Every finding on record at St Patrick's Manor

Based on record review, and interview, the facility failed to provide care consistent with professional standards of practice relative to the administration of prescribed medication for one Resident (#145) out of a total sample of 36 residents. Specifically, for Resident #145, the facility failed to administer a Physician ordered antihypotensive medication (used to treat low blood pressure) as needed (PRN) when Systolic Blood Pressure (SBP - the top number of the blood pressure reading which indicates the force of circulating blood pushing against the artery when the heart beats) measurements were documented below 100 mmHg (millimeters of mercury) for the Resident. Findings include: Review of the facility policy titled Specific Medication Administration Procedures, dated 2017, included but was not limited to: -Purpose: To administer oral medications in a safe, accurate, and effective manner. -Review and confirm medication orders for each individual resident on the Medication Administration Record (MAR) PRIOR to administering medications to each resident. -Review administration medication record for any tests or vital signs that need to be determined prior to preparing the medications. -Discuss with resident and determine if there is a need for any as needed medication such as for pain. Resident #145 was admitted to the facility in March 2021 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, End Stage Renal Disease (ESRD), dependence on Renal Dialysis, Heart Failure - unspecified, and Type 2 Diabetes. Review of the most recent Minimum Data Set, dated dated dated [DATE], indicated that the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status Score of 15 out of 15 possible points. Review of Resident #145's February 2025 Physician's orders indicated: -Vital Sign [sic] Daily every day shift -Midodrine HCl Oral Tablet 5 mg (milligrams) (Midodrine HCl) 1 tablet by mouth as needed (PRN) for low Systolic Blood Pressure (less than 100) twice daily (order active, initiated 4/10/24) Review of Resident #145's Medication Administration Records (MARs) for December 2024, January 2025, and February 2025 indicated the following SBP readings: >December 2024: -12/23/24: SBP 56 mmHg -12/29/24: SBP 96 and SBP 95 mmHg -12/31/24: SBP 98 mmHg >January 2025: -1/3/25: SBP 94 mmHg -1/4/25: SBP 97 mmHg and SBP 90 mmHg -1/5/25: SBP 96 mmHg and SBP 94 mmHg -1/12/25: SBP 95 mmHg -1/25/25: SBP 89 mmHg -1/26/25: SBP 98 mmHg -1/27/25: SBP 98 mmHg >February 2025: -2/3/25: SBP 93 mmHg -2/5/25: SBP 99 mmHg -2/7/25: SBP 90 mmHg -2/8/25: SBP 94 mmHg -2/13/25: SBP 98 mmHg -2/15/25: SBP 92 mmHg and SBP 98 mmHg -2/16/25: SBP 64 mmHg and SBP 95 mmHg Further review of the December 2024, January 2025, and February 2025 MARs indicated no evidence that the as needed (PRN) Midodrine medication was administered per Physician orders when Resident #145's SBP was measured below 100 mmHg. During an interview on 2/25/25 at 9:39 A.M., the surveyor and the Director of Nursing (DON) reviewed Resident #145's MARs for December 2024, January 2025, and February 2025 and observed that the MARs did not indicate that the Midodrine medication was administered as ordered when the Resident's SBP was measured below 100 mmHg. The surveyor and the DON identified 4 occasions in December 2024, and 9 occasions respectively in January 2025, and February 2025, when the Resident's SBP was measured below 100 mmHg, and there was no indication that Midodrine medication was administered as ordered to manage the Resident's hypotension. The DON said that the Nurse should have administered the Midodrine for a SBP below 100 mmHg on the identified dates but there was no evidence that the Nurses had done so. The DON further said that whenever the Resident's SBP was below 100 mmHg, the nursing staff should administer the as needed (PRN) Midodrine as ordered.

Based on record review, and interview, the facility failed to ensure that Advance Directives (a written statement about a resident's wishes regarding medical treatment) were accurately executed for one Resident (#411) out of a total sample of 36 Residents. Specifically, for Resident #411, the facility failed to: -offer the Resident/ Responsible Party the opportunity to formulate and/or review an Advanced Directive for the Resident. -obtain a Physician's order to indicate an accurate code status when the Resident was admitted to the facility with an illegible Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form and a handwritten, incomplete code status card. Findings include: Review of the facility policy titled Advance Directives, dated [DATE], indicated: -Upon admission, MD/Nursing will identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive. -The MOLST will be in the front of the paper chart and all other advance directive document copies will be obtained and located in the legal section of the paper chart. -All advance directive document copies will be communicated to the staff via the care plan and communicated to the resident's physician. -The resident will be assessed upon admission, quarterly, and with change of condition for their ability to make decisions and for changes in resident preferences and choices. -Identify, clarify and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive. Resident #411 was admitted to the facility in February 2025 with diagnoses including Falls, Alzheimer's Disease, Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of Resident #411's February 2025 Physician's orders did not include orders for Advance Directives. Review of Resident #411's Care Plan initiated [DATE], indicated that the Resident was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of Resident #411's medical record indicated a MOLST form that was primarily black/dark, and illegible. Further review of the MOLST form could not determine the Resident's care decisions if a change in condition occurred in which CPR might be necessary. Further review of Resident #411's medical record indicated a handwritten card, titled Referral Info, that was undated and unsigned, and indicated Resident #411 was Do Not Resuscitate (DNR) and Do Not Intubate (DNI). During an interview on [DATE] at 11:13 A.M., the surveyor and Unit Manager (UM) #3 reviewed Resident #411's medical record and UM #3 said the Resident was DNR/DNI according to the black/dark, illegible MOLST form and the handwritten card titled Referral Info that was undated and unsigned. UM #3 also reviewed Resident #411's Physician's orders and said there was no order for the Resident's Advance Directives. The surveyor and UM #3 reviewed the Resident's Care Plan and UM #3 said the Care Plan indicated the Resident was a full code. During an interview on [DATE] at 11:18 A.M., Social Worker (SW) #2 said Resident #411 was presumed a full code as the MOLST was unreadable. During a follow-up interview on [DATE] at 12:35 P.M., UM #3 said the MOLST form should have been reviewed with Resident #411 when the Resident was admitted to the facility. UM #3 said a new MOLST should have been completed, and a Physician order should have been obtained but an updated MOLST and a Physician's order had not been completed.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#232), out of a total sample of 36 residents, was free from physical restraints. Specifically, the facility failed to ensure that Resident #232 was assessed for the use of a potential restraint (two stationary chairs), which were positioned in a way to prevent the Resident from moving freely around the room. Findings include: Review of the facility policy titled Restraints-Physical/Chemical, dated 6/14/24, indicated each resident shall be free from physical and/or chemical restraints imposed for the purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The policy also included the following: -All resident's will be assessed for appropriateness of devices to treat their medical symptoms and ensure the least restrictive alternative is utilized for the least amount of time, to allow each resident and maintain his/her highest practicable well-being. -The facility prohibits the use of restraints to unnecessarily inhibit a resident's freedom of movement or activity. -When a restraint is used, the facility will: >Assess the resident's physical condition and cognitive status as contributing factors in determining whether the resident can remove the restraint if physical or is overly sedated, subdued or limited in his/her functional capacity if chemical. Resident #232 was admitted to the facility in December 2023 with diagnoses including Alzheimer's Disease with early onset, Dementia with moderate behavioral disturbances, Major Depression Disorder, and Generalized Anxiety. Review of Resident #232's Behavior Care Plan, initiated 12/23/23, indicated: -the Resident was at risk for behaviors associated with cognitive decline r/t (related to) Alzheimer's Disease. -the Resident had a behavior to sit self on the floor. Review of Resident #232's Activity Deficit Care Plan, initiated 12/20/23, indicated the following interventions: -Resident had stationary chairs in his/her room positioned in the corner as an activity. He/she continuously stands, pivots, and sits alternating in chairs - initiated 7/15/24. Review of Resident #232's Activities of Daily Living (ADL) Self-care Deficit Care Plan, initiated 12/19/23, indicated the following interventions: -Resident required hand held assist of one staff member. Review of the Resident's Restraint Assessment, dated 12/19/23, indicated: -no restraints were in use. Review of the Minimum Data Set (MDS) Assessment, dated 12/24/24, indicated Resident #232: -Scored 0 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) Assessment, indicating severe cognitive deficit. -was unable to make him/herself understood. -was unable to understand others. -required maximum assistance for transfers. -required maximum assistance for ambulation. -did not utilize restraints. On 2/19/25 at 11:02 A.M., the surveyor observed Resident #232 sitting in his/her room in a stationary chair facing the wall in the corner of the room. The surveyor further observed a closed bathroom door to his/her right side and another stationary chair was positioned on his/her left side, limiting the ability for the Resident to move about or exit the room. The Resident was observed to be repeatedly pushing up from the arms of the chair into the standing position, then sitting back down in the chair. On 2/19/25 at 3:24 P.M., the surveyor observed Resident #232 sitting in his/her room in a stationary chair facing the wall in the corner of the room, a closed bathroom door to his/her right side and another stationary chair positioned on his/her left side, limiting the ability for the Resident to move around or exit the room. During an interview on 2/19/25 at 3:24 P.M., Nurse #3 said staff initiated the intervention of two stationary chairs in the Resident's room as a safety intervention to prevent the Resident from falling. Nurse #3 further said she did not know why the chairs were cornering the Resident into the room and how far apart the chairs should be from one another to allow the Resident to move around the room. Nurse #3 said that the Resident requires assistance from one staff member for ambulation and could not move the chairs his/herself. On 2/20/25 at 11:48 A.M., the surveyor and the Director of Nursing (DON) observed Resident #232 sitting in his/her room in a stationary chair facing the wall in the corner of the room, a closed bathroom door was to his/her right side and another stationary chair was positioned on his/her left side, preventing the Resident from moving around or exiting the room. During an interview at the time, the DON said the stationary chairs are set up as a behavior solution for the Resident continuously standing up. The DON was unable to determine if the chairs limited the Resident's movement in the room. The DON said that the stationary chairs intervention was not assessed as a potential restraint but according to their policy, it should have been. During an interview on 2/20/25 at 12:04 P.M., the DON said the interdisciplinary team (IDT) assessed the stationary chairs as a restraint after it was brought to their attention from the surveyor. The DON further said the position of the stationary chairs had limited Resident #232's ability to move freely in the room and changing the position of the chairs would avoid them being a restraint. During an interview on 2/20/25 at 1:56 P.M., the DON said that the facility should have assessed the stationary chairs as a possible restraint when the intervention was initiated, but did not complete an assessment.

Based on observation, interview, and record review, the facility failed to provide assistance for activities of daily living (ADL - basic life care tasks that individuals perform on a daily basis to maintain their well-being which include grooming) for two Residents (#164 and #556) out of a total sample size of 36 residents. Specifically, the facility failed to: 1. For Resident #164, ensure the Resident was offered and/or provided with grooming of facial hair when the Resident was dependent on facility staff for assist with grooming. 2. For Resident #556, ensure the Resident was offered and/or provided grooming of the fingernails when the Resident was dependent on facility staff for grooming. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated 11/2024 indicated but was not limited to the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living: <Grooming <A resident who is unable to carry out activities of daily living will receive the necessary services to maintain personal hygiene. 1. Resident #164 was admitted to the facility in February 2024 with diagnoses of Hemiplegia, Hemiparesis and Cognitive Communication Deficit. Review of Resident #164's comprehensive, person-centered care plan for ADL's, initiated 2/14/24 and revised 2/12/25, indicated: -The Resident was dependent for personal hygiene and grooming. Review of Resident #164's Minimum Data Set (MDS) Assessment, dated 1/30/25, indicated the Resident: -was moderately cognitively impaired as evidenced by a Brief interview for Mental Status (BIMS) score of 10 out of a total possible score of 15. -was dependent on staff for assist for personal hygiene (grooming). -had not demonstrated any refusal of care. Review of Resident #164's February 2025 Certified Nurses Aides (CNA) Documentation indicated: -The Resident required assistance of another person for personal hygiene, including grooming. -The Resident had not exhibited any refusals of care relative to personal hygiene. On 2/19/25 at 10:42 A.M., the surveyor observed the Resident seated in a recliner in his/her room with facial hair approximately one inch in length present on his/her chin. On 2/19/25 at 4:25 P.M., Resident #164 was observed sitting in a recliner next to the bed in his/her room and remained with approximately one inch of facial hair observed on his/her chin. On 2/20/25 at 11:16 A.M., the surveyor observed the Resident lying in bed and one inch long facial hair remained on his/her chin. On 2/20/25 at 2:41 P.M., the surveyor observed the Resident seated in a recliner in his/her room with one inch long facial hair present on his/her chin. On 2/20/25 at 2:59 P.M., the surveyor observed that CNA #3 was present in Resident #164's room. During an interview at the time, CNA #3 said that the Resident has never refused ADL care or facial hair removal. CNA #3 was observed asking Resident #164 if he/she would like his/her facial hair shaved, and the Resident nodded his/her head yes in response. During an interview on 2/20/25 at 3:15 P.M., the Director of Nursing (DON) said that it was her expectation that the CNA staff would offer and provide facial hair removal with daily care for all residents. 50320 2. Resident #556 was admitted to the facility in December 2024 with diagnoses including Adult Failure to Thrive, Chronic Kidney Disease (CKD) Stage 3, and Depression. Review of Resident #556's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident: -was moderately cognitively impaired as evidenced by a score of 11 out of 15 points on the Brief Interview for Mental Status (BIMS) assessment. -required supervision or touching assistance with personal hygiene. -had no rejection of care. Review of the Resident #556's Care Plan initiated 12/31/24 and revised on 2/13/25 indicated: -the Resident had potential impairment to skin integrity due to decreased mobility, Neuropathy and Osteoarthritis. -interventions initiated on 12/31/24 for potential impairment of skin integrity indicated: >to avoid scratching and keep hand and body parts from excessive moisture. >Keep fingernails short. Further review of the Resident's Care Plan did not indicate a functional status related to assistance required for nail care. Review of the February 2025 CNA Care Card indicated that Resident #556's fingernails should be kept short. On 2/19/25 at 9:27 A.M., the surveyor observed Resident #556 to have long untrimmed nails on all fingers of the left hand with dark brown debris under the fingernails, and a thick buildup of debris at the free edge of the nails and around the edges of the fingernails. The surveyor observed that the Resident's right hand also had long untrimmed jagged nails that were absent of debris. During an interview at the time, the Resident said someone had attempted to cut his/her nails once, but they did not have strong enough nail trimmers to cut his/her fingernails. Resident #556 said no one had attempted to trim his/her fingernails since that time. Resident #556 was unable to recall when the staff had attempted to cut his/her fingernails. Resident #556 said he would like his/her nails trimmed and cleaned. On 2/19/25 at 3:37 P.M., the surveyor observed that the Resident's fingernails remained unchanged from the morning observation with long untrimmed nails on both the left and right hand and brown debris under and around the fingernails of the left hand. During an interview at the time, Resident #556 said he/she was washed-up earlier in the day by a CNA. Review of Resident #556's clinical record did not indicate any refusal of care provided by the staff. Review of the CNA Daily Care Record for 2/19/25, indicated that no fingernail care had been provided to Resident #556 on that day (2/19/25). On 2/20/25 at 8:06 A.M., the surveyor observed that Resident #556 remained with long untrimmed nails on both the left and right hands and brown debris under and around the free edge of the fingernails of the left fingers. During an interview on 2/20/25 at 8:15 A.M, CNA #1 said Resident #556 does not refuse care that she is aware of. CNA #1 said the Resident requires assistance with all his/her ADL care. CNA #1 also said the CNA's do nail care on all residents when they provide care to the residents and whenever nail care needs to be done. CNA #1 said she had not seen Resident #556's fingernails recently. On 2/20/25 at 8:25 A.M., the surveyor observed Nurse #5 assisting the Resident with his/her breakfast meal. During an interview at the time, Nurse #5 said she did notice that the Resident's fingernails needed to be trimmed and cleaned and she would make sure it got done that day. On 2/20/25 at 8:52 A.M., the surveyor and the DON observed that the Resident's fingernails on both the left and the right hands remained untrimmed with brown debris under and around the fingernails of his/her left hand. The DON said the Resident's nails needed to be trimmed and cleaned. The DON said nail care should be done by the CNAs with morning care, and she would make sure Resident #556's nails were trimmed and cleaned right away.

Based on observation, interview, and record review, the facility failed to ensure that assistive devices to maintain hearing and enhance communication were utilized for one Resident (#234), out of a total sample of 36 residents. Specifically, for Resident #234, the facility failed to ensure that ordered hearing aids were applied daily when the Resident required staff assistance for insertion and manipulation of the hearing aids so he/she could maintain hearing and communication abilities. Finding Included: Review of the facility policy titled Hearing Aid Placement, last revised 11/2022, indicated the following: -The facility will provide a system to safely maintain resident hearing aids in support of their resident rights and quality of life. -Hearing aid placement and removal will be documented on the electronic medical record. Resident #234 was admitted to the facility in June 2024 with diagnoses including bilateral glaucoma and auditory hallucinations. Review of Resident #234's Audiology Consult dated 9/24/24, indicated: -Patient requires assistance with insertion and manipulation of hearing aids daily. -Patient to wear hearing aids daily. -Continue with current means of communication. Review of Resident #234's February 2025 Physicians orders indicated: -Bilateral hearing aid, every Day Shift (7 A.M. - 3 P.M.) apply, initiated 6/21/24. Review of Resident #234's Treatment Administration Record (TAR) for February 2025 indicated that he/she has had his/her hearing aids inserted daily in his/her ears. On 2/19/25 at 9:01 A.M., Resident #234 was observed seated in the dining room eating breakfast. The surveyor did not observe that Resident #234 had his/her hearing aids inserted and in use. During an interview at the time, Resident #234 said he/she was unable to hear the surveyor clearly and that he/she usually wears hearing aids. Resident #234 also said that the nursing staff puts the hearing aids in for him/her and he/she would like to have them in while he/she is eating breakfast, so that he/she can hear everyone. On 2/20/25 at 8:02 A.M., the surveyor observed Resident #234 sitting in front of the nurses station and that he/she did not have his/her hearing aids inserted in his/her ears. The surveyor also observed multiple nursing staff and Certified Nurses Aides (CNA) staff walking past the Resident while expressing greetings to him/her. During an interview at the time, Resident #234 said that he/she wished he/she could hear the surveyor better, but he/she did not have on his/her hearing aids, and he/she was waiting for staff to put in his/her hearing aids. On 2/20/25 at 9:07 A.M., the surveyor observed Resident #234 sitting in the unit dining room eating breakfast and seated next to other residents. The surveyor observed that Resident #234 did not have his/her hearing aids inserted and in use. On 2/24/25 at 7:52 A.M., the surveyor observed that Resident #234 was up and dressed for the day. Resident #234 was observed ambulating down the hallway with his/her rolling walker and attempting to communicate with staff on the unit. During an interview at the time, Resident #234 said that he/she could not hear because he/she did not have on his/her hearing aids. Review of Resident #234's medical record failed to indicate any refusals by the Resident to wearing his/her hearing aids. During an interview on 2/24/25 at 8:24 A.M., Nurse #4 said that the hearing aids should be applied by the Nurse once Resident #234 wakes up for the day. Nurse #4 said that the hearing aids instructions are listed on both the Physician's orders and the TAR. Nurse #4 said that she gives the residents their hearing aids before they enter the dining room to eat breakfast. During an interview on 2/24/25 at 11:04 A.M., Unit Manager (UM) #1 said that the staff should be applying the residents hearing aids once they wake up for the day and should be monitoring the residents to see if they have their hearing aids in place. UM #1 also said that residents should have on their hearing aids by the time they eat breakfast and Resident #234 did not have on his/her hearing aids.

Based on observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (nutrients provided directly into the stomach), for one Resident (#111) out of a total sample of 36 residents. Specifically, for Resident #111, the facility failed to ensure that enteral feeds and fluids being administered to the Resident were labeled and dated as appropriate. Findings include: Review of the facility policy titled Nursing Service: Enteral Feeding Management, dated 3/15/23, indicated the following: -Labeling: To avoid misinterpretation, a label should be affixed to all EN (enteral nutrition) formula administration containers (bags, bottles, syringes [used in syringe pump]). -The label should include: >patient demographics >formula type >enteral access delivery site >administration method >initials of the individual hanging the formula >time formula hung >date formula hung > Not for IV (intravenous) Use. -Labels should be standardized with standard components to decrease potential confusion if resident is transferred or when a new Nurse takes over the resident's care. -Clear concise labeling allows for final check by the administering Nurse with the Prescriber's order. Resident #111 was admitted to the facility in September 2022, with diagnoses including Vascular Dementia, dysphagia, and moderate protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #111: -was rarely/never understood and rarely/never understood others. -was severely cognitively impaired, rarely/never made medical decisions, and demonstrated short and long term memory deficits per staff assessment. -received nutrition via a feeding tube and received over 51% of their calories via tube feed. -received fluid intake via a feeding tube and received over 501cc (cubic centimeters ) of fluid for hydration per day. Review of Resident #111's February 2025 Physician's orders indicated: -Enteral Feed order: Two times a day for feeding tube, Jevity 1.5 @60 ml/hr (milliliters per hour), initiated 11/21/24. -Enteral Feed order: In the morning (11-7 shift please add an additional 80 ml of Jevity 1.5 for total input = 1080 ml daily), initiated 2/20/25. -Enteral Feed order: Every shift flush enteral tube with (50) ml of water before and after feedings and before and after medication administration, initiated 11/19/23. -Enteral Feed order: Every shift flush feeding tube with (150 ml) of water every (4 hours), initiated 11/7/24. On 2/19/25 at 9:07 A.M., the surveyor observed Resident #111 lying in bed sleeping and the enteral feed machine was running. The surveyor observed two graduated clear plastic bags hanging from the IV pole, one bag had approximately 100 ml of a beige colored liquid remaining, and the second bag had approximately 300 ml of a clear liquid remaining. The surveyor observed that enteral feeding machine was connected to the Resident and set at 60 ml/hr with a total feed of 847 ml dispensed and time of 235 minutes remaining. The surveyor did not observe a label, date, and content on either of the two bags hanging on the IV pole and being administered to Resident #111. On 2/20/25 at 8:22 A.M., the surveyor observed Resident #111 lying in bed sleeping. The surveyor observed the enteral feed machine was running at 60 ml/hr, with a dispensed total of 905 ml of enteral feed and 195 ml remaining. The surveyor observed two graduated clear plastic bags hung from the IV pole and connected to the Resident, one bag contained a beige liquid and the second bag contained a clear liquid, and both bags did not have a label, date, and time they were hung. On 2/20/25 at 8:32 A.M., the surveyor and Nurse #6 observed Resident #111 lying in bed with the enteral feed machine running. During an interview at the time, Nurse #6 said that she typically works the 7:00 A.M. to 3:00 P.M. shift, and the Resident would already have the enteral feed running from prior shifts. Nurse #6 said that the enteral feeding is hung at 4 P.M. by the 3:00 P.M. to 11:00 P.M. shift and she would take the enteral feeding down around 10:00 A.M. when it was completed. Nurse #6 said that the rate of enteral feeding and water flushes are programmed by a Nurse into the enteral feed machine and Resident #111 received Jevity 1.5 at 60 ml/hr with automatic water flushes every 4 hours. The surveyor observed approximately 100 ml of beige liquid remaining in one of the graduated plastic bags, which Nurse #6 identified as Jevity product and the bag of clear liquid was identified as water for water flushes. Nurse #6 further said that Resident #111 usually has about 100 ml of the Jevity enteral feeding remaining at this time of day. Nurse #6 said she knew how much Jevity and water had been administered from the enteral feed machine which read that 905 ml had been administered with 195 ml remaining. Nurse #6 said that the water bag and Jevity bag were not labeled or dated, and should have been. Nurse #6 said that the nursing staff who hung the two bags should have dated and labeled the water and Jevity bags, but did not do so as required.

Based on observation, interview, and record review, the facility failed to provide respiratory care and services that were consistent with professional standards of practice, for one Resident (#246), out of a total sample of 36 residents. Specifically, for Resident #246, the facility failed to ensure that the Resident's nebulizer setup equipment was appropriately labeled and dated and stored in a storage bag to prevent equipment contamination. Findings include: Review of the facility policy titled Nebulizer Therapy, last reviewed November 2024, indicated the following: -the 11 P.M. to 7 A.M. (night) nursing shift will date and label the tubing and bag. After the equipment has dried, place it in the labeled and dated plastic bag for storage until next use. -equipment to be changed weekly by the 11 P.M. to 7 A.M. nursing shift. The nebulizer machine will also be cleaned weekly by the 11 P.M. to 7 A.M. nursing shift. -mask and bag are changed weekly by the 11 P.M. to 7 A.M. nursing shift or as needed. -documentation of equipment change will be on the resident's treatment sheet. Resident #246 was admitted to the facility in October 2024, with diagnoses including Alzheimer's and Asthma. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #246: -was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of a total score of 15. -required supervision with Activities of Daily Living (ADLs) -was diagnosed with Asthma. Review of the Resident's Care Plan for Asthma, last revised 1/21/25, indicated: -the Resident will remain free from complications of Asthma through the review date. -give medications as ordered. Monitor/document side effects and effectiveness. -give nebulizer treatments and inhalers as ordered. Review of Resident #246's Physician's orders indicated the following: -Ipratropium - Albuterol Solution 0.5 - 2.5 (3) milligrams (MG)/ 3 milliliters (ML), 3 ML inhale orally every 6 hours as needed for shortness of breath (SOB), CLE = Clear, ADV = Adventitious, DIM = Diminished [breath sounds], start date 10/1/24 -Change nebulizer mask or handheld piece, tubing and bag. Date and initial - include Resident's name on the bag, every night shift, every Saturday, start date 2/1/25. -Albuterol - Budesonide Inhalation Aerosol 90 - 80 micrograms (MCG)/actuation (ACT) (Albuterol - Budesonide), 2 puffs inhale orally every 6 hours as needed for shortness of breath and 2 puffs inhale orally in the morning related to Asthma, rinse mouth after use, start date 11/12/24. Review of the Resident's Medication Administration Record (MAR) for February 2025 indicated that the Resident received the Ipratropium - Albuterol inhalation treatment on 2/28/25. Review of Resident #246's Treatment Administration Record (TAR) for February 2025 indicated: >the nebulizer mask/handheld piece, tubing and storage bag had been changed >the storage bag had been dated, initialed, and included the Resident's name on the following Saturdays: -2/1/25 -2/8/25 -2/15/25 -2/22/25 On 2/19/25 at 9:52 A.M., the surveyor observed Resident #246's nebulizer tubing and handheld piece attached to the nebulizer machine was laying on an upholstered chair cushion in the Resident's room. The nebulizer setup and tubing were unlabeled/undated and was not stored in a bag. On 2/20/25 at 8:12 A.M., the surveyor observed that Resident #246's nebulizer, tubing and handheld piece were located on a shelf in a bedside table in the Resident's room. The nebulizer setup and tubing were unlabeled/undated and not observed in a storage bag. On 2/20/25 at 2:22 P.M., the surveyor and Nurse #1 observed Resident #246's nebulizer, tubing and handheld piece laying on a shelf in the bedside table in the Resident's room. The nebulizer tubing and handheld piece remained unbagged, unlabeled and undated. During an interview at the time, Nurse #1 said that it was important for the nebulizer tubing and handheld piece to be bagged as microorganisms can become an infection control problem if they are inhaled by the Resident. Nurse #1 also said that the equipment should be labeled and dated so that staff can know when the equipment was last changed, that the nebulizer equipment should be changed weekly, and it was not. During an interview on 2/20/25 at 3:32 P.M., the Director of Nursing (DON) said that the nebulizer tubing and handheld piece should be bagged when not in use. The DON also said that the nebulizer equipment should be labeled with a date and changed weekly.

Based on observation, and interview, the facility failed to ensure that medications were stored in a secure manner in one medication storage room (Sacred Heart Unit) out of four medication storage rooms observed, out of a total of eight medication storage rooms. Specifically, the facility failed to ensure that only authorized personnel had access to the medication storage room where prescription medications were stored on the Sacred Heart Unit. Findings include: Review of the facility policy titled Medication Storage Safety, initiated 9/14/15, last reviewed/revised 11/2024, included but was not limited to: -The focus is the secure locking of the medication room on each unit. -The unit Nurses are responsible to maintain security of the medication room on their shift. -Each medication Nurse is informed of the need to keep the medication room Closed and Locked at all times. -Access to the medication room is by a key which is on the keychain of the Unit Nurse. On 2/20/25 at 9:15 A.M., the surveyor observed the Central Supply Manager (CSM) in the medication storage room on the Sacred Heart Unit. The CSM was observed standing inside the medication storage room with a cart of supplies propped in the doorway, holding the door open. The surveyor did not observe any other staff in the immediate area. During an interview at the time, the CSM said that he gained access to the medication storage room by unlocking the door with the key. The CSM said that he did not have the key, but Nurse #2 had given him the nursing key ring and he had unlocked the medication storage room door and then returned the keys to Nurse #2. The CSM said that he goes into the medication storage rooms unsupervised all the time to stock over-the-counter medications. The surveyor observed that the following medications were stored in the medication storage room: -prescription medication cards stored in bins on the counter. -two emergency medication kits (e-Kits) containing Narcan (opioid antagonist used to reverse the effects of opiates). -Anaphylaxis medications (used to treat allergic reactions). -a refrigerator containing Insulin (prescription medication used to treat diabetes). During an interview on 2/20/25 at 9:41 A.M., Nurse #2 said he had given his medication key ring to the CSM, so that the CSM could open the medication room door to stock the over-the-counter medications. Nurse #2 who was observed to be around the corner and out of sight of the medication room, said that the CSM brought the keys back to him after unlocking the medication room door. Nurse #2 said he realized afterward that he should not give his nursing key ring to anyone else who was not a Nurse. During an interview on 2/20/25 at 12:15 P.M., the Administrator said that the CSM should not have received the nursing keys from Nurse #2, and should not have been in the medication storage room unsupervised. The Administrator said that the only staff who should have access to the medication storage room were the Licensed Nurses that have the nursing keys and the Licensed Nurse management team.

Based on interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) Assessments for two Residents (#253 and #254) out of three closed records reviewed. Specifically, the facility failed to ensure that MDS assessments for Resident's #253 and #254 were completed accurately, relative to discharge location. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, indicated the following: -This item documents the location to which the resident is being discharged at the time of discharge. >Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. >Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was discharged to a hospital that is contracted with Medicare to provide acute, inpatient care and accepts a predetermined rate as payment in full. 1. Resident #253 was admitted to the facility in December 2024, with diagnoses including unspecified fall and Adult Failure to Thrive. Review of the Resident #253's MDS Assessment, dated 1/1/25 indicated the Resident was discharged to a Short- Term General Hospital (Acute Care Hospital). Review of Resident #253's Nursing Progress Notes and Discharge Summary indicated the Resident returned home on 1/1/25. During an interview on 2/24/25 at 2:56 P.M., MDS Nurse #1 said Resident #253 was discharged from the facility to home on 1/1/25, and the discharge MDS assessment dated [DATE] was coded inaccurately. MDS Nurse #1 said the MDS Assessment code should have reflected the accurate discharge location to home. 45429 2. Resident #254 was admitted to the facility in September 2023, with diagnoses including Alzheimer's Disease and age-related osteoporosis. Review of Resident #254's Discharge MDS assessment dated [DATE], indicated the Resident was discharged from the facility to his/her home in the community. Review of the Resident's SBAR (Situation Background Appearance Review and Notify) Communication Form dated 12/5/24, indicated that the Resident was sent out to the hospital for further evaluation. Review of Resident #254's Nursing Progress Notes indicated that the Resident was transferred to the hospital on 12/5/24. During an interview on 2/24/25 at 2:56 P.M., MDS Nurse #1 said Resident #254 was discharged from the facility to the hospital and the MDS assessment dated [DATE], was coded inaccurately and should be modified to reflect that the Resident had been discharged to the hospital.

Based on record review, and interview, the facility failed to ensure a Bed Hold Policy Notice was issued upon transfer to the hospital for one Resident (#156) out of a total sample of 36 Residents. Specifically, for Resident #156, the facility failed to provide the Resident/Resident Representative with written notice of the facility's bed-hold policy when the Resident was transferred to the hospital. Findings include: Review of the facility's Bed Hold and Return to Facility Policy effective 12/8/18, reviewed 3/2020 indicated: -It is the policy of the facility that residents and/or resident representatives are notified of the Bed Hold and Return to Facility Policy upon admission and transfer, and to ensure that the resident is informed of the State's bed hold duration and payment as well as their right to return to the facility from a hospitalization or therapeutic leave if appropriate. -The facility will document the provision of the Bed Hold and Return to Facility notice to the resident and information given to the representative in the resident's record. Resident #156 was admitted to the facility in June 2022 with diagnoses including End Stage Renal Disease (ESRD), Diabetes Mellitus Type 2 (DM II), Chronic Kidney Disease (CKD) Stage 4. Review of Resident #156's Medical Record indicated: -12/10/24: A Physician's order was obtained to send Resident #156 out to an acute care hospital for evaluation of worsening renal status. -12/10/24: A Nurse's note indicating the Resident was transferred out of the facility to an acute care hospital. During an interview on 2/20/25 at 1:04 P.M., Social Worker (SW) #1 said she was unable to provide evidence that written notice of the Bed Hold and Return to Facility notice had been given to Resident #156 or the Resident Representative upon the Resident's transfer to the hospital.

Based on record review, and interview, the facility failed to ensure a written notification of transfer or discharge was completed for one Resident (#156) out of a total sample size of 36 Residents. Specifically, the facility failed to: 1. Provide the Resident/Resident Representative with written notice of transfer or discharge when the Resident was transferred to the hospital. 2. Notify the Office of the State Long-Term Care Ombudsman of the Resident's transfer to the hospital. Findings include: Resident #156 was admitted to the facility in June 2022, with diagnoses including End Stage Renal Disease (ESRD), Diabetes Mellitus Type 2 (DM II), Chronic Kidney Disease (CKD) Stage 4. Review of Resident #156's medical record indicated: -12/10/24: A Physician's order was obtained to send Resident #156 to the Hospital for worsening renal function. -A Nurses note dated 12/10/24, indicated the Resident had been transferred to the hospital. -No evidence a written notice of transfer or discharge had been provided to the Resident/Resident Representative upon the Resident's transfer to the hospital -No evidence that the Office of the State Long-Term Care Ombudsman had been notified of the Resident's transfer to the hospital. During an interview on 2/20/25 at 1:04 P.M., Social Worker (SW) #1 said she was unable to provide evidence that written notice of transfer or discharge was provided to the Resident/Resident Representative when he/she was transferred to the hospital on [DATE]. SW #1 said she could not provide any evidence the Office of the State Long-Term Care Ombudsman had been notified of Resident #156 being transferred to the hospital. SW #1 said the written notice of transfer or discharge should have been completed when the Resident was transferred to the hospital and should have been added to the notification list of transfers/discharges that is sent to the Ombudsman every two weeks.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Comprehensive Plan of Care and Plan of Care Kardex, indicated he/she required extensive assistance from two staff members during transfers for safety, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her Plans of Care, when on 07/03/24, CNA #1 transferred Resident #1 using a Sit/Stand Lift device (lift device that helps individuals who have difficulty standing up, from a seated position), without having another staff member present to assist her with the transfer, Resident #1 became weak during the transfer, started to slide out of the lift seat, CNA #1 then tried to lower him/her to the floor, Resident #1 immediately complained of pain, was diagnosed with a right femur (thigh bone) fracture and required transfer, with admission to the Hospital for treatment. Findings include: Review of the Facility's Policy, Comprehensive Care Plans, dated 03/21/24, indicated it is policy of the Facility to develop and implement a Comprehensive Person-Centered Plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment, qualified staff responsible for carrying out interventions specified in the residents care plan and notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the report submitted by the Facility via the Health Care Facility Reporting System, dated 07/03/24, indicated while being transferred and sitting in the Sit/Stand (mechanical transfer device), Resident #1 was lowered to the floor. The Report indicated Certified Nurse Aide (CNA) #1 used the Sit/Stand device incorrectly, and did not have another staff member assist her when transferring the resident back to bed to offer peri-care. The Report indicated Resident #1 complained of right hip pain, was assessed and an order was obtained to transfer him/her to the Hospital Emergency Department (ED) for evaluation. Review of the Facility's Internal Investigation's Final Report, dated 07/08/24, indicated that although Resident #1's ED Discharge Summary (from 07/03/24) indicated he/she did not have any fractures, he/she continued to experience pain to his/her right knee area, and an X-ray of his/her right knee was ordered. On 07/08/24, the facility was notified that Resident #1 had an acute distal right femur (thigh bone) supracondylar fracture (bone broken at the knee) with slight posterior displacement. The Report indicated Resident #1 was transferred and admitted to the Hospital. Resident #1 was admitted to the Facility in August 2023, diagnoses included Hemiplegia (paralysis on one side of the body) and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following a Cerebral Infarction (stroke) affecting the left non-dominant side, difficulty walking, lack of coordination, unsteadiness on feet, and Anemia in the setting of Chronic Kidney Disease (Stage 4). Review of Resident #1's Fall Risk Assessment, dated 05/15/24, indicated he/she was assessed by Nursing as being at high risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/16/24, indicated that Resident #1 had severe cognitive impairment and required maximum assistance from staff with transfers and mobility. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, related to mobility status, reviewed and renewed in conjunction with completion of his/her May 2024 MDS, indicated that for transfers he/she required extensive assistance from two staff members. Review of Resident #1's Fall Care Plan, reviewed and renewed in conjunction with completion of his/her May 2024 MDS, indicated safety interventions included to ensure that Resident #1 wore appropriate footwear when ambulating or mobilizing while in wheelchair. Review of Resident #1's Certified Nurse Aide (CNA) Care Kardex (used as a reference guide by CNA's, provides direct care staff with a brief overview of each residents' care needs), dated 06/01/24, indicated that Resident #1 required extensive assistance from two staff members for all transfers. Review of a Nurse Progress Note, dated 07/03/24, (written by Nurse #1) indicated that approximately 4:00 P.M., CNA #1 came to the Nurses Station and said she had lowered Resident #1 to the floor. The Note indicated Resident #1 was found in his/her room, laying on the floor in front of the Sit/Stand Lift device, he/she had no socks or shoes on his/her feet and Resident #1's right hip was partially internally rotated (knee and foot twist toward the midline of the body). The Note indicated Resident #1 was unable to recall what happened, but said he/she had pain in his/her right hip and Resident #1 was transferred to the hospital. During an interview on 07/24/24 at 1:20 P.M., Nurse #1 said on 07/03/24, CNA #1 came to her and said Resident #1 was on the floor in his/her room. Nurse #1 said upon arrival to Resident #1's room, she observed him/her laying on his/her back on the floor in front of the Sit/Stand Lift device. Nurse #1 said CNA #1 told her that she had transferred Resident #1 by herself, (from the wheelchair to the bed to provide care) that Resident #1 lost his/her balance during the transfer, and that she lowered him/her onto the floor. Nurse #1 said she also noted that Resident #1 did not have socks or shoes on his/her feet at the time, and should have. During a telephone interview on 08/07/24 at 2:59 P.M., CNA #1 said she was aware that each resident had a Care Kardex and that she knew how to access them. CNA #1 said that they (CNA's) needed to review the Care Kardex for each of their residents before providing care, but that she had not reviewed Resident #1's CNA Care Kardex on 07/03/24. CNA #1 said when she cared for Resident #1, she had always provided care to him/her by herself, and did not ask for help. CNA #1 said she knew how to work the Sit/Stand Lift and that she had transferred Resident #1 by herself without any assistance from another staff member before without an incident. CNA #1 said Resident #1 became weak during the transfer so she lowered him/her to the floor. CNA #1 said she thought Resident #1 was strong enough to participate, so she did the transfer without assistance from anyone else. Although CNA #1 said that Resident #1 had socks and shoes on his/her feet during the transfer, this conflicted with Nurse #1's interview in which she said when she went to Resident #1's room on 07/03/24 at CNA #1's request, she observed that he/she did not have socks or shoes on. Review of Resident #1's Facility's Radiology Report of his/her X-ray knee exam, dated 07/08/24, indicated he/she had an acute distal femur supracondylar fracture. Review of Resident #1's Medical Record indicated on 07/08/24, Resident #1 was sent to the Hospital for further evaluation, treatment and was admitted . During an interview on 07/24/24 at 4:08 P.M., the Director of Nursing (DON) said it was her expectations that nursing staff be knowledgeable about the residents' Plan of Care and to implement and follow interventions accordingly. The DON said, prior to providing care, including transfers, that the CNA's need to identify how a resident's transfers and how many staff are needed (using the CNA Care Kardex) and CNA's must also follow the Facility's Policies and Procedures. During an interview on 07/24/24 at 5:31 P.M. the Administrator said that on 07/03/24, CNA #1 told her, she was going to provide ADL care to Resident #1, that she used the Sit/Stand lift so she could transfer him/her back to bed for care, that while Resident #1 was standing on the Sit/Stand Lift, he/she started to fall and that she lowered Resident #1 to the floor. The Administrator said she had asked CNA #1 if she had reviewed Resident #1's CNA Care Kardex regarding how Resident #1 transferred, and that CNA #1 replied No. On 07/24/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidence by: A. 07/03/24, Resident #1 fell , was immediately assessed by Nursing for any injuries, Resident #1 had reported he/she had pain to right hip, and was transferred to the Hospital Emergency Department (ED) for evaluation. B. 07/03/24, Resident #1's Care Plan was reviewed and updated to include the 07/03/24 fall, and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers. C. 07/03/24, Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary (Final Report ) which indicated Resident #1 was assessed and treated at the ED with no fractures found. However the he/she continued to experience pain and an X-ray completed at the facility a few days later indicated he/she had a right femur fractures. D. 07/09/24, Resident #1's Care Plan was updated to include that on 07/08/24, Resident #1 was in pain, Facility X-ray, dated 07/8/24, indicated Resident #1's right femur was fracture status post fall on 07/03/24, which was not previously diagnosed , that he/she had been transferred back to the ED and was admitted to the Hospital. E. The Facility's Morning Meeting and the Weekly Risk Meeting Fall Review minutes indicated the Interdisciplinary Team (IDT) reviewed Resident #1's fall that occurred on 07/03/24, his/her X-ray results from 07/08/24, and need for him/her to be transferred back to the Hospital ED for evaluation. The minutes indicated the the IDT continues to discuss (and update as needed) Resident #1's Plan of Care including orthopedic appointments, weight bearing status, nutritional status, and overall health status. F. The Facility Nursing Staff completed an Audit to ensure all residents who used any type of mechanical device, that their individual Care Plan and the CNA Care Kardex indicated the appropriate type of device to be used and how many staff were needed for assistance with the transfer. G. 07/09/24, The Staff Development Coordinator (SDC) and the DON initiated mandatory education for all Licensed Nurses and CNA's, which included completion of competencies on Sit/Stand Lift device, and staff were required to complete return demonstration of appropriate use of the transfer device. Education also included nursing staff requirement to review and follow residents plan of care, knowledge of how to access and review the CNA Care Kardex, prior to providing care. H. 07/12/24, Resident #1's Care Plan was updated to include, right distal femur fracture related to a fall, and that he/she required extensive assistance from two staff members using a Hoyer Lift (mechanical lift used to safely transfer patients). I. 07/17/24, All Sit/Stand Lift devices were Inspected by the Maintenance Department, to ensure all parts were functioning properly and transfer device was safe to use. J. Physical Therapy Department Staff also initiated and completed Audits related the incident to ensure all residents including new admissions, that their transfer status degree and number of staff needed for assistance during the provision of all care need areas identified were up to date on residents Plan of Care and CNA Care Kardex. K. Random Audits were completed by administrative staff, on Resident transfers with the Sit/Stand Lift to ensure that transfer procedures from Sit/Stand Lift Competencies are being followed by staff. Random Audits will be completed by the DON three times weekly for 3 months. L. The DON presented the Audit results at monthly Quality Assurance Performance Improvement (QAPI) meeting, where the QAPI Committee discussed the results. The DON will present the Audit results for three months, then quarterly until the Committee determines 100 % staff compliance is met, and the concern area thereafter will be present for yearly review. M. Review of the facility's most recent QAPI meeting minutes indicated leaderships plan is to continue to review the concern areas for potential deficient practice, including falls, to ensure that residents were provided with appropriate level of assistance as determined by assessments and identified in the residents Plan of Care and CNA Care Kardex. N. The Director of Nurses (DON) and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk of falls, was known to have poor safety awareness, weakness due to a stroke and required the assistance of two staff members for transfers, the Facility failed to ensure Resident #1 was provided with the necessary level of staff assistance during a transfer to prevent an incident/accident resulting in a serious injury. On 07/03/24, CNA #1 transferred Resident #1 with a Sit/Stand Lift device (device that helps individuals who have difficulty standing up, from a seated position) without having another staff member present to assist her, during the transfer Resident #1 started to slide out of the lift seat, CNA #1 then tried to lower him/her to the floor, Resident #1 immediately complained of pain to his/her right hip, was transferred to the Hospital Emergency Department (ED) and was diagnosed several days later with a right femur (thigh bone) fracture which required surgical intervention to repair. Findings include: Review of the Facility's Policy, Fall Prevention Program Policy and Procedure, dated reviewed 02/26/24, indicated it is policy of the Facility's Accidents/Supervision to ensure resident safety is a commitment to provide an environment that is free from Accident hazards over which the facility has control and provides supervision and assistance devices to each resident based on the identified hazards or risks to each resident to prevent accidents. Review of the Facility's (Sit/Stand Lift) Stand Aid Lift Competency Checklist, dated January 2023, indicated staff to check the residents' Plan (CNA) Care Kardex for the correct number of assistants necessary to transfer the resident and use a gait belt if the resident requires help pulling themselves up. Review of the report submitted by the Facility via the Health Care Facility Reporting System, dated 07/03/24, indicated while being transferred and sitting in the Sit/Stand (mechanical transfer device), Resident #1 was lowered to the floor. The Report indicated Certified Nurse Aide (CNA) #1 used the Sit/Stand device incorrectly, and did not have another staff member assist her when transferring the resident back to bed to offer peri-care. The Report indicated Resident #1 complained of right hip pain, was assessed and an order was obtained to transfer him/her to the Hospital Emergency Department (ED) for evaluation. The Report indicated Resident #1 returned to the facility the same day, and that the ED Discharge Summary indicated there were no fractures. However, review of the Facility's Internal Investigation's Final Report, dated 07/08/24, indicated that Resident #1 continued to experience pain to his/her right knee area, and an X-ray of his/her right knee was ordered. On 07/08/24, the facility was notified that Resident #1 had an acute distal right femur (thigh bone) supracondylar fracture (bone broken at the knee) with slight posterior displacement. The Report indicated that when the facility's Physician Assistant reviewed Resident #1's Hospital Discharge Summary from 07/03/24, it was determined that although the Hospital ED Physician had ordered an X-ray of his/her right femur, that it had not been completed. Therefore, Resident #1 was not diagnosed with a right femur fracture until 07/08/24, at which point he/she was transferred back and admitted to the Hospital, for further treatment. Resident #1 was admitted to the Facility in August 2023, diagnoses included Hemiplegia (paralysis on one side of the body) and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following Cerebral Infarction (stroke) affecting the left non-dominant side, difficulty walking, lack of coordination, unsteadiness on feet, and Anemia in the setting of Chronic Kidney Disease (Stage 4). Review of Resident #1's Fall Risk Assessment, dated 05/15/24, indicated he/she was assessed by Nursing as being at high risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/16/24, indicated that Resident #1 had severe cognitive impairment and required substantial, maximum assistance (more than half the effort) from staff with transfers and mobility. Review of Resident #1's Fall Care Plan, reviewed and renewed in conjunction with completion of his/her May 2024 MDS, indicated safety interventions included the following; ensure Resident #1 wore appropriate footwear when ambulating and mobilizing (when in wheelchair). Review of Resident #1's Activities of Daily Living (ADL) Care Plan related to mobility and transfers, reviewed and renewed in conjunction with completion of his/her May 2024 MDS, indicated interventions included that for all transfers he/she required extensive assistance of two staff members. Review of Resident #1's Certified Nurse Aide (CNA) Care Kardex (used as a reference guide by CNA's and provides direct care staff with an overview of each residents' needs), dated 06/01/24, indicated interventions included that he/she required extensive assistance from two staff members with all transfers. During a telephone interview on 08/07/24 at 2:59 P.M., CNA #1 said she was assisting Resident #1 in his/her room with a transfer from his/her wheelchair to his/her bed using a Sit/Stand Lift. CNA #1 said Resident #1 was unable to pull him/herself up from the wheelchair to the Sit/Stand Lift because he/she was too weak. CNA #1 said she had to pull Resident #1 up to standing position very hard, using her hand and then assisted Resident #1 onto the seat of the Sit/Stand Lift. CNA #1 said when she was moving the Sit/Stand Lift closer to Resident #1's bed, she observed that Resident #1 was sliding out of the lift seat, so she had held onto Resident #1 with one hand and used her other hand to push the lift away, while using her own body to lower Resident #1 to the floor. CNA #1 said after Resident #1 was on the floor, she called out for help, but no one came. CNA #1 said Resident #1 was in pain when he/she was on the floor, he/she was making groaning sounds, so she left Resident #1 alone on the floor and went to the Nurse's station to get help. CNA #1 said she had worked with Resident #1 in the past and had always provided care to him/her by herself. CNA #1 said she usually does her job by herself, and does not ask for help. During an telephone interview on 07/25/24 at 10:10 A.M., the Nursing Supervisor said on 07/03/24, CNA #1 reported that Resident #1 fell in his/her room and that she lowered Resident #1 to the floor. The Nursing Supervisor said upon entering Resident #1's room, Resident #1 was on the floor, moaning, making sounds, and leaning slightly on his/her left side holding his/her right hip. The Nursing Supervisor said she was concerned about Resident #1's fall, his/her complaints of pain, and because Resident #1 was prescribed an anticoagulant medication which put him/her at risk for bleeding, that Resident #1 was transferred to the Hospital ED for evaluation. During an interview on 07/24/24 at 12:18 P.M., the facility's Physician Assistant (PA) said on 07/03/24, CNA #1 reported that Resident #1 fell . The PA said she had asked CNA #1 what happened, and that CNA #1 said Resident #1 let go of the handlebars of the Sit/Stand Lift and that she lowered him/her to the floor. The PA said upon arrival to Resident #1's room, he/she was found laying on his/her back on the floor in front of the Sit/Stand Lift device. The PA said Resident #1 said he/she had pain in his/her legs, and she observed that Resident #1's right leg was internally rotated (knee and foot twist toward the midline of the body). The PA said she assessed Resident #1 and ordered that he/she be transferred to the Hospital ED for further evaluation. The PA said Resident #1 returned to the facility on [DATE], and that the Hospital ED Report indicated that Resident #1 did not have any fractures. The PA said Resident #1 continued to have pain including to his/her right knee, and that nursing had observed and reported his/her right knee had become swollen. The PA said she re-assessed Resident #1 who was still complaining that he/she was in a lot of pain. The PA said on 07/08/24, the Facility obtained an X-ray of Resident #1's right femur (thigh bone) which indicated Resident #1 had a distal right femur fracture and Resident #1 was transferred back and admitted to the Hospital that same day. The PA said she reviewed Resident #1's Hospital ED Records from 07/03/24 and said the Hospital did not obtain an X-ray of Resident #1's right femur per Hospital ED Physician Orders. The PA said the type of fracture Resident #1 sustained would be the result of movement with force, and that Resident #1's fall on 07/03/24 would have been a contributing factor. The PA said when Resident #1 returned from the Hospital ED on 07/03/24, he/she had remained bed ridden, that he/she had not gotten out of bed at all, until 07/08/24, when he/she was transferred back to the Hospital. During an interview on 07/24/24 at 4:08 P.M., the Director of Nursing (DON) said on 07/03/24, upon entering Resident #1's room, Resident #1 had been laying on the floor, moaning and he/she seemed to be in a lot of pain. The DON said CNA #1 said she was using the Sit/Stand Lift to provide Activities of Daily Living (ADL) care (personal care) to Resident #1 which included the need to transfer him/her from the wheelchair back into bed. The DON said CNA #1 said Resident #1 was standing up on the Sit/Stand Lift device holding onto the handlebars, before she (CNA #1) lowered him/her to the floor. The DON said the Sit/Stand Lift was not to be utilized by staff during ADL care and was only to be used for short distances transfers. During an interview on 07/24/24 at 5:31 P.M. the Administrator said on 07/03/24, upon entering Resident #1's room, Resident #1 was laying on the floor, moaning, crying and was in pain. The Administrator said CNA #1 said she was providing ADL care to Resident #1, that he/she was standing on the Sit/Stand Lift, started to fall and that she lowered Resident #1 to the floor. However, during a telephone follow-up interview on 08/08/24 at 2:39 P.M., CNA #1 said that on 07/03/24, she had not put a gait belt belt or had a another staff member help her during Resident #1's transfer. CNA #1 confirmed that Resident #1 was sitting on the seat of the Sit/Stand Lift device, not standing, when he/she became weak, and started sliding out of the chair, before she lowered him/her to the floor. This contradicted what CNA #1 reported to the PA, DON and Administrator, when she told them that Resident #1 was standing up in the Sit/Stand Lift device, holding onto the handle bars, before she had lowered him/her down to the floor. On 07/24/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidence by: A. 07/03/24, Resident #1 fell , was immediately assessed by Nursing for any injuries, Resident #1 had reported he/she had pain to right hip, and was transferred to the Hospital Emergency Department (ED) for evaluation. B. 07/03/24, Resident #1's Care Plan was reviewed and updated to include the 07/03/24 fall, and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers. C. 07/03/24, Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary (Final Report ) which indicated Resident #1 was assessed and treated at the ED with no fractures found. However the he/she continued to experience pain and an X-ray completed at the facility a few days later indicated he/she had a right femur fractures. D. 07/09/24, Resident #1's Care Plan was updated to include that on 07/08/24, Resident #1 was in pain, Facility X-ray, dated 07/8/24, indicated Resident #1's right femur was fracture status post fall on 07/03/24, which was not previously diagnosed , that he/she had been transferred back to the ED and was admitted to the Hospital. E. The Facility's Morning Meeting and the Weekly Risk Meeting Fall Review minutes indicated the Interdisciplinary Team (IDT) reviewed Resident #1's fall that occurred on 07/03/24, his/her X-ray results from 07/08/24, and need for him/her to be transferred back to the Hospital ED for evaluation. The minutes indicated the the IDT continues to discuss (and update as needed) Resident #1's Plan of Care including orthopedic appointments, weight bearing status, nutritional status, and overall health status. F. The Facility Nursing Staff completed an Audit to ensure all residents who used any type of mechanical device, that their individual Care Plan and the CNA Care Kardex indicated the appropriate type of device to be used and how many staff were needed for assistance with the transfer. G. 07/09/24, The Staff Development Coordinator (SDC) and the DON initiated mandatory education for all Licensed Nurses and CNA's, which included completion of competencies on Sit/Stand Lift device, and staff were required to complete return demonstration of appropriate use of the transfer device. Education also included nursing staff requirement to review and follow residents plan of care, knowledge of how to access and review the CNA Care Kardex, prior to providing care. H. 07/12/24, Resident #1's Care Plan was updated to include, right distal femur fracture related to a fall, and that he/she required extensive assistance from two staff members using a Hoyer Lift (mechanical lift used to safely transfer patients). I. 07/17/24, All Sit/Stand Lift devices were Inspected by the Maintenance Department, to ensure all parts were functioning properly and transfer device was safe to use. J. Physical Therapy Department Staff also initiated and completed Audits related the incident to ensure all residents including new admissions, that their transfer status degree and number of staff needed for assistance during the provision of all care need areas identified were up to date on residents Plan of Care and CNA Care Kardex. K. Random Audits were completed by administrative staff, on Resident transfers with the Sit/Stand Lift to ensure that transfer procedures from Sit/Stand Lift Competencies are being followed by staff. Random Audits will be completed by the DON three times weekly for 3 months. L. The DON presented the Audit results at monthly Quality Assurance Performance Improvement (QAPI) meeting, where the QAPI Committee discussed the results. The DON will present the Audit results for three months, then quarterly until the Committee determines 100 % staff compliance is met, and the concern area thereafter will be present for yearly review. M. Review of the facility's most recent QAPI meeting minutes indicated leaderships plan is to continue to review the concern areas for potential deficient practice, including falls, to ensure that residents were provided with appropriate level of assistance as determined by assessments and identified in the residents Plan of Care and CNA Care Kardex. N. The Director of Nurses (DON) and/or designee are responsible for overall compliance.

Based on interviews and records reviewed, for one of three sampled residents (Resident #2), whose primary spoken language was not English, the Facility failed to ensure he/she was free from abuse, when on 4/08/24, during the evening shift, when Resident #2 approached Nurse #1, who was in the hallway at the medication cart, to ask for his/her supplement, Nurse #1 yelled at Resident #2 in a humiliating and verbally aggressive manner saying, you are in America now, you need to learn to speak English! The altercation was witnessed by two other residents, who said Resident #2 was upset and crying after Nurse #1 yelled at him/her. Findings include: Review of the Facility's Policy titled Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of Resident or Misappropriation of Resident Property, dated January 2023, indicated the following: - Employees, consultants, contractors, volunteers, and other caregivers will provide an environment for residents that is safe and free from abuse, neglect, exploitation, mistreatment, and misappropriation, treating each resident with respect, dignity, and the provision of privacy. - Verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend, or disability. - Mental abuse includes but is not limited to humiliation, harassment, threats of punishment, deprivation, or abuse and further includes Nursing Home Staff taking, keeping, distributing, or using photographs or recordings of a resident and/or resident's personal space in any manner that would demean or humiliate a resident. Resident #2 was admitted to the Facility in March 2023, diagnoses included Parkinson's disease without dyskinesia, type 2 diabetes mellitus, major depressive disorder, sleep terrors, spinal stenosis, and hypertension. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 3/13/24, indicated that he/she was cognitively intact, made his/her own decisions, could speak and understand a limited amount of English, and utilized a translation application on an electronic device (his/her iPad) to communicate his/her needs to staff. The MDS indicated that Resident #2 required moderate assistance from one staff member to meet his/her care needs. Review of the Facility's Investigation, dated 4/11/24, indicated Resident #1 reported he/she heard Nurse #1 state to Resident #2, You are now in America, and you need to learn English because no one is going to understand you! The Investigation also indicated that Nurse #1 made {inappropriate}statements regarding Resident #1, and those statements were confirmed by a second nurse (later identified as Nurse #2) who worked on the same unit on 4/08/24. The Investigation indicated that Nurse #2 reported that while they were charting around 10:00 P.M., Nurse #1 stated, I told the Chinese patient that he/she needs to learn English, and that Nurse #1 went on to say to Nurse #2 and the Certified Nurse Aides (CNA's) who were also present at the nursing station, I came from [NAME], and I learned English, why can't he/she? The Investigation indicated the Administrator received an email on 4/11/24 at 2:40 A.M., from Resident #1's Family Member (FM #1) concerning Nurse #1 being rude to Resident #1 on 4/08/24 (during the evening shift). The Investigation indicated FM #1 also included in the email that Resident #1 reported to her that Nurse #1 was also verbally abusive towards Resident #2. The Investigation indicated that Nurse #1 refused to participate in the Facility's Investigation into the allegations, conducted by the Administrator. Review of Nurse #2's Written Witness Statement, dated 4/08/24, indicated that she spoke to Resident #2's Family Member (FM #2) on the phone on 4/08/24, and that FM #2 told her (Nurse #2) that Resident #2 reported being yelled at by Nurse #1 for asking for his/her supplement. The Statement indicated that FM #2 stated he did not like it that Resident #2 was crying. The Statement indicated Nurse #2 reported the incident to the Nurse Supervisor. Further review of Nurse #2 Written Witness Statement indicated that at 9:15 P.M., while providing care to Resident #1, he/she reported to her (Nurse #2) that he/she had overheard Nurse #1 yelling loudly at Resident #2, and that he/she felt sorry for Resident #2. During an interview on 4/30/24 at 3:02 P.M., Nurse #2 said that on 4/08/24 at approximately 7:30 P.M., Resident #2 approached her, he/she crying and looked sad. Nurse #2 said that when she asked Resident #2 what was wrong, he/she said {using his/her iPad as an interpreter}, that Nurse #1 yelled and screamed at him/her, which scared and humiliated him/her. Nurse #2 said that while Resident #2 was describing the incident, Resident #3 came over and stated that he/she had witnessed Nurse #1 yelling and humiliating Resident #2, and that it also scared him/her. Nurse #2 said she spoke to Resident #2's Family Member (FM #2) that night, who reported receiving a very emotional call from Resident #2, who was crying about being yelled at for asking Nurse #1 for his/her supplement. Nurse #2 said that FM #2 stated that he did not like it that Resident 2 was crying. Nurse #2 said she immediately reported the incident to the Nurse Supervisor after she spoke to FM #2. Nurse #2 said later that night, around 9:15 P.M., while providing care to him/her, Resident #1 also reported that he/she overheard Nurse #1 yelling and screaming at Resident #2, telling him/her, You are in America and need to learn English. This is America! Nurse #2 said later that same night when she was at the nursing station doing her charting, Nurse #1 was on the other side of the nursing station, and that two Certified Nurse Aides, were also there. Nurse #2 said Nurse #1 bragged to them and said, I told the Chinese patient that he/she needs to learn English. Nurse #2 said Nurse #1 went on to say, I came from [NAME] and learned English, why can't he/she learn? I am not catering to him/her. Nurse #2 said that as Nurse #1 got up and was passing her, that she (Nurse #1) looked at her and said, Don't let me go ghetto on you. Nurse #2 said Nurse #1 made her uncomfortable, and that she could not imagine how the residents' felt. During an interview on 4/30/24 at 1:05 P.M., Resident #2, due his/her limited English, requested that the Surveyor contact and speak to Family Member #2 about the incident. During a telephone interview on 5/07/24 at 9:00 A.M., Family Member #2 (who spoke on Resident #2 behalf, with his/her permission) confirmed receiving a call from a very emotional Resident #2 on 4/08/24, during which he/she reported that Nurse #1 (whom Resident #2 identified by name) had very aggressively and loudly yelled at him/her that night. FM #2 said that Resident #2 told him that Nurse #2 had yelled at him/her and said Why don't learn English? This is America! FM #2 said Resident #2 told him that he/she had only gone to Nurse #1 to ask for his/her supplement. During an interview on 4/30/24 at 3:40 P.M., Certified Nurse Aide (CNA) #3 said when she was at the nursing station area doing her documentation on 4/08/24 for the evening shift, that Nurse #1 was on the other side of the nursing station bragging about what she (Nurse #1) had done, and that Nurse #1 made the following statements; I told the Chinese patient that he/she needs to learn English, I came from [NAME], and I learned English, why can't he/she? and I am not catering to him/her! During an interview on 4/30/24 at 12:55 P.M., Resident #3 said he/she had witnessed Nurse #1 suddenly snap at Resident #2, that Nurse #1 had been aggressively yelling at Resident #2 in humiliating manner. Resident #3 said he/she could see that Resident #2 was scared and that he/she was crying. Resident #3 said that he/she felt terrible for Resident #2. Resident #3 said he/she was distraught because Nurse #1 was treating Resident #2 that way, and said after witnessing Nurse #1's behavior, he/she was fearful of Nurse #1 and did not interact with her (Nurse #1) the rest of the night. During an interview on 4/30/24 at 1:10 P.M., Resident #1 said he/she had witnessed Nurse #1 yelling and in an aggressive manner at Resident #2. Resident #1 said he/she was in the hallway, had been standing close to Nurse #1's medication cart during the altercation and said that Resident #2 looked scared and was crying. Resident #1 said Nurse #1 was also rude to him/her during the shift. Resident #1 said that the next day, he/she told Family Member #1 about how rude Nurse #1 was throughout the shift. Review of the Facility's Investigation Summary Report, dated 4/11/24, indicated that upon their investigation, Nurse #1 admitted to making inappropriate comments at the nurse's station in the presence of other staff members. The Surveyor was unable to interview Nurse #1 as she did not respond to the Department of Public Health's telephone call or letter requests for an interview. During an interview on 4/30/24, at 1:50 P.M., the Administrator said she received an email from Resident #1's Family Member (FM #1) at 2:40 A.M. on 4/11/24, that alleged Nurse #1 had been verbally inappropriate to Resident #1 and Resident #2. The Administrator said she immediately called the Nursing Supervisor, initiated an investigation, and suspended Nurse #1. The Administrator said Nurse #1 was from the Agency and had been scheduled to work 4/08/24 (3:00 P.M. to 11:00 P.M. & 11:00 P.M. to 7:00 A.M.) which was the unit in which Resident #1 and Resident #2 resided on. The Administrator said Nurse #1 was terminated and would no longer be contracted through the Agency to work at their facility.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 4/08/24 during the evening shift after the Nurse Supervisor received a report of an allegation of abuse from Nurse #2 that Nurse #1 had been verbally abusive towards to Resident #2, the Nurse Supervisor failed to immediately notify the Administrator and Director of Nursing (DON) of the alleged abuse, and did not suspend Nurse #1, as a result Nurse #1 continued to work the overnight shift (11:00 P.M. to 7:00 A.M.) providing care to Resident #2 and other residents, placing them at risk for the potential for further abuse. Findings include: Review of the Facility's Abuse Policy, dated 02/2023, indicated that after ensuring the residents are protected, Nursing Home Staff must immediately report to his or her Supervisor or the Administrator any allegation or suspicion of abuse, neglect, mistreatment, or exploitation, including injuries of unknown source as well as any allegation or suspicion of the misappropriation of resident property. The Supervisor shall immediately notify the Administrator of all reports. Review of the Facility's Abuse Reporting Immediate Response Supervisor Checklist Form, with a revised date of 1/26/23, indicated the Nurse Supervisor or Designee will immediately initiate an Abuse protocol when a report of Abuse, Neglect, Misappropriation is alleged, The Checklist Actions included, but was not limited to the following; -Protect resident immediately from harm. -Remove any threat/potential threat (if resident is upset, staff to stay with resident). -Employee involved in allegation is immediately removed from unit, away from all residents, and with supervision. -Attach suspension form with instructions given to employee and then employee is removed from premises and suspended by Supervisor. -Nurse Supervisor immediately notifies Director of Nursing (DON) or Designee, continue until you reach the DON or Designee, if no answer after three tries approximately five minutes apart, call the Administrator. -Do Not text or Email, Speak Directly with Director or Designee. The Facility's Internal Investigation, dated 4/11/24, indicated that the management team did not become aware of the incident (allegation of verbal abuse of Resident #2 by Nurse #1 that occurred on 4/08/24 during the evening shift) until 4/11/24 when the Administrator received an email from Resident #1's Family Member (FM #1) that voiced concerns about Nurse #1 being rude at Resident #1. The Investigation indicated that FM #1 also stated in the email that Nurse #1 was also verbally abusive towards Resident #2. The Investigation indicated Nurse #1 was on the schedule on 4/11/24 on different unit and was suspended that day. The Investigation included a written statement from Nurse #2, dated 4/08/24 which indicated that on 4/08/24, at 7:30 P.M., Resident #2 was crying and upset and reported to her (Nurse #2) that Nurse #1 was rude and yelling at him/her. The Investigation indicated that Resident #3 also witnessed and confirmed that Nurse #1 screamed at Resident #2 and made him/her cry. The Investigation indicated Resident #3 was standing beside the medication cart and witnessed the incident, and that it had scared him/her (Resident #3). During an interview on 4/30/24 at 3:02 P.M., Nurse #2 said that at approximately 7:30 P.M., on 4/08/24. Resident #2 approached her, that he/she was crying and sad. Nurse #2 said that when she asked Resident #2 what was wrong, he/she used his/her iPad (as an interpreter) and said that Nurse #1 yelled and screamed at him/her, which scared and humiliated him/her. Nurse #2 said that while Resident #2 was describing the incident, Resident #3 came over and stated that he/she had witnessed Nurse #1 aggressively yelling and humiliating Resident #2, which also made him/her feel scared. Nurse #2 said she immediately reported this to the Nurse Supervisor. Review of the Facility's Nursing Schedule, dated 4/08/24, indicated Nurse #1 worked from 3:00 P.M. to 11:00 P.M. (for the entire shift) and continued to work on the overnight shift (11:00 P.M. to 7:00 A.M.) on the same unit, and therefore continued to provide care to Resident #2 and other residents on that unit. During a telephone interview on 5/01/24 at 10:30 A.M., the Nurse Supervisor said that on 4/08/24 during the evening shift Nurse #2 reported to her that Resident #2 was upset about how Nurse #1 had treated him/her. The Nurse Supervisor said it was unclear to her if it was abuse. The Nurse Supervisor said she did not recall if she sent a text that night to notify the Administrator, of the incident. The Nurse Supervisor said she was aware of the Facility's Abuse Policy. During an interview on 4/30/24 at 1:50 P.M., the Administrator said the Nurse Supervisor had not followed facility policy after becoming aware on 4/08/24 of an alleged incident of abuse of Resident #2 by Nurse #1. The Administrator said an investigation should have been initiated, Nurse #1 should have been suspended and the Director of Nurses and Administrator should have been notified, per the Facility's Abuse Policy.

Based on observations, interviews, and policy review, the facility failed to ensure that residents were treated with dignity during communal dining on one Unit (Sacred Heart), out of eight units observed. Specifically, the facility staff failed to be in a seated position while assisting Resident #96 during mealtime. Findings Include: Review of the facility policy titled Assisted Dining Totally Dependent on Staff for Dining last revised June 2021, indicated the following: -Staff will provide the necessary level of assistance to those residents who are unable to feed themselves or who need assistance or encouragement to eat. -Staff will place tray within view of the resident. -Staff will sit down and make eye contact while assisting the resident. Resident #96 was admitted to the facility in January 2023 with diagnoses including non-traumatic brain dysfunction (a dysfunction of the brain caused by internal factors) and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #96 was rarely/never able to make themselves understood and rarely/never able to understand others. Further Review of the MDS Assessment indicated the Resident was severely cognitively impaired with both short and long term memory impairments as evidenced by a staff assessment for mental status, and required substantial to maximum assist with eating tasks. On 11/30/23 at 12:08 P.M. through 12:52 P.M., the surveyor observed the following during the lunchtime meal in the Dining Room on the Sacred Heart Unit: -12:08 P.M.: the meal cart arrived on the unit and Certified Nurses Aide (CNA) #2 and Nurse #2 began setting up the residents lunch meal trays in the unit Dining Room. -12:37 P.M.: CNA #2 wheeled Resident #96 into the Dining Room and set him/her up at a small table with his/her meal tray. Resident #96 was observed to be unable to feed him/herself and did not initiate self-feeding. CNA #2 proceeded to feed Resident #96 while standing next to the Resident's wheelchair. -12:42 P.M.: CNA #2 paused in assisting Resident #96 with his/her meal to obtain an item for another resident, left the dining room, and returned. The surveyor observed when CNA #2 returned, she resumed assisting Resident #96 with the meal while still standing. -12:44 P.M.: Nurse #2 brought over a chair to the table where Resident #96 was being assisted, and offered the chair to CNA #2 who did not sit down and continued to assist the Resident while standing. -12:52 P.M.: Resident #96 completed his/her meal and CNA #2 escorted him/her out of the Dining Room. During an interview on 11/30/23 at 1:51 P.M., CNA #2 said that Resident #96 required assistance with eating and he/she was unable to initiate any eating independently. CNA #2 further said that she was the only CNA in the Dining Room and therefore did not sit down to assist Resident #96 as she was checking on other Residents if they needed assistance. During an interview on 12/1/23 at 10:59 A.M., the Administrator said the CNA should have been seated while assisting the Resident with his/her meal.

Based on interviews, policy and record review, the facility failed to notify the Physician of a significant change in condition for one Resident (#28) out of a total sample of 35 residents. Specifically, the facility failed to notify the Physician to allow for re-evaluation and the potential need to alter the treatment plan, on four occasions when blood sugar values were high for Resident #28. Findings include: Resident #28 was admitted to the facility in April 2023, with diagnoses including Type 2 Diabetes ((DM II) and repeated falls. Review of Resident #28's Physician's orders for May 2023 and June 2023 indicated the following: Humalog Injection Solution 100 unit/ml (milliliters; Insulin Lispro) subcutaneously before meals related to Type 2 Diabetes Mellitus. Inject as per sliding scale: If 70-200 = (inject) 0 ml 201-250 = 4 ml 251-300 = 6 ml 301-349 = 8 ml 350+ = 10 ml 400 or greater - notify MD Review of Resident #28's Medication Administration Record (MAR) for May 2023 and June 2023 indicated the following blood sugar levels: 5/22/23 - 503 mg/dL (milligrams per deciliter) - high [less than 140 mg/dL is normal, greater than 200 mg/dL indicates Diabetes] 5/29/23- 402 mg/dL - high 5/30/23 - 401 mg/dL - high 6/23/23 - 401 mg/dL - high Review of Resident #28's progress notes indicated that the Physician had not been notified of the elevated blood sugars (400 mg/dL or greater) as ordered. Review of the facility policy for Diabetes Management, last revised June 2023, indicated: -A Physician's or Nurse Practitioner's order must be obtained prior to routine blood glucose monitoring being performed. The order will include the frequency of testing and the parameters for which the Physician or Nurse Practitioner (NP) should be notified. -Abnormal results, pertinent observations, interventions, and their effectiveness must be recorded in the resident's medical record. Review of Resident #28's Minimum Data Set (MDS) Assessment, dated 10/18/23, revealed that he/she had a Brief Interview of Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. During an interview on 11/29/23 at 12:01 P.M., Family Member #1 said that they felt that Resident #28's Insulin had not been managed well by the facility Physician in May of this year (2023) and that the Resident had been having high blood sugar levels. During an interview on 12/5/23 at 9:46 A.M., the Assistant Director of Nurses (ADON) said that the Physician should have been notified of the Resident's elevated blood sugar levels. The ADON said that he could not provide evidence that the Physician had been notified of the elevated blood sugar levels on 5/22/23, 5/29/23, 5/30/23 and 6/23/23.

Based on observation, interview, record and policy review, the facility failed to adhere to infection control standards and implement their policy relative to Transmission-Based Precautions ([TBP] Isolation Precautions: actions implemented in addition to standard precautions based upon means of transmission [ .Droplet] in order to prevent or control infections) for two Residents (#149 and #108) out of five applicable residents, in a total sample of 35 residents. Specifically, the facility failed to ensure that Isolation Precautions remained in effect for the required duration for Residents #149 and #108, after both Residents tested positive for COVID-19. Findings include: Review of the facility policy titled Coronavirus (COVID-19) Policy, dated 3/17/23, indicated: -The facility would follow the most current Massachusetts Department of Public Health (MA DPH) guidelines to include MA DPH's memorandum titled Update to Caring for Long-Term Care Residents during the COVID-19 Response. -Discontinuation of Isolation Precautions would be determined on a case-by-case basis, in conjunction with . state . national . health authorities. Review of the MA DPH memorandum titled Update to Infection Prevention and Control Considerations when Caring for Long Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23, indicated: -This memorandum replaced MA DPH's memorandum titled Caring for Long-Term Care Residents during the COVID-19 Response. -Residents with COVID-19 could be released from isolation after five days from symptom onset: >if afebrile for at least 24 hours. >any symptoms have improved and they have a negative viral test collected on Day 5 or later. >if asymptomatic, after five days from specimen collection date of the positive COVID-19 test and have a negative viral test collected on Day 5 or later. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Ending Isolation and Precautions for People with COVID-19: Interim Guidance, dated 8/22/23, indicated the following recommendations for ending Isolation Precautions: -Isolation can be discontinued at least 5 days after symptom onset (Day 0 is the day symptoms appeared, and Day 1 is the next full day thereafter) . -Isolation can be discontinued at least 5 days after the first positive viral test (Day 0 is the date the specimen was collected for the positive test, and Day 1 is the next full day thereafter). 1. Resident #149 was admitted to the facility in December 2022, with a diagnosis of personal history of COVID-19. Review of Resident #149's COVID-19 Testing Worksheet dated 11/25/23, indicated the Resident tested positive for COVID-19 on 11/25/23. On 11/29/23 at 10:25 A.M., the surveyor observed Resident #149 in his/her room. There was a sign which indicated Isolation Precautions posted outside the Resident's room which listed all staff were required to wear an N95 mask, gown, gloves, and eye protection upon entry to the room. The surveyor also observed a plastic three-drawer bin containing personal protective equipment (PPE) in the hallway outside the Resident's room, which included disposable gowns, gloves, N95 masks, and eye protection. Review of Resident #149's November 2023 Physician's orders dated 11/25/23, indicated: -Isolation Precautions: Droplet every shift for COVID-19 + (positive) Further review of the Physician's orders indicated Resident #149's Isolation Precautions were discontinued on 11/30/23. On 11/30/23 at 10:00 A.M., the surveyor observed Resident #149's room and the hallway area outside of the Resident's room. The surveyor did not observe any signage for Isolation Precautions posted outside the Resident's room and there were no PPE supplies observed in the hallway outside the Resident's room. 2. Resident #108 was admitted to the facility in October 2023, with a diagnosis of personal history of COVID-19. Review of Resident #108's COVID-19 Testing Worksheet dated 11/25/23, indicated the Resident tested positive for COVID-19 on 11/25/23. On 11/29/23 at 11:32 AM, the surveyor observed signage posted outside Resident #108's closed door which indicated Isolation Precautions were required and that all staff who entered the room were required to wear an N95 mask, gown, gloves, and eye protection. The surveyor also observed a plastic three-drawer bin containing PPE in the hallway outside the Resident's room, that included disposable gowns, gloves, N95 masks, and eye protection. Review of Resident #108's November 2023 Physician's orders indicated an order dated 11/25/23, as follows: -Isolation Precautions: Droplet every shift for COVID-19 + Further review of the order indicated Resident #108's Isolation Precautions were discontinued on 11/30/23. On 11/30/23 at 10:02 A.M., the surveyor observed Resident #108's room and the hallway area outside of the Resident's room. No signage for Isolation Precautions were posted and there were no PPE supplies observed in the hallway outside the Resident's room. The surveyor also observed the following on 11/30/23 from 10:02 A.M. through 11:17 A.M.: -Certified Nurses Aide (CNA) #1 entered and exited Resident #108's room on four occasions while wearing a surgical mask. CNA #1 did not put on (don) any other PPE to enter the Resident's room during the four occasions. -At 10:05 A.M., Nurse #1 entered the Resident's room while wearing a surgical mask. Nurse #1 did not put on any other PPE to enter the room at this time, and proceeded to take the Resident's blood pressure, then exited the room. During an interview at the time, Nurse #1 said facility Administration informed him that day (11/30/23) that each resident who had previously been on Isolation Precautions on the Unit were now clear and no longer required these precautions. -At 11:18 A.M., CNA #1 entered Resident #108's room and closed the door. CNA #1 wore no mask upon entry to the room and did not don any other PPE prior to entering the Resident's room. -CNA #1 exited Resident #108's room at 11:21 A.M. During an interview on 11/30/23 at 11:21 A.M., CNA #1 said facility Administration and the Infection Preventionist (IP) informed staff that morning that all residents on the Unit who had been on Isolation Precautions for COVID-19 no longer required these precautions. During an interview on 11/30/23 at 1:04 P.M., the IP said the date of a resident's positive test or symptom start date for COVID-19 was considered Day zero and that Isolation Precautions could be discontinued for residents on Day five as long as a negative COVID-19 test was obtained. The IP further said she would review the guidance for discontinuation of Isolation Precautions and get back to the surveyor as to whether Residents #149 and #108 should have had Isolation Precautions discontinued on Day five or after five days passed since their positive COVID-19 tests. During a follow-up interview on 11/30/23 at 2:03 P.M., with the Administrator and the IP present, the Administrator said that Isolation Precautions were discontinued one day too soon for both Residents #149 and #108, and that the Isolation precautions should not have been discontinued until 12/1/23.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives indicated he/she was a Full Code (in the event of cardiac or respiratory arrest, attempts at resuscitation would be initiated) and that he/she wanted to be transferred to the Hospital for care, the Facility failed to ensure nursing provided him/her with basic life saving measures including Cardio-Pulmonary Resuscitation (CPR), in an attempt to resuscitate him/her. On [DATE] at approximately 3:50 P.M., Resident #1 was found unresponsive by Nurse #1, he/she was without a pulse or respirations, had no blood pressure and his/her skin was warm to the touch. Nurse #1 and the Nursing Supervisor both checked Resident #1's medical record to determine his/her code status, but misinterpreted what was indicated on his/her Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) Form, thought he/she had elected to be a Do Not Resuscitate (DNR), and therefore did not administer CPR to him/her. Resident #1 was pronounced dead at the Facility. Findings include: Review of the Facility's Policy titled, Cardio-Pulmonary Resuscitation (CPR) Policy, reviewed [DATE], indicated that: - to ensure that licensed nursing staff are trained and ready to provide residents with basic life support, including Cardio-Pulmonary Resuscitation (CPR), Abdominal Thrust Procedure and Automatic External Defibrillator (AED) use, through regular hands-on practice and recognized certification. - licensed nursing staff are educated to initiate CPR as recommended by the American Heart Association (AHA), unless: A. A valid Do Not Resuscitate order is in place. B. The resident presents with obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present. C. Initiating CPR could cause injury or peril to the rescuer. - Licensed nursing staff will maintain current CPR certification for healthcare providers including hands-on skills practice and in person assessment ad demonstration of skills through the American Heart Association (AHA) or the American Red Cross. - Facility will provide education and competency assessment to licensed nurses, related to: - Facility Policy and standards of care related to the initiation and withholding of CPR and other emergency care. - Assessment of signs of irreversible death. - Resuscitation directives/comfort care. - CPR and the use of automated external defibrillators (AED) - Hands-off communication, including resuscitation status. - Related documentation, including the presence or absence of criteria outline by the AHA (signs of irreversible death). American Heart Association 2020 guidelines indicated that the delivery of quality Cardio-Pulmonary Resuscitation(CPR) improves a victim's chances of survival. The critical characteristics of quality CPR include: - If a victim is found unresponsive and in cardio-pulmonary arrest, activate emergency response, and get a defibrillator. - Start compressions within 10 seconds of recognition of a cardiac arrest. - Push hard, push fast. Compress at a rate of at least 100/min. - Allow complete chest recoil after each compression. - Give effective breaths that make the chest rise. - After CPR begins, use an AED as soon as it is available, check the heart rhythm to evaluate if there is a shockable rhythm. AED's can greatly increase the chance of survival. - When a cardiac arrest occurs, the human brain can only survive 4 to 6 minutes without oxygen. After 6 minutes irreversible brain damage or death occurs, but timely CPR can restart the heart and get the victim breathing again. Review of the Massachusetts Board of Registration of Nursing Advisory Ruling on Nursing Practice, titled Nursing Practice and Cardio-Pulmonary Resuscitation, revised [DATE], indicated that to go guide the decision making of the nurse, in context of practice in all settings where healthcare is delivered require initiating cardio-pulmonary 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. 469 except when a patient has a current valid Do Not Resuscitate (DNR) order/status. Resident #1 was admitted to the facility in [DATE], diagnoses included Coronary Artery Disease and Cerebral Vascular Accident (stroke) with left hemiparesis (muscle weakness or partial paralysis on one side of the body), lung cancer, depression and anxiety. Review of Resident #1's Advanced Directives, documented on his/her Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) Form, dated [DATE] and signed by Resident #1, indicated he/she elected to be a Full Code, for nursing to attempt to resuscitation (administer CPR), and he/she wanted to be transferred to the Hospital for treatment. The Form further indicated that Resident #1 had chosen Do Not Intubate (DNI) and Do Not Ventilate (DNV) status. Review of Resident #1's Advance Directives Plan of Care, dated [DATE], indicated Resident #1 was a Full Code. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, (score range of 13 to 15 indicates intact cognition), was able to make him/herself understood and was able to understand others. Review of the Social Worker Progress Note, dated [DATE], indicated she discussed Resident #1's MOLST Form with him/her and Resident #1 said he/she did not want to change his/her MOLST. The Note indicated Resident #1 told the Social Worker that he/she wanted to receive CPR and wanted to go to the Hospital, but that he/she wanted to be a DNI, DNV, did not want a feeding tube and did not want dialysis. During an interview on [DATE] at 4:38 P.M., the Director of Social Services said Resident #1 was his/her own person, and when she spoke to him/her about his/her Advanced Directives, that Resident #1 had said he/she did not want to make any changes to his/her MOLST. The Director of Social Services said, Resident #1 told her he/she wanted to be given CPR and wanted to be transferred to the Hospital for treatment. Review of Nurse #1's Written Witness Statement, dated [DATE], indicated that on [DATE], at approximately 3:50 P.M. he found Resident #1 in bed, he/she had no pulse, was not breathing, and his/her body was still. The Statement indicated Nurse #1 went to Resident #1's medical record to look at his/her MOLST Form to check for Resident #1's Code Status, read that he/she was a DNR and this is why he did not initiate CPR. The Statement indicated he (Nurse #1) immediately called the front desk to overhead page the Nursing Supervisor to come to the Unit STAT. The Statement indicated the Nursing Supervisor called a minute later and he (Nurse #1) told the Nursing Supervisor that he had a dead body, and she should come immediately. During an interview on [DATE] at 1:43 P.M., Nurse #1 said on [DATE] at approximately 3:50 P.M. Resident #1's Significant Other approached him in the hallway and said Resident #1 had stopped breathing. Nurse #1 said when he entered Resident #1's room, Resident #1 was lying in bed in the supine position (lying on his/her back) and the head of the bed was up at a 45-degree angle. Nurse #1 said Resident #1's eyes were opened, he/she was looking straight ahead, his/her lips were closed and Resident #1's skin color had been pale white. Nurse #1 said Resident #1 did not respond to verbal stimuli and he/she had been lying still. Nurse #1 said upon further assessment, he checked Resident #1's right radial pulse, no pulse was present and his/her skin was warm to the touch. Nurse #1 said he placed an pulse oximeter (device that measures the saturation of oxygen carried in your red blood cells, good normal range is 90%-99%) on Resident #1's finger and was unable to detect an oxygen saturation level. Nurse #1 said he was unable to visually see Resident #1's chest rising, that he had placed his hand on his/her chest and Resident #1 was not breathing. Nurse #1 said he placed his finger under Resident #1's nose and was unable to feel any air movement. Nurse #1 said he went immediately to the Nurse's Station to look in Resident #1's medical record to review his/her MOLST Form, and thought it indicated Resident #1's Code Status was a DNR. Nurse #1 said he was in panic mode because he was the only nurse on the unit at the time. Nurse #1 said he called the front desk to overhead page the Nursing Supervisor STAT. Nurse #1 said the Nursing Supervisor immediately called and asked what was wrong. Nurse #1 said he told the Nursing Supervisor that there was a dead resident on the Unit and to come right away. Nurse #1 said he called the Physician to notify them, informed the Physician that Resident #1 was a DNR, had expired in his/her room, had no pulse, and was not breathing. Nurse #1 said the Physician gave him orders for an RN Pronouncement and for them to release Resident #1's body to the Funeral Home. Nurse #1 said when he looked at Resident #1's MOLST Form, he did not look at the entire MOLST Form, looked at the left side of the form and did not see Attempt Resuscitation checked off. Nurse #1 said when he looked at Resident #1's MOLST he read Do Not Intubate and Do Not Ventilate and took it as Resident #1 was Do Not Resuscitate. Nurse #1 said the next day ([DATE]) during the change of shift report, he was informed that Resident #1 Advanced Directive Status had been a Full Code. Review of the Nursing Supervisor Written Witness Statement, undated, indicated approximately 3:50 P.M. she received a call from the front desk to call Nurse #1's Unit STAT. The Statement indicated she called the Unit and Nurse #1 reported Resident #1 was dead. The Statement indicated upon her arrival to the unit, she met with Nurse #1, who said he had reported the death to the on-call Nurse Practitioner, and had obtained an order for a RN pronouncement and to release body to Funeral Home. The Statement indicated she checked Resident #1's physician's orders and proceeded with the RN Pronouncement. During an interview on [DATE] at 3:21 P.M., The Nursing Supervisor said her beeper informed her to call the front desk at approximately 3:50 P.M. The Nursing Supervisor said she was informed to call Nurse #1's Unit STAT, and when she called the Unit, Nurse #1 told her a resident was dead and hung up the phone. The Nursing Supervisor said she went to the Unit and Nurse #1 told her that Resident #1 had died . The Nursing Supervisor said she grabbed Resident #1's medical record, looked at Resident #1's MOLST Form and then she logged onto Point Click Care (PCC, Electronic Medical Record) on the Facility's computer. The Nursing Supervisor said when she logged into PCC, she only reviewed Resident #1's Physician Orders for the RN Pronouncement and to release his/her body to Funeral Home. The Nursing Supervisor said she looked at Resident #1's medical record to compare his/her last name with PCC and to look at his/her Code Status. The Nursing Supervisor said when she looked at Resident #1's MOLST Form, she read transfer to Hospital, Do Not Intubate and Do Not Ventilate. The Nursing Supervisor said she must have mistakenly read Resident #1's MOLST as a Do Not Resuscitate. The Nursing Supervisor said after verifying Resident #1's Physician Order for the RN Pronouncement, she went to Resident #1's room. The Nursing Supervisor said upon assessment of Resident #1, he/she was noted to be without a pulse, respirations, or blood pressure. The Nursing Supervisor said she checked Resident #1's capillary refill (test to check blood flow to the tissues) and that his/her skin color returned quickly, then she turned Resident #1's body side to side to check his/her backside and said that Resident #1's skin was warm to the touch and pink. The Nursing Supervisor said she completed her assessment of Resident #1's and returned to the Nurses Station. The Nursing Supervisor said she did look at Resident #1's MOLST From a second time in order to complete the paperwork for the RN Pronouncement, but said she only glanced at the MOLST. The Nursing Supervisor said she completed the RN Pronouncement and gave it to Nurse #1. The Nursing Supervisor said on [DATE] she received a call from Facility Administration and was informed that Resident #1's elected Code Status (per his/her MOLST Form) was a Full Code, that CPR should have initiated by nursing staff, and that he/she was only a DNI and DNV. The Nursing Supervisor said the Director of Nursing reviewed Resident #1's MOLST Form with her and informed her that she missed the Full Code Status. During an interview on [DATE] at 1:14 P.M., The Director of Nursing (DON) said Resident #1's MOLST Form indicated he/she had elected to be a Full Code, for staff to Attempt to Resuscitate him/her, but Do Not Intubate. The DON said as Licensed Professionals, she would expect that nurses should be able to assess a resident, accurately read the residents' MOLST Form to determine a residents' code status, initiate a Code Blue for a resident who is a Full Code and initiate CPR immediately. The DON said Nurse #1 and the Nursing Supervisor were interviewed at the Facility. The DON said after reviewing the MOLST form with Nurse #1, he said when he looked at Resident #1's MOLST Form, he read Do Not Resuscitate and Do Not Intubate and said that he read the MOLST wrong. The DON said after reviewing Resident #1's MOLST Form with the Nursing Supervisor, she said that she made a mistake, that she read Resident #1's Code Status as a DNR, and then the Nursing Supervisor completed the RN Pronouncement. The DON said she does not know how Resident #1's MOLST Form was not accurately read by Nurse #1 and the Nursing Supervisor since Resident #1's MOLST was clearly marked as him/her being a Full Code and the MOLST Form itself was not damaged or unreadable. The DON said she showed the Nursing Supervisor Resident #1's MOLST several times and the Nursing Supervisor was unable to explain how she interpreted the information as Resident #1 being a DNR. The DON said Resident #1 should have been administered CPR on [DATE] by nursing.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), who was alert, oriented and made his/her own health care decisions, the Facility failed to ensure that he/she was fully informed in advance and given information including the risk and benefits of psychotropic medications prior to their use, when Resident #2 was administered 11 doses of an antianxiety medication by nursing, before obtaining his/her consent to administer the medication. Findings include: Review of the Facility Policy titled, Psychoactive Medication Consent Form Attachment B, dated 4/11/22, indicated that the facility will safeguard the rights or their residents who are prescribed psychotropic medications by establishing a process to obtain informed consent from the resident, resident representative, and/or the resident's health care proxy. The Policy indicated the following; -A psychotropic medication is a medication prescribed to treat symptoms of mental illness; -The Physician (MD)/Nurse Practitioner (NP) will assess the resident and determine if psychotropic medication is indicated, and a diagnosis will be provided; -The residents' capacity to make informed decisions will be determined by the MD/NP; -At the same time as the initial prescription, the prescriber must discuss with the resident or the resident's legal representative the purpose for administering the psychotropic medication; -A facility representative must then document this discussion by completing the form (Attachment B) including all necessary signatures; and -Informed consent must be obtained prior to the administration of the medication. Resident #2 was admitted to the Facility in April 2023, diagnoses included, end stage renal disease, anxiety, depression, anemia, malnutrition, and type 2 diabetes mellitus. Review of Resident #2's Admission Minimum Data Set (MDS) Assessment, dated 5/05/23, indicated he/she was alert, oriented, was his/her own decision maker, and had scored a 15/15 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). Review of Resident #2's Physician's Order, for April 2023, indicated he/she had a new physician's order with an effective date of 4/29/23 for nursing to administer; -Alprazolam (Xanax, antianxiety medication) 0.5 milligrams (mg), administer one tablet by mouth two times daily. Review of Resident #2's Medical Record, indicated that there was no documentation to support that nursing obtained his/her informed consent to be administered Alprazolam, as ordered by his/her physician. Review of Resident #2's Medication Administration Record, dated from 4/29/23 through 5/15/23, indicated he/she received 11 doses of Alprazolam before the facility obtained consent form him/her to administer the psychotropic medication. During an interview on 07/25/23 at 1:07 P.M., the Staff Development Coordinator (SDC) said she conducts orientation with new nurses and agency nurses on informed consent with the use of psychotropic medications and reviews the process during the yearly skills fair for all staff. During an interview on 07/27/23 at 1:05 P.M., Nurse # 6 said upon admission, for residents with physicians orders for for psychotropic medications, a consent form needs to be signed by the resident, or if the residents' Health Care Proxy is invoked then the form would need to be signed by the Health Care Agent. During an interview on 07/24/23 at 2:12 P.M., the Unit Manager said the nurse who admits the resident was responsible for obtaining the informed consent for the administration of psychotropic medications and if unable, the nurse was expected to pass along the information to not administer the medication until consent was received. During an interview on 07/25/23 at 7:59 A.M., Nurse # 2 said a consent form needs to be signed before starting psychotropic medications. During an interview on 07/25/23 at 10:56 A.M., the Director of Nurses (DON) said the expectation the nurses was to obtain written consent and have the form signed for psychotropic medication prior to administering any psychotropic medication. The DON said the written consent for the administration of Alprazolam was not obtained upon admission for Resident #2, or prior to it being administered to him/her.

Based on observation, record review and interviews, the facility failed to ensure that a soft belt restraint was secured effectively to maintain safety and prevent a fall for 1 Resident (#19) in a total sample of 30. Findings include: Resident #19 was admitted to the facility in 9/17/09 with a [DIAGNOSES REDACTED]. Record review on 1/9/12 indicate the following: Fall Risk assessment dated ,[DATE] (2 months prior to fall incident) indicated a total score of 20 (total score of 10 or above represents HIGH RISK). On 1/9/12, record review of the the most recent annual Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) summary score of 3 (0-7=highly impaired cognitive status). MDS also indicated that the resident was not steady for balance and only able to stabilize with assistance of two persons. Review of the 5/11 physician's orders [REDACTED]. Review of the Medication Administration Record indicated that Resident #19 was receiving Seroquel (an antipsychotic medication), 25 mg tablet 1 tablet by mouth in the morning and Lorazepam (a medication to reduce anxiety) 2 mg/ml solution-give 0.5 ml (1 mg) sublingually (under the tongue) twice a day as needed for anxiety. The MAR indicated that on several occasions Resident #19 refused or spit out medications. Review of Resident #19's care plan for falls and restraint use indicated the following: Quarterly fall assessment and as needed. Three half siderails elevated when in bed to define spatial boundaries and assist with mobility, low bed position, family consent for restraint use, personal safety alarm when in bed, check placement and function per policy, soft waist restraint when out of bed, restraint off 12-2 P.M., checks during that time every 15 minutes for 1 week and reevaluate, may remove restraint when family present, OT evaluation for seating to get more comfortable chair, Angel Program, psychiatric follow-up as needed. Record review on 1/9/12 indicated that the resident had a fall on 5/25/11. Review of the incident report of 5/25/11 indicated that staff responded to a yell and Resident #19 was found lying on the floor, next to the recliner chair on left side with soft belt restraint still around waist, restraint ties at his/her back, complaining of rib pain with small bleeding laceration over left eyebrow. Resident #19 was sent to ER. All x-rays were negative including head CT scan. Due to severe osteoporosis, a 11th rib fracture could not be determined. Resident #19 required two sutures to his/her left eyebrow. Review of the Staff Development section of the facility follow-up investigation dated 5/25/11, concluded that resident #19's restraint was unable to be adequately secured while used with recliner because the ties were unable to have the magnus hitch knot as when used in the wheelchair. Review of the staff development interventions dated 5/25/11 include the following: Education to staff not to use restraint in the recliner unless resident is able to have 1:1 visits with family and family requests for the restraint to be applied. All nursing units educated not to apply a restraint if resident in recliner or unable to secure with "magnus hitch knot" Resident to be visible, placed in wheelchair when out of bed Restraint to be used when in a wheelchair, not recliner Attempt nursing ambulation 2-3 times per morning and afternoon shifts Continue monitoring for pain & behaviors and report efficacy of medication changes attempt restraint reduction at a later time On 1/9/12 at 2:30 P.M. the Director of Nursing (DON) said that the CNA appropriately applied the soft belt restraint to Resident # 19 shortly after morning care per daily routine. The DON also said that the soft belt restraint was not a new kind of restraint. The Surveyor asked the DON what he/she thought was the reason for the fall, to which the DON said that the restraint did not have long enough ties to go around the recliner. The Surveyor also asked if the DON was aware of any manufacturer's guidelines regarding the use of a soft belt restraint on chairs other than a wheel chair. The DON said that he/she did not have any newly purchased restraints which would include the manufacturer's recommendations and that there were only 5 current residents using restraints within the facility. The Surveyor interviewed CNA#1 on 1/10/12 at 10 A. M. on the E 2 unit. CNA#1 said that the soft belt restraint was to be used only with a wheelchair and "magnus hitch knot" to reduce the possibility of ties coming loose and for quick release during an emergency. CNA#1 demonstrated how the soft belt restraint should be applied and released to the residents. CNA#1 said that Resident #19's condition had deteriorated and no longer got out of bed to the chair and that it was more comfortable for the resident to be repositioned in bed every two hours. Further interview with the DON on 1/10/12 at approximately 1:30 P.M. said that he/she felt the fall was an unavoidable isolated incident and the resident had no falls before or after the 5/25/11 fall. The DON provided the survey team with the revised Physical Restraint Policy. Review of the Physical Restraint Policy (section 4) revised in 8/11 indicated the following revisions: soft belt restraints and Lap Buddies can only be applied when a resident is in a wheelchair. Magnus Hitch knot to be used with soft belts for resident safety and expedient removal. Physical Restraints are never to be applied when a resident is in bed or recliner or positional chair.

Complaint # ,[DATE] Based on record review and staff interview, the facility failed to ensure that one of three sampled residents (Resident #1), who had restless leg syndrome, was as free from accident hazards as possible. On [DATE] Resident # 1 sustained severe bilateral lower extremity (BLE) lacerations when Resident #1's BLEs got tangled in the bed's upper siderails. CNA #1 said, and the written statement, dated [DATE], indicated that during morning rounds Resident #1 was found bleeding from both legs that were positioned between the unspecified siderail. CNA #1 and CNA #2 said Resident #1 was positioned sideways in the upper bed and the BLEs were positioned beneath the lower rail of the left upper siderail and Resident #1 was moving both legs back and forth rapidly. Findings included: The Hospital Discharge Summary, dated [DATE], indicated that Resident #1 was transferred to the Facility for continued care following an admission from home for treatment of [REDACTED]. Unit Manager #1 was interviewed at 8:00 A.M. on [DATE]. Unit Manager #1 said, and the admission siderail rationale screen, dated [DATE], indicated that Resident #1 requested to have siderails while in bed, and was provided 2 half upper siderails that served as an enabler to promote independence. The admission physician orders, dated [DATE], included 2 siderails (half siderails) up when in bed. The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated that Resident #1 had memory problems and had moderately impaired cognitive skills. The MDS indicated that Resident #1 required supervision during ambulation while using a walker. The MDS indicated that Resident #1 required limited assistance for bed mobility and transfers. The MDS indicated that Resident #1 was able to express needs and was able to understand others. The Director of Rehabilitation was interviewed at 10:30 A.M. on [DATE]. The Director of Rehabilitation said, and the physical therapy (PT) discharge summary, dated [DATE], indicated that Resident #1 was seen for lower extremity therapeutic exercises to facilitate independence in mobility tasks and had met all goals. The Director of Rehabilitation said and the PT discharge note indicated that Resident #1 was independent with bed mobility. The physician telephone orders, dated [DATE], included apply ace wraps to BLE in the AM (morning) and remove in the PM (evening). The physician telephone orders, dated [DATE], included house moisturizer to legs and feet two (BID) times daily and geri-sleeves to BLEs in the PM (evening) after ace wraps were removed. The plan of care updated [DATE], indicated that Resident #1 was at risk for skin breakdown due to decreased mobility and approaches included monitor skin daily while assisting with routine physical care and notify the physician with any changes in skin integrity. The plan of care included geri-sleeves and ace wraps as needed to BLEs due to BLE edema. The Hospice Assessment, dated [DATE], indicated that Resident #1 was admitted for Hospice Care due to end stage pulmonary disease that required continuous oxygen therapy via nasal cannula and the secondary [DIAGNOSES REDACTED]. The Hospice Nursing skin assessment indicated that the skin on Resident #1's BLEs was described as dry and fragile but intact. The Treatment Record dated [DATE], indicated that Resident #1 had geri-sleeves applied on both lower extremities in the evening. Agency Nurse #1 was interviewed at 10:15 A.M. on [DATE]. Agency Nurse #1 said Agency Nurse #1 had worked at the Facility for many years and was familiar with Resident #1's nursing care needs. Agency Nurse #1 said Agency Nurse #1 toileted Resident #1 shortly before 1:00 A.M. on [DATE]. Certified Nurse Assistant (CNA) #1 was interviewed at 10:35 A.M. on [DATE]. CNA #1 said CNA #1 was assigned to Resident #1's personal care needs during the night shift (11:00 P.M. on [DATE] to 7:00 A.M. on [DATE]). CNA #1 said, during the night shift Resident #1 was toileted approximately three times and each time Resident #1 was left resting comfortably in bed with the upper two siderails raised and geri-sleeves on BLEs. CNA #2 was interviewed at 3:30 P.M. on [DATE]. CNA #1 and CNA #2 said they assisted Resident #1 with toileting shortly before 4:30 A.M. and Resident #1 was left resting comfortably in bed. Agency Nurse #1 said Resident #1 was given the antianxiety medication Ativan 0.5 mg at approximately 5:20 A.M. and Resident #1 was left lying on Resident #1's back with the head of the bed elevated about 30 degrees, the 2 upper siderails raised, and Resident #1 had geri-sleeves on the BLEs. CNA #1 said, and the written statement, dated [DATE], indicated that during morning rounds Resident #1 was found bleeding from both legs that were positioned between the unspecified siderail. CNA #1 and CNA #2 said Resident #1 was positioned sideways in the upper bed and the BLEs were positioned beneath the lower rail of the left upper siderail and Resident #1 was moving both legs back and forth rapidly. CNA #1 and CNA #2 said they gently guided the BLEs from beneath the siderail and summoned the nurse. Agency Nurse #1 said, and the nurse's note, dated [DATE], indicated at 5:40 A.M. Resident #1 was found bleeding from the BLEs that had been caught beneath the upper siderail resulting in skin tears of the BLEs. Agency Nurse #1 said the geri-sleeves were cut off to provide first aid. Agency Nurse #1 said, and the nurse's note indicated that the areas were covered with pressure dressings to stop the bleeding and Resident #1 was transfered to the Hospital for evaluation per physician orders. Nursing Supervisor #1 was interviewed at 9:30 A.M. on [DATE]. Nursing Supervisor #1 said Nursing Supervisor #1 was summoned to Resident #1's bedroom and observed 2 nurses giving first aid to both Resident #1's legs while Resident #1 laid in the bed with 2 upper siderails raised and both legs were in constant motion. Nursing Supervisor #1 said Nursing Supervisor #1 assisted with phone calls and paperwork while Agency Nurse #1 provided first aid. The Director of Nurses (DON) was interviewed at 7:30 A.M. on [DATE]. The Director of Nurses said she was notified by Nursing Supervisor #1 of Resident #1's BLE lacerations, and an internal investigation was initiated. The DON said following the incident the DON examined the contents of Resident #1's room, including the bed and siderails, and there was evidence of blood beneath the rounded edge of the lower part of the left upper siderail. The DON said the siderail had no sharp edges. The DON said the clinical record review and staff reviews indicated that Resident #1 was left properly positioned at 5:20 A.M. and unfortunately Resident #1 turned sideways in the bed and placed both legs beneath the upper left siderail and sustained severe bilateral skin lacerations of both anterior shins. The Medical Director was interviewed at 1:00 P.M. on [DATE]. The Medical Director said, and the Medical Director's chart review report, undated, indicated Resident #1 was appropriately placed on Hospice Care and recommendations were followed. The Medical Director said, and the report indicated that Resident #1 had gerigloves on the BLEs due to fragile skin and unfortunately sustained bilateral skin tears of both anterior shins when Resident #1 turned sideways and placed both legs beneath the upper siderail. The emergency room (ER) Report, dated [DATE], indicated that Resident #1 was admitted for evaluation of severe degloving (soft tissue down to the bone was peeled off) injuries of the anterior BLEs that had not lacerated the muscular fascia. The ER Report indicated that Resident #1 had extremely thin skin and was not appropriate for surgery to repair the wounds because Resident #1 was at the end of Resident #1's life and recommendations included pain management, dressing changes to the wounds, and continued hospice services. The Internal Investigation Report, dated [DATE], indicated that: Resident #1 was assessed and immediately transferred to the Hospital for evaluation of severe lacerations to both lower extremities; all staff members on duty that night were interviewed; Resident #1's room and equipment were examined for evidence that could cause injury; interviews indicated that Resident #1 was lying on Resident #1's left side in a fetal position with the left leg beneath the left upper siderail and the right leg on top of the left leg. Family Member #1 was interviewed at 2:30 P.M. on [DATE]. Family Member #1 said the concern was that Resident #1 sustained severe lacerations to both legs that resulted in Resident #1's death on [DATE]. Family Member #1 said the Facility said Resident #1 sustained the injuries because Resident #1's legs got tangled in an upper siderail but refused to provide a copy of the internal investigation or the report they sent to the Department of Public Health (DPH). Family Member #1 said Family Member #1 will make an appointment with the Facility for a meeting to review the cause of the injury once the report from DPH was received.