his/her care needs met as a result. Nurse #1 said that on 03/22/21 after CNA #1 entered Resident #1's room, Nurse #1 heard CNA #1 say words to the effect of, I'm not giving you the bed remote, you can get up and get it yourself. Nurse #1 said she went to Resident #1's room after CNA #1 exited the room, and observed that Resident #1's the remote control for his/her bed was on the floor and his/her call light was also not within reach. Nurse #1 said that Resident #1 was not functionally able to get out of bed and/or able to pick something up off of the floor without extensive assistance from staff. Nurse #1 said that Resident #1 reported to her on several occasions in the past (exact dates unknown) that CNA #1 had also taken his/her call light away because CNA #1 said he/she used the call light too much. Nurse #1 said she reported Resident #1's prior allegations to her (unidentified) supervisors. Nurse #2 said that on 03/22/21, Resident #1 told him that CNA #1 refused to give Resident #1 his/her call light or bed remote control when he/she asked for them.

Based on observation, record review and interview, the facility staff failed to 1). identify and address a significant weight loss for 1 sampled resident (#70) in a total sample of 25 residents. Findings include: Review of the facility's Weight Height and Weigh Management policy, dated 3/28/18, indicated the following: *A discrepancy of (+ or -) 5 lbs (pounds) for a monthly weight will require that the resident be re-weighed within 24 hours to validate the weight discrepancy by a licensed nurse. *If the weight loss or gain is considered significant (5% over 30 days or 10% over 6 months) the Registered Dietitian and Physician must be notified and this notification must be documented in the resident's medical record. *The Resident's plan of care will be reviewed and revised to include necessary interventions related to significant weight loss by the interdisciplinary team. Resident #70 was admitted to the facility in 6/2018 with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set (MDS), dated [DATE] indicated that he/she requires assistance with bathing, dressing and toileting. During an interview with Resident #70 on 7/31/19 at 9:51 [NAME]M., the surveyor observed him/her to be very thin and frail. Review of Resident #70's Nutrition Care Plan, indicated the following: Goal: I will maintain adequate intake for stable weight, no further weight loss to gradual weight gain. Interventions: *Provide diet as ordered. Provide magic cup and pudding to lunch and dinner. (initiated 6/26/18) *Provide supplements as ordered. (initiated 6/26/18) Review of Resident #70's weights indicated the following: 8/1/18: 99.4 lbs 8/6/18: 100.2 lbs 8/13/18: 98.2 lbs 8/20/18: 99.4 lbs 9/11/18: 95.2 lbs 9/18/18: 92.8 lbs - (a significant weight loss of 6.6% of his/her total body weight in 30 days). Review of the Dietitian's assessment completed on 9/27/2018 indicated that Resident #70's usual body weight was 100 lbs. The Dietitian indicated that Resident #70 had a significant weight loss and indicated the following nutrition plan: arrest weight loss, gradual weight gain, maintain oral intake, continue current care plan. There were no new interventions implemented to address Resident #70's weight loss. Further review of Resident #70's weights indicated he/she was weighed once per month in 10/2018 and 11/2018: 11/6/18: 89 lbs. (a significant weight loss of 10.46% of his/her total body weight in 3 months). Review of the clinical record indicated that although Resident #70 had continued weight loss in 10/2018 and 11/2018, there was no evidence in the medical record to indicate that Resident #70 was assessed by a dietitian and no new interventions were implemented to address the weight loss. Review of Resident #70's nursing and physician progress notes [REDACTED].#70 for 9/2018, 10/2018 and 11/2018. During an interview with Unit Manager #1 on 8/1/19 at 9:33 [NAME]M., she said that when a resident has a significant weight loss, the nursing staff notifies the physician, dietitian and the resident will be followed at weekly risk meetings. Unit Manager #1 said that she did not know that Resident #70 had weight loss in 9/2018, 10/2018 and 11/2018 and she could not say if the Physician was aware of the weight loss. Unit Manager #1 reviewed Resident #70 clinical record with the surveyor she could not say why the dietitian did not implement new interventions or update Resident #70's care plan. Review of Resident #70's weights for 12/2018 indicated his/her weight was taken once in 12/2018: 12/5/18: 88 lbs (a significant weight loss of 11.47% of his/her total body weight in 4 months). Review of the nutritional assessments indicated that Resident #70 was not assessed for his/her additional weight loss by a Dietitian until 12/21/18; 16 days after his/her documented weight of 88 lbs. The assessment indicated the Dietitian recommended giving Resident #70 pudding and a magic cup (a supplement) at lunch and dinner, and increasing his/her Ensure to 3 times a day. The recommendations for the use of pudding and a magic cup were interventions implemented on 6/26/18 per Resident #70's Nutrition Care Plan. Review of the physician's orders [REDACTED]. During a follow up interview with Unit Manager #1 on 8/1/19 at 10: 50 [NAME]M., she said she did not know why the ensure was not increased. During an interview with the Dietitian on 8/1/19 at 10:31 [NAME]M., she said that she was not the dietitian that assessed Resident #70 in 9/2018 and that she did not know why no new interventions to address his/her significant weight loss were implemented. She said that she could not recall if Resident #70 had weight loss in 10/2018 or 11/2018. She said that Resident #70's weight loss was assessed in 12/2018. During an interview with the Physician on 8/1/19 at 3:47 P.M., he said that he could not recall being informed of weight loss for Resident #70 prior to 12/2018 and that he did not begin monitoring Resident #70's weights until then. For the month of 7/2019, Resident #70's weights ranged between 88 and 88.2 lbs. As of 8/1/19, Resident #70's weights did not return to his/her documented usual body weight of 100 lbs. During an interview with the Director of Nursing and the Administrator on 8/1/19 at 11:59 [NAME]M., they said they could not say why interventions were not implemented regarding Resident #70's weight loss.

2. For Resident #4, the Facility failed to follow the falls prevention interventions of diversional activities for safety monitoring, functioning alarms, proper footwear, bedside mats, functioning wheelchair locks and anti-tippers, and toileting, to prevent ten unwitnessed falls in the resident's bedroom. Resident #4 was admitted to the facility in 7/11 with [DIAGNOSES REDACTED]. The 12/11 care plan to be free from injury for the potential for falls included the following interventions: -Provide proper footwear. -Use safety and assistive devices. -Diversional activities to assist in safety management. Review of Nurse's Notes, Change of Condition Documentation, and Quality Concerns Document, dated 12/2/11 at 11:55 A.M., indicated that staff found the resident sitting on the floor. The investigation indicated the resident attempted to transfer from wheelchair to bed without the wheelchair being locked. The alarm was not sounding, but was in the on position. The resident was not in any diversional activity for safety monitoring, as care planned. The investigation added a new care plan intervention of "anti-roll backs on the wheelchair." On 12/4/12, chair and bed alarms were added to the care plan. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 12/7/11 at 6:00 A.M., indicated staff heard a "thud" and found the resident lying on the right side, head against a bedside table. The resident attempted self transfer from bed to wheelchair. Staff indicated the bed alarm was not working. Floor mats were placed on both sides of the bed. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 2/1/12 at 10:00 A.M., indicated that staff found the resident on the bedroom floor. The resident attempted to transfer from bed to wheelchair. The resident was not in a diversional activity, as care planned. The bed alarm was replaced, as it did not sounded. An alarmed floor mat was added to the care plan. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 5/28/12 at 5:25 A.M., indicated that staff found the resident on the floor in the bedroom. The resident attempted to transfer from bed to wheelchair. The resident was not in a diversional activity, and the bed alarm was not sounding, as care planned. There was no indication if floor mats were in place, as planned. On 6/26/12, the care plan was updated to include: toilet the resident every 2 hours. On 7/31/12, the care plan was updated to include: Tabs alarm on the bathroom door. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 8/22/12 at 9:45 P.M., indicated that staff found the resident sitting on the bedroom floor. The resident's alarm did not sound loudly enough for staff to hear, and the resident did not have any footwear on, as care planned. The care plan was updated to place the resident back to bed after the "7 PM cigarette." Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 9/4/12 at 6:30 P.M., indicated that staff found the resident on the bedroom floor. The resident attempted to transfer from chair to bed, fell and was sitting next to the bed. The resident's alarm was not on, and the resident was not placed in diversional activities, prior to the evening smoking time, as care planned. A motion sensor was placed on the resident's right bedside. On 9/13/12, the care plan was updated to include: discontinue all alarms (as they agitated the resident). Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 9/23/12 at 2:15 A.M., indicated that staff heard a "thump," and found the resident lying on the floor next to bed. The resident attempted to transfer independently. There was no documentation that floor mats were placed on both sides of the bed, as care planned. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/8/12 at 5:00 P.M., indicated that staff found the resident on the floor, next to the wheelchair and bed. The resident had attempted to transfer independently. The investigation found that the wheelchair's anti-tippers were not functioning properly. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/14/12 at 6:30 P.M., indicated that a visitor alerted staff that the resident was on the bedroom floor with pants down and incontinent of urine. Investigation indicated that staff had no idea if the resident had been toileted every two hours as care planned. The resident was alone in the bedroom, and not in diversional activities. Review of Nurse's Notes, Change of Condition Documentation, Quality Concerns Document, dated 10/17/12 at 6:20 P.M., indicated that staff found the resident sitting on the bedroom floor. The resident was not placed in diversional activities for safety monitoring before the "7 PM cigarette" break, as care planned. During interview on 11/5/12 at 9:50 A.M., the Director of Nurses stated that the Facility had not followed the resident's care plan for: diversional activity and supervision, ensuring effective assistive devices such as anti-tippers, wheelchair brake engagement, floor mats, functioning alarms, planned toileting, and proper footwear to prevent 10 unwitnessed falls in the same location. Please refer to F 323 3. For Resident #8, the facility failed to ensure: that alarms were functional, that non-skid socks were worn, that the resident was supervised when using the bathroom, and that diversional activities were provided to monitor the resident's safety, as planned, to prevent falls. Resident #8 was admitted to the facility in 10/11 with [DIAGNOSES REDACTED]. The care plan to be free from injury for the potential for falls related to unsteady gait and poor safety awareness, from 3/12, included the following interventions: -Provide proper footwear (non-skid socks). -Use safety and assistive devices. -Diversional activities to assist in safety management. -Chair and bed alarm, -Assist of one for transfers. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 3/30/12 at 9:55 A.M., indicated that staff found the resident on the floor after slipping out of the wheelchair. Interview with staff noted that the chair alarm was not turned back on after toilet use. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 9/5/12 at 7:15 A.M., indicated the resident was on the toilet with staff present. The resident shifted position to transfer back to the wheelchair and fell on to the right side on the floor. Staff indicated the resident had not been kept in the line of vision by them, when toileting the resident, as planned. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/7/12 at 9:55 P.M., indicated staff heard a loud noise in the hallway, and found the resident on the floor. The alarm was not "on." The resident stated it made too much noise. The resident was not wearing non-slip socks, as planned. The resident was now to have a Tabs alarm while in bed and chair to prevent the resident from shutting off the alarm. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/19/12 at 4:50 P.M., indicated the resident was yelling "Help!" Staff found the resident on the bedroom floor between the bed and wheelchair, after attempting to put on shoes. The Tabs alarm was not clipped to the resident, as planned. The resident had not been placed in diversional activities for safety monitoring. During interview on 11/5/12 at 9:50 A.M., the Director of Nursing stated the Facility had not provided effective supervision during toileting and/or diversional activities for the wandering resident, proper footwear, and functioning alarms to prevent repeated unwitnessed falls. Please refer to F 323 4. For Resident #19, the Facility failed to follow the physician's orders [REDACTED]. Resident #19 was admitted to the Facility in 10/12 with [DIAGNOSES REDACTED]. The Nursing Assessment of 10/29/12 indicated that the resident had multiple stasis ulcers on the lower extremities. Review of the Physician's Interim Orders of 11/2/12 included: *Discontinue current treatments to both lower extremities. * Cleanse right knee, right lateral knee, left knee and left lateral shin with normal saline, apply Santyl Ointment and a clean dressing 2 times per day. *Cleanse left lower shin and right calf with normal saline, and apply a Xeroform dressing every day. The Treatment Administration Record was updated and included the following new orders of 11/2/12: * Cleanse right knee, right lateral knee, left knee, left lateral shin and "incorrectly" - left lower shin with normal saline, apply Santyl Ointment and a clean dressing 2 times per day. *Cleanse right calf with normal saline, and apply a Xeroform dressing every day. On 11/5/12 at 10:30 A.M., Resident #19 was observed lying in bed. Both lower extremities were wrapped from knees to feet with gauze dressings. On 11/5/12 at 11:15 A.M., Unit Manager #1 and Nurse #1 said that the treatment to the left lower shin was incorrectly written on the Treatment Administration Record. The physician ordered a Xeroform dressing to the left lower shin and not Santyl Ointment. Based on observation, record review, and interview, the Facility failed to follow the written plan of care and/or physician's orders [REDACTED].#8, #9, and #19). Findings include: 1. For Resident #9 the Facility failed to follow the plan of care regarding fall interventions. Resident #9 was alone in the room, did not consistently receive close supervision and the alarm was not consistently on. Resident #9 was admitted to the Facility in 2/12. Review of the falls care plan of 2/21/12 included the following interventions: - Bed and chair alarms. Review of the falls care plan indicated that on 3/13/12, the care plan was updated to include the following: - Not to be left alone in room when in wheelchair. - Non-skid socks - Offer toileting prior to helping Resident #9 back to bed. Review of the Nurse's Note and the Facility's investigation of 4/4/12 indicated that, after breakfast, Resident #9 was alone in the bedroom and put him/herself to bed. At 11:45 A.M., Resident #9 was found on the floor calling for help, after attempting to get from the bed to the wheelchair. Resident #9's alarm was turned off. Resident #9 did not sustain an injury. Resident #9's alarm did not function and the resident was alone in the room in the wheelchair. Review of the falls care plan indicated that, on 4/4/12, the care plan was updated to include "Close supervision." Review of the Nurse's Note and the Facility's investigation of 4/11/12 indicated that after lunch, Resident #9's alarm sounded and he/she was found on the floor after attempting to go back to bed, while alone in the room in the wheelchair. Resident #9 did not sustain an injury. Resident #9 was alone in the room in the wheelchair and did not receive close supervision as care planned. Review of the falls care plan indicated that, on 4/11/12, the care plan was updated to include the following: - Resident to eat in large dining room at the end of the hall for more supervision, - and Resident is to go back to bed after meals. Review of the Nurse's Note and the Facility's investigation of 4/15/12 indicated that, at 1:30 P.M., Resident #9's alarm sounded. Resident #9 was found on the floor in the bedroom, in the wheelchair attempting to go to bed, without close supervision as planned. Resident #9 sustained a discoloration to the left hand. Further review of the Facility's investigation indicated that Resident #9 was finished eating lunch and was not put to bed after lunch as care planned. Review of the Nurse's Note and the Facility investigation of 4/23/12 indicated that, at 4:30 P.M., Resident #9's alarm sounded. Resident #9 was found on the floor in the bedroom alone after attempting to put him/herself to bed from the wheelchair. Resident #9 sustained a laceration to the left eyebrow and was sent to the hospital and received sutures. Resident #9 was alone in the room, in the wheelchair and did not receive close supervision as care planned. On 11/5/12 at 11:10 A.M., the Surveyor observed Resident #9 sitting in the wheelchair at the end of the hallway with an alarmed seatbelt on the wheelchair. The above was reviewed with Unit Manager #1 and Unit Manager #2 on 11/5/12 at 1:20 P.M. Please refer to F323

2. For Resident #4, the Facility failed to ensure that the resident had adequate supervision and assistive devices when transferring in the bedroom to prevent ten unwitnessed falls. Resident #4 was admitted to the facility in 7/11 with [DIAGNOSES REDACTED]. The care plan to be free from injury for the potential for falls related to a history of falls, decreased range of motion/balance, status [REDACTED]. -Give directions in safety awareness. -Spanish only use, interpreter, gestures. -Fall Risk Assessment quarterly and PRN (As Needed). -Provide safe environment with dry floor, well lit areas, no clutter in pathways, and proper footwear. -Use safety and assistive devices. -Ambulate with rolling walker one assist. -Diversional activities to assist in safety management. Review of Nurse's Notes, Change of Condition Documentation, and Quality Concerns Document, dated 12/2/11 at 11:55 A.M., indicated the resident had an unwitnessed fall in the bedroom. Staff were called and found the resident sitting on the floor with complaints of left hip and leg pain, and a purple discolored bruise 2.5 cm. (centimeters) by 1.8 cm. The investigation indicated the resident attempted to transfer from wheelchair to bed without the wheelchair being locked, that the alarm was not sounding but turned on. The resident was non-compliant with asking for help, and was not in any diversional activity for safety monitoring as care planned. The investigation indicated the care plan was updated to include: "anti-roll backs on the wheelchair." Change of Condition Documentation, of 12/4/11 at 11:55 A.M., indicated the resident had been lowered to the floor by staff during smoking activities, without injury. Chair and bed alarms were now added to the care plan. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 12/7/11 at 6:00 A.M., indicated staff heard a "thud," and found the resident lying on the bedroom floor with head against a bedside table. The resident tried to put self into the wheelchair from the bed. No injury was noted. Staff indicated the bed alarm was not working, and questioned whether the resident disabled the alarm. New interventions included: non-skid strips in front of the closet and bed, and floor mats on both sides of the bed. The resident was to be assisted to wheelchair daily. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 2/1/12 at 10:00 A.M., indicated that staff found the resident on the floor after an unwitnessed fall in the bedroom. The resident attempted to transfer from bed to wheelchair. No injury was noted. The resident was not in a diversional activity, as care planned. The bed alarm was replaced as it had not sounded. An alarmed floor mat was added to the care plan. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document,dated 5/28/12 at 5:25 A.M., indicated that staff found the resident on the floor after an unwitnessed fall in the bedroom. The resident attempted to transfer from bed to wheelchair and was incontinent. The resident was not in a diversional activity as care planned, and the bed alarm was not sounding. There was no indication if floor mats were in place, as care planned. Staff reminded the resident to "use the call light and stop turning the alarm off." No injury was noted. The resident's annual MDS assessment of 6/28/12, indicated the resident had severe cognitive impairment with BIMS (Brief Interview for Mental Status) score of 5/15, was inattentive, was resistive to care at times, required extensive assist of one for transfers, ambulation, toilet use, hygiene, and bathing, had unsteady balance, was frequently incontinent of bowel and bladder and had fallen since the last assessment. On 6/26/12, the care plan was updated to include toileting the resident every 2 hours. The care plan was updated on 7/31/12 to include: place a Tabs alarm on the bathroom door. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 8/22/12 at 9:45 P.M., indicated that staff found the resident on the floor after the fifth unwitnessed fall in the bedroom. The resident attempted to transfer, fell and was sitting in front of the bed. No injury was noted. The resident's alarm did not sound loudly, and the resident did not have any footwear on, as care planned. The care plan was updated to place the resident back to bed after the "7 PM cigarette." Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 9/4/12 at 6:30 P.M., indicated that staff found the resident on the floor after an unwitnessed fall in the bedroom. The resident attempted to transfer from chair to bed, fell and was sitting next to the bed. The resident's alarm was not on, and the resident was not placed in diversional activities as care planned, prior to the evening smoking time. The resident was put on 15 minutes checks, and a motion sensor was placed on the resident's right bedside. On 9/13/12, the care plan was updated to discontinue all alarms as they agitated the resident. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 9/23/12 at 2:15 A.M., indicated that staff heard a "thump," and found the resident lying on the bedroom floor for the seventh unwitnessed fall. The resident attempted to transfer independently. No injury was noted. There was no evidence that floor mats were placed on both sides of the bed as care planned. Staff recommended the resident's wheelchair be placed next to the bed as the resident needed a support when self transferring, and the bed be placed in the lowest position. The care plan was also updated on 9/27/12 to "check on 2:00 A.M. rounds and offer the patient the BR" (Bathroom.) Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/8/12 at 5:00 P.M., indicated that staff found the resident next to the wheelchair and bed, on the floor. The resident attempted to transfer independently. The investigation found that the wheelchair's anti-tippers were not functioning properly. The low bed intervention was discontinued on 10/9/12. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/14/12 at 6:30 P.M., indicated that a visitor alerted staff that the resident was on the bedroom floor with pants down and incontinent of urine. Investigation indicated that staff had no idea if the resident had been toileted every two hours as care planned. The resident was alone in the bedroom and not in diversional activities. No injury was noted. Staff were again instructed to toilet the resident every two hours, Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/17/12 at 6:20 P.M., indicated that staff found the resident sitting on the bedroom floor and had the 10th unwitnessed fall in the bedroom. No injury was noted. Again, the resident was not placed in diversional activities for safety monitoring before the "7 PM cigarette" break. The care plan was updated to have the resident eat meals in the assisted Dining Room and be assisted with toilet use pre and post meals. Observation of the resident, on 10/31/12 at 1:15 P.M., found the resident dressed and sitting in a wheelchair with anti-tippers, eating lunch in the assisted Dining Room. At 3:00 P.M., the resident was seated next to the Nursing Station in the wheelchair, passively observing unit traffic. Interview on 10/31/12 at 4:22 P.M. with Certified Nursing Aide (CNA) #2 indicated the resident was difficult to understand, was impulsive and wandered in the wheelchair, attempted to self transfer at times, was incontinent of bowel and bladder, required frequent toileting, and was alert and confused. Interview on 11/5/12 at 9:50 A.M., the Director of Nursing stated that the Facility had not provided effective supervision and safety devices to prevent repeated unwitnessed resident falls. 3. For Resident #8, the Facility failed to ensure that the resident had adequate supervision and assistive devices when transferring from one surface to another to prevent four falls. Resident #8 was admitted to the facility in 10/11 with [DIAGNOSES REDACTED]. The care plan to be free from injury for the potential for falls related to unsteady gait and poor safety awareness, of 3/12, had the following interventions: -Give directions in safety awareness. -Fall Risk Assessment quarterly and PRN (As Needed). -Provide safe environment with dry floor, well lit areas, no clutter in pathways, and proper footwear (non-skid socks). -Use safety and assistive devices. -Rolling Walker, gait belt and assist of one. -Diversional activities to assist in safety management. -Chair and bed alarm. -Assist of one for transfers. -Encourage the resident to use call light and to stop unplugging the alarms. Review of Nurse's Notes, Change of Condition Documentation, and Quality Concerns Document, dated 3/30/12 at 9:55 A.M., indicated the resident had an unwitnessed fall in the bedroom. Staff found the resident on the floor, having slipped out of the wheelchair. No injury was noted. Interview with staff noted that the chair alarm should have been turned back on before and after the resident toileted self. The care plan was updated to include non-skid bedside strips and Dycem in the wheelchair. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 9/5/12 at 7:15 A.M., indicated the resident was on the toilet with staff present. The resident shifted position to transfer back to the wheelchair and fell on to the right side on the floor. Staff indicated the resident had not been kept in the line of vision, when toileting the resident. No injury was noted. The resident's annual MDS assessment of 9/14/12 indicated the resident had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 4/15, was inattentive, had disorganized thinking, wandered, required extensive assist of one for transfers, ambulation, toilet use, hygiene, and bathing, was unsteady in balance, and was frequently incontinent of bowel and bladder. The resident received anti-psychotic and anti-depressants daily. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/7/12 at 9:55 P.M., indicated staff heard a loud noise in the hallway, and found the resident on the floor. The resident had ambulated from the bed to the hallway, and fell . The resident had complaints of back of the head and right buttock pain. The alarm was not "on." The resident stated it made too much noise. The resident was not wearing non-slip socks, as planned. New interventions included: Tabs alarm while in bed and chair to prevent the resident from shutting off the alarm. Review of Nurse's Notes, Change of Condition Documentation and Quality Concerns Document, dated 10/19/12 at 4:50 P.M., indicated the resident was yelling "Help!" Staff found the resident on the bedroom floor between the bed and wheelchair, after attempting to put on shoes. The Tabs alarm was not clipped to the resident, as planned, and the resident was not placed in diversional activities for supervision. No injury was noted. Observation of the resident, on 11/1/12 at 9:05 A.M., indicated the resident was dressed and sitting in a wheelchair with Tabs alarm attached to the resident's shirt. The resident was eating breakfast in the unit Dining Room. At 10:20 A.M., the resident was self propelling the wheelchair back and forth in the unit hallway. Interview on 11/1/12 at 11:10 A.M. with CNA #1 indicated that the resident was alert and confused, required assist of one with gait belt for transfers and ambulation, was incontinent of bowel and bladder, frequently attempted to stand from the wheelchair which staff interpreted as a need to be toileted or with a urinary tract infection onset. The resident frequently wandered, wore a Tabs alarm in bed and chair, and needed close supervision, During interview on 11/5/12 at 9:50 A.M., the Director of Nursing stated the facility had not provided effective supervision and functioning safety devices to prevent repeated unwitnessed falls. Based on observation, record review, and staff interview, the Facility failed to provide adequate supervision and effective interventions to prevent accidents from occurring for 3 (#4, #8, and #9) of 13 applicable residents with accidents in a total sample of 24. Findings include: 1. For Resident #9, the Facility failed to provide adequate supervision and assistance devices to prevent Resident #9 from falling and sustaining a laceration to the head, which required sutures to close. Resident #9 sustained 7 unwitnessed falls in his/her room from 3/3/12 - 4/23/12. Resident #9 was admitted to the Facility in 2/12 with [DIAGNOSES REDACTED]. Review of the falls care plan of 2/21/12 included the following interventions: - Give direction in safety awareness. - Provide safe environment with dry floor, well lit areas, no clutter in pathways, and proper footwear. - Bed and chair alarms. The initial Minimum Data Set (MDS) assessment of 2/28/12 indicated that Resident #9 was cognitively intact as evidenced by a score of 13 out of possible 15 on the Brief Interview for Mental Status (BIMS); required extensive assistance with transfers, ambulation and toilet use; had a [DIAGNOSES REDACTED]. Review of the Nurse's Note and the Facility's investigation of 3/3/12 indicated that, at 8:20 P.M., Resident #9 attempted to transfer from the bed to the wheelchair in an attempt to go to the bathroom. Resident #9 was found on the floor. There was no injury. Review of the falls care plan indicated on 3/3/12, the care plan was updated to include the following: - Bed in lowest position when Resident #9 is in bed. - Bed in highest position when Resident #9 is out of bed. Review of the Nurse's Note and the Facility's investigation of 3/13/12 indicated that, at 2:30 P.M., a loud noise was heard, along with Resident #9's alarm sounding. Resident #9 was found on the floor in a "small puddle of blood." Resident #9 stated that he/she was attempting to go back to bed and slipped. Further investigation indicated that Resident #9 slipped in water he/she spilled. Resident #9 sustained a hematoma to the right occipital area and a 3 centimeter (cm) x 0 .75 cm skin tear/laceration. Resident #9 was sent to the emergency room for evaluation. Review of the falls care plan indicated that, on 3/13/12, the care plan was updated to include the following: - Not to be left alone in room when in wheelchair. - Non-skid socks - Offer toileting prior to helping Resident #9 back to bed. Review of the Nurse's Note and the Facility's investigation of 3/31/12 indicated that, at 9:30 A.M., Resident #9 was offered toileting and declined, and then was assisted to bed. At 9:45 A.M., Resident #9's alarm sounded and Resident #9 was found on the floor. Resident #9 did not sustain any injury. Review of the falls care plan indicated that, on 3/31/12, the care plan was updated to include the following: - Encourage diversional activities and snacks. Review of the Nurse's Note and the Facility's investigation of 4/4/12 indicated that, after breakfast, Resident #9 had put self to bed, while alone in the room in the wheelchair. At 11:45 A.M., Resident #9 was found on the floor calling for help after attempting to transfer from the bed to the wheelchair. Resident #9's alarm was not sounding and was in the "off" position. Resident #9 did not sustain an injury. Review of the falls care plan indicated that, on 4/4/12, the care plan was updated to include the following: - Close supervision. Review of the Nurse's Note and the Facility's investigation of 4/11/12 indicated that Resident #9's alarm sounded. He/she was found on the floor after attempting to go back to bed, after lunch, while alone in the room in the wheelchair. Resident #9 did not sustain an injury. Review of the falls care plan indicated that on 4/11/12, the care plan was updated to include the following: - Resident to eat in large dining room at the end of the hall for more supervision. - Resident is to go back to bed after meals. Review of the falls care plan indicated that, on 4/14/12, the care plan was updated to include the following: - Plan of care needs to be followed at all times. - Staff to be re-inserviced. Review of the Nurse's Note and the Facility's investigation of 4/15/12 indicated that, at 1:30 P.M., Resident #9's alarm sounded. Resident #9 was found on the floor in his/her room, in the wheelchair attempting to go to bed without close supervision. Resident #9 sustained a discoloration to the left hand. Further review of the Facility's investigation indicated that Resident #9 was finished eating lunch and was not put to bed after lunch as planned. Review of the Nurse's Note and the Facility investigation of 4/23/12 indicated that, at 4:30 P.M., Resident #9's alarm sounded. Resident #9 was found on the floor in the bedroom after attempting to put self to bed. Resident #9 was alone in the room, in the wheelchair, without close supervision. Resident #9 sustained a laceration to the left eyebrow and was sent to the hospital for evaluation. Review of the Nurse's Note of 4/24/12 indicated that Resident #9 returned from the hospital with sutures to the left eyebrow. On 11/5/12 at 11:10 A.M., the Surveyor observed Resident #9 sitting in the wheelchair at the end of the hallway with an alarmed seatbelt on the wheelchair. During a discussion with Unit Manager #1 on 11/5/12 at 1:20 P.M., Unit Manager #1 said that she was concerned about Resident #9's falls.

Based on record review and interview, for 1 of 2 sampled residents, Resident #1, the Facility failed to ensure: - that an allegation of abuse was reported immediately to the Administrator; - that the allegation was thoroughly investigated; and - that further potential abuse was prevented, when on or about 11/4/11, Activity Aide #1 observed Certified Nurse Aide (CNA)#1 slap Resident #1's hands. Activity Aide #1 reported the incident to the Recreation Director (Activity Aide #1's immediate supervisor); the Recreation Director did not report the incident to the Administrator or Director of Nursing (DON) per Facility policy, and the incident was not discovered or investigated until 11/17/11, when another incident occurred involving CNA #1 and Resident #2. The findings included: The Facility policy relative to Abuse Reporting indicated that if an allegation of abuse was made, staff should report it to their supervisor, the Director of Nursing, or the Administrator. The DON was interviewed on 12/1/11 at 7:45 A.M. The DON said that while investigating the 11/17/11 incident involving CNA #1 and Resident #2, the DON became aware of an incident which took place on or about 11/4/11 and involved CNA #1 and Resident #1. The DON said that Activity Aide #1 told the DON that, on or about 11/4/11, when Activity Aide #1 saw CNA #1 slap Resident #1's hands, Activity Aide #1 reported the incident to her direct supervisor, the Recreation Director. The DON said that the Recreation Director never reported the incident involving CNA #1 and Resident #1 to the DON or the Administrator per Facility policy and as a result, the incident with Resident #1 not investigated or reported in a timely manner. . Activity Aide #1 was interviewed on 12/1/11 at 1:50 P.M. Activity Aide #1 said that on or about 11/4/11, Resident #1 was seated by the door of the dayroom where Activity Aide #1 was conducting an activity. Activity Aide #1 said that Resident #1 was tugging at the incontinence brief that Resident #1 was wearing when CNA #1 came by and slapped Resident #1's right hand. Activity Aide #1 said she saw and heard the slap. Activity Aide #1 said she heard CNA #1 say, in a loud voice, words to the effect of don't do that you will make my job harder. Activity Aide #1 said that she reported the incident to the Recreation Director, who was her direct supervisor. Activity Aide #1 said that she was never interviewed about the incident with Resident #1 and when Activity Aide #1 mentioned the incident with CNA #1 during the investigation of a new incident on 11/17/11 with Resident #2, it was evident that the Director of Nursing had not been made aware of the previous incident. The Recreation Director was interviewed on 12/1/11 at 1:15 P.M. The Recreation Director first said that the Recreation Director had no recall of anyone reporting an incident involving Resident #1 and CNA #1. Later in the interview, the Recreation Director said that the Recreation Director did not recall a resident name, but said that Activity Aide #1 said there was a staff member who was too quick and not being good to a resident. The Recreation Director was not sure if the resident was Resident #1 or Resident #2. The Recreation Director said she did not report the incident per Facility policy. The incident report, dated 11/17/11, indicated that Certified Nurse Aide (CNA) #1 sat Resident #2 down in the chair, roughly, after toileting Resident #2. The report indicated that Resident #3 said that CNA #1 jerked Resident #2's chair and that Resident #2 did not think that CNA #1 liked Resident #2. Activity Aide #1 said that on 11/17/11, Activity Aide #1 returned to the unit after lunch and noticed Resident #2 crying. Activity Aide #1 said that Resident #2 was unable to speak due to the crying and Resident #3, who was sitting with Resident #2, told Activity Aide #1 that Resident #3 saw CNA #1 be rough with Resident #2 and slam her into the chair after toileting. Activity Aide #1 said that Activity Aide #1 reported this to Social Worker #2 right away and Social Worker #2 directed Activity Aide #1 to the Unit Manager. Resident #2 was interviewed at 3:30 P.M. on 12/1/11. Resident #2 said that a tall girl was rough with Resident #2, banged the chair into the wall and hurt Resident #2 a few weeks ago. Resident #3 was interviewed at 3:40 P.M. on 12/1/11. Resident #3 said Resident #3 saw a staff member pick Resident #2 up and slam Resident #2 into the chair, making Resident #2 cry. The statements obtained from Resident #2 and Resident #3, by the Director of Nursing (DON), indicated that Resident #2 said that CNA #1 jerked Resident #2 in the chair and Resident #2 hurt Resident #2's knee. The statement indicated that Resident #2 said that there had been previous issues with CNA #1. The statement given by Resident #3 indicated that Resident #3 saw CNA #1 slam Resident #2 into the wheelchair. The DON said that the Recreation Director and CNA #1 were both terminated from the Facility.

2. Resident #9 was admitted to the facility in 12/2009 with [DIAGNOSES REDACTED]. For Resident #9, the facility failed to consistently ambulate the resident on a daily basis to ensure the resident could maintain his/her ability to ambulate to his/her maximum potential. Review of an Annual MDS dated [DATE], and a Quarterly MDS of 8/25/11, indicated that the resident was cognitively intact, and required one person physical assist for transfers and walking in the room and the corridor. During an interview with Resident #9 on 10/24/11 at 3:40 P.M., the resident indicated to the surveyor that he/she would like to walk more. When the surveyor asked the resident if he/she was able to walk a little bit each day the resident answered, "Oh no, not every day." The resident told the surveyor that the other day he/she asked one of the staff members who would be walking with him/her today and he/she got the reply, "Nobody." Review of the clinical record revealed a "Record of Inservice Training", for Resident #9 completed by the facility's Restorative CNA. This document was not dated; however, during interview, on 10/25/11 at 10:00 A.M., the Restorative CNA said that it should have been dated (6/9/11). The document indicated that Resident #9 had been discharged from the Restorative Ambulation Program and had reached his/her goal. The document further indicated 5 CNA's had signed the Inservice training form indicating staff education had been completed regarding the resident's ROM (Range of Motion) and Ambulation. The document indicated that the Resident could ambulate up to 400 feet with a gait belt, rolling walker, and one assist. "Resident is doing great." Further discussion with the Restorative CNA and UM#2 on 10/25/11 at 1:45 P.M., indicated that following discharge from the Restorative Ambulation Program, the Resident's name is placed on the ambulation list which indicates each residents appropriate assistive device, and the distance they should be ambulated. A separate form is kept in the book to record how far the resident is ambulated by the CNA's on the day shift and on the evening shift. The Surveyor asked to see Resident #9's ambulation sheets; however, there were no ambulation sheets for the resident in the ambulation log book. Review of the log book revealed there was no list of resident's to be ambulated by the CNA's. The Restorative CNA began to ask the CNA's on the unit where the CNA ambulation sheets had gone that she had completed for the resident's when they were discharged from Restorative Nursing, and got no reply. During discussion with UM#2 on 10/25/11 at 1:50 P.M., she acknowledged there was a problem with the ambulation program on the unit. UM#2 also acknowledged the concern for the lack of consistency in Resident #9's ambulation by the CNAs and the potential for a decline in ambulation status. Based on observation, record review, and staff and resident interviews, the facility failed to ensure that 2 residents (#2 and #9) in a total sample of 24 residents, received appropriate treatment and services to maintain or improve functional mobility (ambulation). Findings included: 1. For Resident #2, the facility failed to maintain the resident's ambulation status, and failed to request a physical therapy screen when the resident's ambulation status declined. Resident #2 was admitted to the facility in 1/09. [DIAGNOSES REDACTED]. Review of the Physician order's dated 10/7/11 revealed an order for [REDACTED]. When the resident started on the Restorative ambulation program (11/10), he/she was ambulating with contact supervision or contact guard (occasional contact). The distance that the resident was ambulated was not clear. Review of the resident's Certified Nursing Assistant (CNA) care card (no date) indicated the resident ambulated with a walker and an assist of one. Review of the resident's Impaired Mobility Care Plan rewritten on 2/11 ( updated in 8/11 and 10/11) indicated that the resident was ambulated with an assist of one using a gait belt and a rolling walker. Review of the ADL (Activities of Daily Living) flow sheets, dated 3/11, indicated the resident was an extensive physical assist of one for ambulation in the bedroom and out of the bedroom. It further indicated that Resident #2 ambulated daily on the 7:00 A.M. - 3:00 P.M. shift, but rarely ambulated on the 3:00 P.M. - 11:00 P.M. shift. Review of the ADL flow sheets, dated 4/11 indicated the resident did not ambulate at any time during the month of April. A dash was inserted in all days and shifts indicating, "did not apply." Review of the resident's Quarterly MDS (Minimum Data Set) Assessment on 5/13/11 indicated; the resident was able to make self understood and was able to clearly comprehend others, had no behaviors, no signs or symptoms of depression, was extensive assistance for bed mobility, transfers, dressing and toilet use, and was a limited assistance of one for transfer and ambulation. Review of the ADL flow sheets, dated 5/11 and 6/11 indicated the resident did not ambulate at any time during these months. A dash was inserted in all days and shifts indicating, "did not apply." Review of the resident's Quarterly MDS Assessment on 7/22/11 indicated; the resident was able to make self understood and was able to clearly comprehend others, had no behaviors, no signs or symptoms of depression, was extensive assistance for bed mobility, transfers, dressing and toilet use, and was a limited assistance of one for transfer and ambulation. Review of the ADL flow sheets, dated 7/11, 8/11 and 9/11 indicated the resident did not ambulate at any time during these months. A dash was inserted in all days and shifts indicating, "did not apply." Review of Resident #2's Annual MDS Assessment, dated 10/14/11, revealed that the resident was able to make self understood, was able to clearly comprehend others, was an extensive assist for bed mobility, was totally dependent on two for transfers and the resident did not ambulate. Review of the Impaired Mobility Care Plan, updated on 10/14/11 indicated the resident was non ambulatory at this time due to illness. Review of the 10/1- 10/19/11 ADL flow sheets, indicated the resident did not ambulate. A dash was inserted in all days and shifts indicating, "did not apply." On 10/19/11 at 10:15 A.M., the resident was observed by the surveyor out of bed sitting in a chair, resting his/her head on the over the bed table. The resident stated that he/she was "just sleepy and getting over a cold." On 10/21/11 at 11:30 A.M., the resident was observed by the surveyor, in the bedroom sitting in a wheelchair, reading a book and waiting for lunch. During an interview on 10/21/11 at 2:30 P.M. with the MDS Nurse, it was indicated that she thought the resident's decline was due to an illness and if the resident did not improve, a significant change MDS would be done. The MDS nurse was not aware that the resident had not ambulated for 7 months. On 10/21/11 at 2:45 P.M., during interview, Unit Manager #2 said that she had not seen Resident #2 ambulate for a long time. UM #2 also said that the Physical Therapy Department had not been notified. During review of the medical record, there was a new order, dated 10/21/11, for a Physical Therapy evaluation and treatment due to functional decline. The Physical Therapy evaluation, dated 10/22/11, indicated the resident's prior level of functioning was an assist of 1 with a rolling walker. The patient's goals stated, "I would like to be able to do a little walking." The resident's ambulation status was unable to be tested secondary to pain (not described). The Physical Therapist documented the resident would benefit from skilled physical therapy 3 times a week for 4 weeks. During interview on 10/25/11 at 8:30 A.M., the Director of Rehabilitation said that Resident #2 had a Physical Therapy evaluation, and the evaluation showed a functional decline in the resident's ambulation. On 10/25/ 11 at 11:30 A.M., the surveyor observed the resident lying in bed with his/her eyes closed; a customized walker was observed in the resident's room, next to the wheelchair. On 10/25/11 at 1:00 P.M., during interview, CNA (Certified Nursing Assistant) #3 said that she had never ambulated the resident, but recalled a "long time ago" she had seen Physical Therapy ambulating the resident. On 10/25/11 at 1:15 P.M., during an interview with Resident #2, the resident stated that he/she had not been walking, but the Physical Therapy department had come to see him/her, and that he/she was going to start walking again.

Based on interview and record review, the Facility failed to provide written information specifying the duration of the Ten Day Medicaid bed hold period to 1 of 1 sampled resident and the resident's legal representative (Resident #2) who was hospitalized following an elopement from the Facility while awaiting admission to a psychiatric unit on a Section 12. A Section 12 is an application for temporary involuntary hospitalization made by a physician who after examining a person has reason to believe that failure to hospitalize such person would create a likelihood of serious harm by reason of mental illness . Social Worker #1 called the hospital and Resident #2's legal representative the day after Resident #2's elopement and said the Facility would not be holding Resident #2's bed for the duration of the ten day Medicaid bed hold period because Resident #2 left the Facility against medical advice. Findings included: Resident #2's social service note, dated 3-28-11, was reviewed and indicated Resident #2 was evaluated by the Facility psychiatric service and sent to the hospital for further evaluation of a rapid change in mental status as evidenced by agitation and being verbally inappropriate to other residents. Resident #2's social service note dated 3-29-11 was reviewed and indicated that Resident #2 returned from the hospital in the morning and continued with the same behavioral symptoms as on 3-28-11. The social service note indicated that Resident #2 was loud, not always redirectable and accusatory. The social service note indicated that the Facility psychiatric service was contacted and recommended that Resident #2 be sent to the hospital on a Section 12. The social service note indicated that the Facility psychiatric service was unable to locate a bed for Resident #2 on a psychiatric unit capable of managing Resident #2's medical needs. The social service note indicated that while arrangements for Resident #2's hospitalization were being made, Resident #2 used Resident #2's cell phone to call a cab and left the Facility. Resident #2's social service note indicated that Social Worker #1 was able to ascertain the destination of the cab and notified the police department of Resident #2's location. The social service note indicated that the police requested a copy of the Section 12 document and picked Resident #2 up at a hotel and transported Resident #2 to the hospital. Resident #2's social service note dated 3-30-11 indicated that Social Worker #1 was made aware that Resident #2 was admitted to the hospital. The social service note indicated that Social Worker #1 advised the hospital case manager and Resident #2's health care proxy agent that Resident #2 was not on a ten day Medicaid hold because Resident #2 had left the Facility against medical advice. Social Worker #1 was interviewed throughout the day of the Investigation on 4-19-11. Social Worker #1 said Resident #2 did not receive a notice regarding the Facility bed Hold Policy on 3-29-11 because Resident #2 left the Facility unexpectedly in a taxi cab. The Surveyor asked Social Worker #1 whether Resident #2 was on a Section 12 awaiting psychiatric services at the time Resident #2 left the Facility in the taxi cab and Social Worker #1 said that Resident #2 was on a Section 12. Social Worker #1 said that on 3-30-11 Social Worker #1 notified the hospital case manager and Resident #2's health care proxy agent that Resident #2's bed was not being held for the duration of the ten day Medicaid bed hold because Resident #2 had left the Facility against medical advice. Resident #2's Health Care Proxy Agent was interviewed by telephone on 4-26-11 at 12:00 PM. The Health Care Proxy Agent said that on 3-29-11 while Resident #2 was on a Section 12, the Facility allowed Resident #2 to leave in a taxi cab. The Health Care Proxy Agent said that on day 2 of Resident #2's hospitalization , Social Worker #1 notified the Health Care Proxy Agent that the Facility was not considering Resident #2 to be on a ten day Medicaid bed hold period because Resident #1 had left the Facility against medical advice.