Every finding on record at Sunny Acres Skilled Nursing and Rehabilitation CTR

Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#32) out of a total sample of 18 residents. Specifically, for Resident #32, the facility staff failed to follow the Physician order's relative to the foley (type of indwelling urinary catheter) catheter size, increasing the Resident's risk for indwelling urinary catheter complications. Findings include: Review of the facility policy titled, Catheter Care, Changing Foley Catheter, revised May 2020, indicated the following: -the Foley catheter will be changed only when needed, unless otherwise specified by the Physician, Nurse Practitioner (NP) or Physician Assistant (PA). -Foley catheters should be changed when: <urinary tract infection is suspected <clogged or unable to irrigate <displaced (balloon [retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body] suspected to be in urethra) <resident discomfort <MD (Medical Doctor/Physician) order Resident #32 was admitted to the facility in May 2023 with diagnoses including urinary retention and obstructive and reflux uropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #32: -was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. -has an indwelling urinary catheter -was dependent on staff for activities of daily living (ADL's- basic skills such as bathing, dressing, eating, etc.). Review of Resident #32's Nursing Notes indicated: -4/1/25: the urinary catheter was found out, balloon was uninflated with 200 ml (milliliters) urine in the closed drainage bag. Urinary catheter reinserted without complications, draining dark yellow urine with another 200 ml out. -4/2/25: change 14 Fr (French scale or system used to size catheters) foley catheter as needed for obstruction. As needed administration was effective. -4/9/25: may flush catheter with 60 cc (cubic centimeters/milliliters) every shift as needed every 8 hours to prevent blockages. Unable to irrigate, new foley [catheter] inserted. Review of Resident #32's May 2025 Physician's orders indicated the following: -Change 14 Fr foley catheter as needed for obstruction or signs and symptoms of infection daily, and as needed daily, start date 11/15/23. -Change 14 Fr foley catheter every month on the 8th of each month every night shift starting on the 8th and ending on the 8th every month with a start date of 4/20/25 -may flush catheter with 60 cc every shift as needed, every 8 hours as needed, to prevent blockages, start date of 8/23/24 Review of Resident #32's Care Plan for Urinary Catheter, last revised 4/14/25, indicated: -has an indwelling urinary catheter related to urinary retention, neurogenic bladder due to CVA, obstructive and reflux uropathy, BPH with lower urinary tract symptoms. -the Resident will remain free from catheter-related trauma through review date. -change continuous drainage bag once weekly for infection prevention. -change indwelling urinary catheter 14 Fr monthly, and once monthly as needed for blockage or leakage. During an interview on 5/4/25 at 9:03 A.M., Resident #32 said that he/she has experienced pain with his/her indwelling urinary catheter. On 5/5/25 at 10:02 A.M., the surveyor and Unit Manager (UM) #1 observed Resident #32's urinary catheter size to be 16 Fr/ 5 ml. During an interview at the time, UM #1 said that Resident #32's urinary catheter size should be 14 Fr according to the Physician's orders but it was not. During an interview on 5/5/25 at 10:23 A.M., the Director of Nursing (DON) said that the Physician's orders relative to Resident #32's urinary catheter size were not followed and the orders should have been followed. The DON also said that there should have been a Physician's order for a balloon size, so that the nursing staff knew what [volume] to inflate the catheter balloon to, but there was no Physician's order for a balloon size. Further review of the medical record failed to indicate documented evidence that the Physician and/or Physician Assistant (PA) had been notified or consulted with to allow for a different sized foley catheter other than the 14 Fr as ordered by the Physician. The medical record also failed to indicate orders for the specific balloon size/volume to be utilized with the foley catheter changes.

Based on interviews, and record reviews, the facility failed to administer Pneumococcal Vaccinations for one Resident (#44) of five applicable residents, out of a total sample of 18 residents. Specifically, for Resident #44, the facility failed to administer Pneumococcal Vaccines when the Resident was eligible to receive, and consented to, the Pneumococcal immunization, putting the Resident at risk of acquiring pneumococcal illnesses. Findings include: Review of the facility's policy titled Resident Pneumococcal Vaccine, undated, indicated the following: -Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician approved pneumococcal vaccination protocol. -Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the CDC guidance titled Pneumococcal Vaccine Recommendations, dated 10/26/24, indicated the following for individuals [AGE] years of age and older: -Administer PCV (Pneumococcal Conjugate Vaccine) 15 (Pneumococcal immunization that protects against 15 types of Pneumococcal disease), PCV20 (Pneumococcal immunization that protects against 20 types of Pneumococcal disease), or PCV21 (Pneumococcal immunization that protects against 21 types of Pneumococcal disease), for all adults 50 years or older: -Who have never received any Pneumococcal Conjugate Vaccine. -Whose previous vaccination history is unknown. -Give one dose of PCV20 or PCV21 at least 1 year after PCV13. 1. Resident #44 was admitted to the facility in February 2022 with diagnoses including Diabetes Mellitus (DM) and acute pyelonephritis. Review of Resident #44's Immunization Record indicated the Resident received a dose of Prevnar 13 Vaccine (PCV13) on 5/17/19 (prior to facility admission). Review of Resident #44's clinical record indicated: -The Resident was greater than [AGE] years of age. -No evidence the Resident had received any Pneumococcal Vaccinations since the dose of Prevar 13 on 5/17/19. -Consent for administration of Pneumococcal Vaccine signed by the Resident on 2/8/22. Review of the CDC PneumoRecs VaxAdvisor online calculator indicated the following recommendation for Resident #44: -Give one dose of PCV20 or PCV21 at least 1 year after PCV13. During an interview on 5/5/25 at 1:10 P.M., the Director of Nursing (DON) said that Resident #44 should have received the Pneumococcal Vaccine, but he/she had not. The DON also said that the Resident had signed a consent for the Pneumococcal Vaccine in 2022 after he/she was admitted to the facility.

Based on observation, and interview, the facility failed to ensure that medications were stored in a safe and secure manner for one unit (Unit 1) out of a total of two units. Specifically, the facility failed to ensure that six over-the-counter medications were not stored in an unlocked drawer at the nurses station where the medications were readily accessible to unauthorized individuals and were at risk for improper temperature, humidity, and light controls. Findings include: Review of the undated facility policy titled Medication Labeling and Storage indicated the following: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use . On 5/6/25 at 8:37 A.M., the surveyor observed Unit Manager (UM) #1 open an unlocked drawer at the nurses station on Unit 1 where the following medications were observed to be stored in the drawer: -one bottle of 8-hour Arthritis Pain (Acetaminophen extended release pain medication) tablets -one bottle of Calcium 600 mg tablets -two bottles of Aspirin 81 mg tablets -one bottle of Beano (anti-gas medication) extra strength tablets -one bottle of GenTeal tears eye drops During an interview on 5/6/25 at 8:38 A.M., UM #1 said that the medications should not have been stored in an unlocked drawer at the nurses station desk because anyone could get into them [access].

Based on record review and interview, the facility failed to honor the rights of two Residents (#33 and #49) out of a total sample of 18 residents, to formulate Advanced Directives (an individual's wishes regarding medical treatment). Specifically, 1. For Resident #33, the facility staff executed a Medical Order for Life-Sustaining Treatment (MOLST - a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders) form that was signed by the Residents' Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) when the Resident continued to be capable of making his/her own health care decisions. 2. For Resident #49, the facility staff executed a MOLST form that was signed by the HCP, which should have been signed by the Resident because the Resident's HCP was not invoked (put into effect - evaluation of capacity by a Physician indicating that a resident is unable to make medical decisions) and the Resident was capable of making his/her health care decisions. Findings include: Review of the Massachusetts Health Care Proxy (HCP - a person who can make health care decisions for you if you are unable to communicate these yourself) form, revised 1/2018, indicated: -that .Your Agent cannot act for you until your Doctor determines, in writing, that you lack the ability to make health care decisions. Review of the facility policy titled Advanced Directives, undated, included: -Upon admission the interdisciplinary team (IDT) assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. -The interdisciplinary team conducts ongoing review of the resident's decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision making capacity. -Changes are documented in the care plan and medical record. Review of the facility policy titled Medical Orders for Life Sustaining Treatment (MOLST), revised 1/2023, indicated: -A qualified Health Care Provider, preferably a Registered Nurse (RN) or Social Worker (SW), may conduct an initial review of the MOLST with the resident, or if the resident lacks decision making capacity the legally recognized agent, within the first required 14-day assessment period as part of the comprehensive assessment and care planning process. 1. Resident #33 was admitted to the facility in April 2023, with diagnoses including Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy) and Type 2 Diabetes Mellitus (DM II - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). Review of the Resident's HCP form dated 1/16/07, provided evidence that the HCP form was signed by the Resident. Review of the Resident's MOLST form, dated 3/22/23, indicated that in the event of cardiac or pulmonary arrest the Resident should not be resuscitated. The form was signed by the Resident's HCP with no indication that the decision was reviewed with the Resident. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Further review of the Resident's clinical record did not provide any evidence that the Resident's capacity or incapacity to make health care decisions was ever evaluated or documented by the Physician. During an interview on 6/25/24 at 4:00 P.M., Social Worker (SW) #1 said that Resident #33 was their own person (able to make their own health care decisions) and that their HCP was not invoked by the Physician, and had never been invoked since admission to the facility. The surveyor and SW #1 reviewed Resident #33's MOLST form and SW #1 said that the MOLST form should not have been signed by the HCP because the HCP was never invoked. SW #1 also said that Resident #33 still made all their own decisions about their care and that the MOLST form should have been reviewed and signed by the Resident. 45429 2. Resident #49 was admitted to the facility in May 2024 with diagnosis including Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty). Review of the Resident's HCP form, dated 5/13/24, provided evidence that the form was signed by the Resident. Review of the Resident's MOLST form, dated 6/1/24, indicated that in the event of a medical emergency the Resident wished to be resuscitated and that all life saving measures should be initiated. The MOLST form was signed by the Resident's HCP with no evidence that the decision was reviewed with the Resident. Review of Resident #49's care plan for Advance Directives initiated 6/3/24, indicated that there was a HCP on file and the HCP was not invoked. Review of the MDS assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 14 out of 15 on the BIMS assessment. Further review of the Resident's clinical record did not provide any evidence that the Resident's capacity or incapacity to make health care decisions was ever evaluated or documented by the Physician. During an interview on 6/24/24 at 5:11 P.M., the surveyor and SW #1 reviewed Resident #49's MOLST form. SW #1 said that the form had been signed by the HCP and should have been signed by the Resident because the Resident's HCP was not invoked.

Based on observation, interview, record review and policy review, the facility failed to provide treatments in accordance with professional standards of practice for one Resident (#64) out of a total sample of 18 residents. Specifically, the facility staff failed to manage hypoglycemic (low blood sugar) episodes as required and implement and perform care and treatment consistent with the Physician orders and professional standards of practice for a Resident with Diabetes Type 1 (DM I - a chronic autoimmune disease that prevents the pancreas from making insulin), when the Resident's blood glucose levels decreased to less than 70 mg/dL on multiple occasions. Findings include: Resident #64 was admitted to the facility in September 2023 with diagnoses including Diabetes Type 1 and hypoglycemia. Review of the facility policy titled Nursing Care of the Older Adult with Diabetes Mellitus, undated, indicated the following: -the Provider will order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. -manage hypoglycemia according to protocols and Provider orders. -call Provider immediately if resident is hypoglycemic (blood sugar less than 70 mg/dL [milligrams per deciliter]). Review of the facility policy for Management of Hypoglycemia, undated, indicated the following: -Signs and symptoms of Hypoglycemia: weakness, dizziness, faintness, restlessness, twitching, tachycardia, pale/cool/moist skin, excessive perspiration, irritability, blurred/impaired vision, headaches, numbness of the tongue/lips, thick speech, stupor, unconsciousness, convulsions and coma. -Level 1 Hypoglycemia (less than 70 mg/dL): give the resident an oral form of rapidly absorbed glucose (15-20 grams), notify the Provider immediately, remain with resident and re-check blood glucose in 15 minutes, if blood glucose is within range provide resident with meal or a snack, if blood sugar remains less than 70 mg/dL repeat blood glucose and notify the Physician for further orders. -Level 2 Hypoglycemia (less that 70 mg/dL): administer glucagon (intramuscular), notify the Provider immediately, remain with the resident, place resident in a comfortable and safe place (bed or chair), monitor vital signs, re-check blood sugar in 15 minutes (as above). -Document the resident's blood glucose before and after intervention. -Note blood sugar after each administration of rapid acting glucose and the follow-up blood sugar. -Record the resident's level of consciousness before and after intervention. -Document Provider instructions. During an interview on 6/24/24 at 9:55 A.M., Resident #64 said that he/she was anxious about the facility's management of his/her blood sugars and that his/her blood sugars were frequently low. The Resident also said that he/she had trouble sleeping at night for fear that he/she would not wake up. Review of Resident #64's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident was cognitively intact as exhibited by a Brief Interview for Mental Status Score (BIMS) of 15 out of a total 15 points. -The Resident was had a diagnosis of Diabetes Mellitus. -The Resident received insulin injections and hypoglycemic medication. Review of Resident #64's Medication Administration Records (MAR) indicated blood glucose levels of less than 70 mg/dL on the following dates: -1/16/24: 66 mg/dL -1/23/24: 65 mg/dL -2/2/24: 59 and 65 mg/dL -3/10/24: 46 mg/dL -3/12/24: 46 mg/dL -4/1/24: 59 mg/dL -4/3/24: 68 mg/dL -4/10/24: 55 mg/dL -4/27/24: 54 mg/dL -4/30/24: 56 mg/dL -5/7/24: 66 mg/dL Review of Resident #64's MAR and progress notes indicated that nursing staff did not initiate the hypoglycemic protocol or notify the Physician regarding the Resident's low blood glucose levels during any of the dates documented above. Review of Resident #64's care plan for Diabetes Mellitus created 10/12/23, and last revised 6/5/24, indicated: -Monitor blood glucose levels as ordered. -Administer medications as ordered. -Assess for signs and symptoms hyperglycemia (high blood sugar) and hypoglycemia. Review of Resident #64's care plan for hypoglycemia created 10/12/23, and last revised 6/5/24, indicated: -Administer medications as ordered. Evaluate/record/report effectiveness/adverse side effects. -Monitor blood glucose as ordered. -Monitor for signs of hypoglycemia. -Provide diabetic snacks as ordered. Review of Resident 64's Physician's orders for June 2024, indicated that there were no orders in place for the following treatment and management of the Resident's diabetic care until 6/24/24 (the start date of the facility's recertification survey): -assess and monitor Resident response to hypoglycemic treatment. -check finger-stick blood glucose every 15 minutes until emergency services arrives. -diabetic foot care. -if blood sugar is greater than 400, recheck and notify Physician. -if finger stick blood sugar is less than or equal to 70 mg/dL and Resident is responsive and able and willing to swallow, treat with 15 to 20 grams of carbohydrates and assess finger stick blood sugar in 15 minutes. -offer diabetic snack at hour of sleep. -monitor for signs and symptoms of hypo/hyperglycemia every shift. -may check blood sugar as needed for signs and symptoms of hyper/hypoglycemia. Notify Physician if less than 70 mg/dL or greater than 350. -GlucaGen HypoKit (ready to use rescue pen) Solution Reconstituted 1 mg- inject 1 mg intramuscularly as needed for blood sugar less than 70 mg/dL if resident is not responsive or not able and willing to swallow. -Insta-Glucose (simple sugar used to treat very low blood sugar)- give one application by mouth as needed (PRN), with a start date of 6/25/24 During an interview on 6/25/24 at 4:21 P.M., Unit Manager (UM) #1 said that the Physician should be notified if a resident's blood sugar is below 70 mg/dL and it should be documented in the nursing progress notes. During a follow-up interview on 6/25/24 at 4:51 P.M., UM #1 said that there was no documentation in Resident #64's nursing progress notes addressing the treatment of the Resident's low blood sugars and there should have been per the facility policy. During an interview on 6/26/24 at 1:40 P.M., the Director of Nursing (DON) said that Resident #64's Physician's orders for diabetic care should have been in place and they were not in place until 6/24/24. The DON also said that the Nurses should have been following the facility policy and contacted the Physician when the Resident's blood sugar fell below 70 mg/dL, and documented this in the nursing progress notes and they did not as required.

Based on record review and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, review of the facility's Licensed Nurses schedule and interviews indicated that the facility failed to have an RN working at least eight consecutive hours over a 24-hour period for four days between 5/26/24 - 6/22/24, when no nursing staff waivers were in place. Findings include: Review of the Nursing Staff Schedule provided by the facility dated 5/26/24 - 6/8/24, indicated no evidence of any RN coverage in the facility on 6/1/24, 6/2/24, and 6/8/24. Further Review of the Nursing Staff Schedule dated 6/9/24 - 6/22/24, indicated there was no evidence of any RN coverage in the facility on 6/16/24. During an interview for the facility entrance conference meeting on 6/24/24 at 8:19 A.M., the Administrator said there were no nursing staff waivers in place. During an interview on 6/26/24 at 9:53 A.M., Nurse #1, an LPN who was scheduled to work 6/1/24 and 6/2/24 said she could not recall those specific days. Nurse #1 said if there was no RN in the building and an RN was needed, there was always an RN on-call who the staff could contact. Nurse #1 did not indicate who the on-call RN would be. During an interview on 6/26/24 at 2:26 P.M., the Director of Nursing (DON) said there was no payroll evidence that the required RN coverage was provided in the facility on 6/1/24, 6/2/24, 6/8/24, and 6/16/24, because there was no RN working in the facility on any of those dates.

Based on observation, interview, record and policy review, the facility failed to implement Contact Precautions (use of gloves and a gown for all interactions with a resident and their environment) to prevent the potential transmission of communicable diseases (a disease or infection that is easily spread from one individual to another) and infections within the facility for two Residents (#49 and #58), out of a total sample of 18 residents. Specially, the facility failed to: 1) For Resident #49, ensure that staff: -wore the required Personal Protective Equipment (PPE - items used to prevent the spread of infection such as gowns, gloves, face masks) while caring for the Resident with Clostridium difficile (C. diff- a bacterium that causes an infection of the colon [the longest part of the large intestine]. Symptoms can range from diarrhea to life-threatening damage to the colon) and Contact Precautions were indicated. -performed the appropriate hand hygiene (hand washing with soap and water) for C. diff after exiting the Resident's room. 2) For Resident #58, ensure that staff: -implemented the required PPE in a timely manner when the Resident was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA: strain of gram-positive bacteria resistant to several antibiotics, making it difficult to treat, which spreads through contact with infected individuals) in the urine and Contact Precautions were indicated. Findings include: Review of the facility policy titled Transmission-Based (Isolation Precautions) dated 2023, indicated the following: -It was the facility's policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. -Transmission-Based Precautions (TBP) refer to actions implemented in addition to Standard Precautions that are based upon the means of transmission in order to prevent or control infections. -Contact Precautions- refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or residents' environment. -The facility will use standard approaches, as defined by the CDC (Centers for Disease Control and Prevention) for transmission-based precautions. -An order for Transmission-Based Precautions will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. -Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room . -Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. -Recommendations for Clostridium difficile (C. diff) - hand hygiene with soap and water. 1) Resident #49 was admitted to the facility in May 2024, with diagnoses including C. diff, colostomy (a surgical procedure that creates an opening for the colon through the abdominal wall) status and adult failure to thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment). Review of the CDC Guidelines for the Prevention of C. diff, dated 3/6/24, indicated that washing your hands with soap and water is the best way to prevent the spread of the infection. Review of Resident #49's care plan for C. diff infection, initiated on 5/31/24, indicated the following interventions: -I need good handwashing. -I need to use soap and water to wash my hands. -I cannot use anti-bacterial gels to clean my hands. -maintain Contact Precautions. On 6/26/24 at 8:57 A.M., the surveyor observed CNA (Certified Nurses Aide) #1 enter Resident #49's room which had a Contact Precautions sign posted outside of the room. The Contact Precautions sign indicated to put on (don) a gown and gloves and to perform hand hygiene (with alcohol-based hand rub) before entering the room and to take off (doff) the gown and gloves and perform hand hygiene (the sign did not specify soap and water for C. diff as required) after exiting the Resident's room. The surveyor observed CNA #1 enter the room without donning PPE, take the Resident's eaten breakfast tray from their bedside table, exit the room and place the tray on a cart. The surveyor observed that CNA #1 did not wash her hands after exiting the Resident's room. During an interview at the time, CNA #1 said that she did not understand how it was possible for her to pick up the Resident's dirty tray and also hand wash after she left the Resident's room. During an interview on 6/26/24 at 9:02 A.M., Unit Manager #1 said that staff should wear the PPE documented on the sign outside of Resident #49's room and should hand wash after exiting the room as well. On 6/26/24 at 11:58 A.M., the surveyor observed CNA #1 enter Resident #49's room with the appropriate PPE donned. CNA #1 then took off the PPE and exited the room, performed hand hygiene with alcohol-based hand rub and did not handwash with soap and water. During an interview at the time, CNA #1 said that she was unaware of what communicable disease the facility was trying to prevent the spread of. During an interview on 6/26/24 at 12:04 P.M., CNA #2 said that the nursing staff at the facility inform the CNA's what to do for hand hygiene. CNA #2 said the CNA's were told that it was okay to use alcohol-based hand hygiene to enter and exit Resident #49's room. On 6/26/24 at 12:05 P.M., the surveyor observed CNA #3 enter Resident #49's room with the appropriate PPE donned. The surveyor observed CNA #3 enter the Resident's bathroom, handle the Resident's linens and place them in the bathroom. CNA #3 was observed to then pick up a drinking cup and medication cup which she then discarded in the trash. CNA #3 removed her PPE in the room and exited the room to perform hand hygiene using alcohol-based hand rub. CNA #3 did not wash her hands with soap and water after exiting the room. During an interview on 6/26/24 at 12:10 P.M., CNA #3 said that there has never been a time where nursing staff have informed the CNA's to use soap and water instead of the alcohol-based hand rub. During an interview on 6/26/24 at 2:51 P.M., the Infection Preventionist (IP) said that the staff should have worn the appropriate PPE when entering Resident #49's room and washed their hands with soap and water after exiting the room. 42761 2) Review of the Center for Disease Control and Prevention's (CDC) guidelines titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs: germ that is resistant to many antibiotics), dated 4/2/24, indicated the following relative to Contact Precautions: -Use Contact Precautions for all residents infected or colonized with a MDRO in any of the following situations with excretions that are unable to be contained. -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves). Review of CDC guidelines titled, Preventing Methicillin-resistant Staphylococcus aureus (MRSA: an MDRO), dated 4/12/24, indicated: -MRSA can survive on some surfaces for hours, days or even weeks. -MRSA can spread to people who touch a contaminated surface (a place where the germ lives or is present). -MRSA prevention efforts can reduce infections. Resident #58 was admitted to the facility in June 2024, with a diagnosis of Urinary Tract Infection (UTI: bacterial infection in any part of the urinary system). Review of Resident #58's Urine Culture Results, reported to the facility on [DATE], indicated the Resident was positive for a MRSA infection in his/her urine. Review of Resident #58's June 2024 Certified Nurses Aide Flow Sheets indicated the Resident was incontinent of urine and was dependent on facility staff for toilet hygiene on 6/23/24 and 6/24/24. Review of Resident #58's clinical record indicated no evidence that an order for Contact Precautions had been obtained. On 6/24/24 at 9:50 A.M., the surveyor observed Resident #58 lying in bed in his/her room. The surveyor observed that no signage was posted on the Resident's door or wall outside the room to indicate the need for use of Contact Precautions. On 6/24/24 at 9:54 A.M., the surveyor observed two staff members adjust the position of Resident #58's bed then assisted Resident #58 to reposition in bed by handling the Resident's body and the Resident's bed linens. The surveyor then observed one of the staff members handle items on the Resident's night stand and bedside table, then assisted the Resident to consume liquids. Neither staff member wore a gown or gloves while assisting the Resident with personal care. On 6/25/24 between 9:13 A.M. and 11:00 A.M., the surveyor observed the following: -Resident #58 was lying in bed. -Staff members entered and exited the room each time the call light was activated and handled items in the Resident's room. -No staff were observed to wear a gown or gloves when they entered the Resident's room. -No signage was observed to be posted on the Resident's door or wall outside the room to indicate the need for use of Contact Precautions. On 6/26/24 at 9:24 A.M., the surveyor observed that a Contact Precautions sign posted outside of Resident #58's room door. The surveyor observed Nurse #3 put on a gown and gloves when she entered the room. During an interview on 6/26/24 at 9:50 A.M., Nurse #3 said that Resident #58 had been placed under Contact Precautions that morning for a MRSA infection in his/her urine. During an interview on 6/26/24 at 2:51 P.M., the Infection Preventionist (IP) said if she was not in the facility and an infection or MDRO that required implementation of Contact Precautions was identified, the Nurse was required to implement those precautions. The IP said she was not in the facility on 6/23/24 when Resident #58's urine culture results were faxed to the facility, identifying that the Resident was positive for a MRSA infection. The IP said the Nurse that received the fax should have implemented Contact Precautions for the Resident on 6/23/24, when the fax was received, but this was not done. The IP then said Contact Precautions for Resident #58 were not implemented until the morning of 6/26/24 because that was when she was alerted that the Resident was positive for a MRSA infection in his/her urine, but the Contact Precautions should have been implemented on 6/23/24.

Based on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards of practice for two Residents (#56 and #58) out of a total sample of 18 residents. Specifically, the facility staff failed to: 1. off-load (minimizing or removing weight placed on the foot to help prevent and heal ulcers) Resident #58's heels when the Resident was in bed, had been identified as being at risk for skin breakdown, and had an active Physician's order to off-load his/her heels when in bed, increasing the Resident's risk for developing a pressure injury (PI: meaning an area of damage to skin or underlying soft tissue, usually over a bony prominence, as a result of prolonged pressure). 2. follow the Physician's order for Resident #56 not to exceed three grams (3 g: 3,000 milligrams [mg]) of Acetaminophen administration in a 24-hour period when facility staff administered 3,650 mg of Acetaminophen to the Resident in one 24-hour period. Findings include: 1. Review of the John Hopkins Medicine document titled, Pressure Injuries, dated 2024, (https://www.hopkinsmedicine.org/health/conditions-and-diseases/pressure-ulcers), indicated the following relative to the prevention of Pressure Injuries (PI): -Pressure injuries are most likely to occur in older adults, particularly those who live in nursing homes. -When you rarely move, your body weight restricts the blood flow to your arms, legs, neck, and back. -The lack of blood flow to the skin and tissues under the skin may cause them to break down. -Pressure injuries tend to surface on parts of the body where the skin is mashed between a bone and a surface such as a . mattress. -To prevent pressure injuries, relieve pressure on the skin . -If in bed, raise your heels slightly off the mattress . Resident #58 was admitted to the facility in June 2024, with diagnoses including: fracture of greater trochanter of the right femur (right hip fracture), chronic pain syndrome, abnormal weight loss, and need for assistance with personal care. Review of Resident #58's active Physician's order dated 6/7/24, indicated: -Off-load heels while in bed, every shift. Review of Resident #58's Potential for Pressure Ulcer Development Care Plan initiated 6/7/24, indicated the following: -The Resident had potential for pressure ulcer development related to decreased mobility . -The Resident's goal was to have intact skin, free of redness . or discoloration by/through the review date of 7/2/24. -The Resident required assistance from staff for repositioning. -The Resident required the use of pressure relieving/reducing devices. Review of Resident #58's Activities of Daily Living (ADL) Care Plan, dated 6/7/24, indicated the following: -The Resident had a self-care performance deficit. -The Resident required moderate assistance from two staff for turning and repositioning in bed. Review of Resident #58's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total points. On 6/24/24 at 9:54 A.M., the surveyor observed Resident #58 lying on his/her back in bed. The surveyor further observed that the foot of the Resident's bed was elevated, the Resident's knees were slightly bent, and his/her heels were in direct contact with the mattress (not off-loaded). During an interview at the time, Resident #58 said he/she had pain everywhere and that his/her back and feet hurt the most. On 6/24/24 at 9:59 A.M., the surveyor observed two staff members repositioning Resident #58 in his/her bed. The surveyor observed staff lowering the foot of the bed, lifting the Resident's body up toward the head of the bed, then elevating the head of the bed. The surveyor did not observe any intervention provided to off-load the Resident's heels and his/her heels remained in direct contact with the mattress. One staff member was observed to assist the Resident to consume a drink, then both staff members left the room. The surveyor did not observe either staff member address and offer any intervention to off-load the Resident's heels before leaving the room. On 6/25/24 at 10:30 A.M., the surveyor observed Resident #58 lying in bed with his/her head slightly elevated. The surveyor further observed that the foot of the bed was in a flat position and the Resident's heels were in direct contact with the mattress. During an interview at the time, Resident #58 said no one offers to put anything under his/her legs to lift his/her heels off the mattress. Resident #58 further said that his/her heels hurt sometimes and that his/her right heel hurt like electricity or fire. The surveyor did not observe any positioning devices in Resident #58's room for off-loading the Resident's heels while in bed. On 6/25/24 at 11:00 A.M., the surveyor and the Director of Nursing (DON) observed Resident #58's right heel. The DON lifted the Resident's right heel off the mattress and the surveyor observed that the Resident's heel was red while the rest of the Resident's foot was not discolored. The DON used her finger to apply pressure to the Resident's right heel. The skin on the heel blanched (turned white), but looked soft, then returned to red when the DON removed the pressure of her finger. During an interview at the time, the Resident said his/her right heel hurt sometimes, that the pain felt like the nerves were sore, and said, like zip-zap. During an interview at the time, the DON said the Resident's right heel was red and boggy (abnormal tissue texture characterized by sponginess that can result from pressure to the area). The surveyor and the DON reviewed Resident #58's Physician's orders for off-loading the Resident's heels when the Resident was in bed. The DON said staff should have used some pillows under the Resident's lower legs to off-load the Resident's heels in bed, unless a different type of specialized device to off-load his/her heels was indicated. The surveyor observed no additional pillows or devices for off-loading Resident #58's heels in the Resident's room at the time. During an interview on 6/25/24 at 11:51 A.M., Nurse #2 said he was assigned to provide care for Resident #58 on 6/24/24 and 6/25/24. Nurse #2 said Resident #58 did not report right heel pain on 6/24/24, but reported pain in his/her right heel during the morning of 6/25/24. Nurse #2 further said the Resident described the pain to feel like electricity. Nurse #2 said he thought the Resident was experiencing nerve pain based on the Resident's pain description, so he provided the Resident with some pain medication, but he did not assess the position or condition of the Resident's heel. 2. Review of the facility's policy titled, Administering Medications, dated April 2019, indicated the following: -Medications are administered in accordance with Prescriber orders, including any required time frame. -If a dosage is believed to be inappropriate or excessive for a resident, . , the person preparing or administering the medication will contact the Prescriber, the resident's Attending Physician, or the facility's Medical Director to discuss the concerns. Review of Harvard Medical School's document titled, Acetaminophen Safety: Be Cautious but not Afraid, dated 4/3/24, (https://www.health.harvard.edu/pain/acetaminophen-safety-be-cautious-but-not-afraid) indicated: -it is safest for individuals to take only what is needed, and not to exceed 3,000 mg of Acetaminophen use per day, especially when one uses Acetaminophen often. -Taking too much Acetaminophen can damage the liver, sometimes leading to a liver transplant or death. -The body breaks down most of the Acetaminophen in a normal dose and eliminates it in urine Some of the drug is converted into a toxic byproduct .If too much Acetaminophen is taken - all at once or over a period of days-more toxin can build up than the body can handle. Resident #56 was admitted to the facility in May 2024 with diagnoses including: Polyosteoarthritis (Arthritis in five or more joints at the same time) and Left Acetabulum (hip joint) fracture. Review of Resident #56's MDS assessment dated [DATE], indicated that the Resident was severely cognitively impaired as evidenced by a BIMS score of three out of 15 total points. Review of Resident #56's June 2024 Physician's orders indicated the following active orders: -Acetaminophen Oral Tablet 500 mg; give 2 tablets by mouth every 8 hours for pain, initiated 5/25/24. -Acetaminophen Tablet 325 mg; give 2 tablets by mouth every 6 hours as needed (PRN) for pain. Do not exceed 3 g (grams) of Acetaminophen/24 hours, dated 5/25/24. -Acetaminophen Tablet 325 mg; give 2 tablets by mouth every 6 hours as needed (PRN) for temp (temperature) 100 F (Fahrenheit) or above. Do not exceed 3 g of Acetaminophen/24 hours, dated 5/25/24. Review of Resident #56's Pain Care Plan, initiated 5/26/24, indicated the following: -The Resident had pain related to a fall with fracture and Osteoarthritis. -Staff were to administer analgesia (pain medication) as ordered. Review of Resident #56's June 2024 Medication Administration Record (MAR) indicated the following: -The Resident received all scheduled doses of Acetaminophen (3 g) each 24-hour period. -Staff administered one as needed (PRN) dose of two 325 mg (total = 650 mg) Acetaminophen tablets on 6/13/24. -The Resident's total dose of Acetaminophen when the as needed (PRN) dose was administered on 6/13/24 was 3,650 mg (500 mg (2 tablets) x 3 = 3000 mg + 650 mg = 3650 mg ) in excess of 3 g/3000 mg). During an interview on 6/26/24 at 9:50 A.M., Nurse #3 said all residents with orders for Acetaminophen have an order not to exceed 3 g in a 24-hour period due to the effects excess dosing of Acetaminophen can have on the liver. Nurse #3 said if a resident had already received 3 g of Acetaminophen in a 24-hour period and had pain or fever, she would look in the resident's Physician's orders for an alternate medication to treat the symptoms. Nurse #3 said if an alternate medication was not ordered, she would call the Physician and obtain new orders. The surveyor and Nurse #3 reviewed Resident #56's June 2024 MAR and the Acetaminophen administration for 6/13/24. Nurse #3 said the Resident was administered Acetaminophen in excess of the dosage allowed by the Physician's order. During an interview on 6/26/24 at 10:00 A.M., the DON said residents' electronic health records (EHR) did not contain alerts for staff to indicate when the residents had already received the maximum doses of ordered medications. The DON said it was the Nurse's responsibility to review the medications already administered to determine whether an as needed (PRN) medication could be administered. The surveyor and the DON reviewed Resident #56's June 2024 MAR and the DON said staff had administered Acetaminophen to Resident #56 on 6/13/24 in excess of the dose ordered by the Physician.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert, oriented and able to make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner by staff, when on 2/19/23 after Nurse #1 was made aware that Resident #1 had sustained a skin tear and wanted a bandage applied to the area, Nurse #1 told Resident #1 he/she would have to wait, and that it would be his/her (Resident #1) fault that she (Nurse #1) would not get a dinner break that night. Resident #1 said Nurse #1 was rude and disrespectful to him/her that night, and that it had not made him/her feel very good. Findings include: The Facility's Policy titled, Resident Rights, undated, indicated that employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents. These rights include the resident's right to a dignified existence and to be treated with respect, kindness, and dignity. Resident #1 was admitted to the Facility in February 2023, with diagnoses that included unspecified macular degeneration, unspecified glaucoma, hypertension, and cerebrovascular disease. Review of Resident #1's most recent Minimum Data Set Assessment, dated 02/09/23, indicated his/her cognitive patterns were intact, and he/she was able to make his/her needs known to staff. The Facility's Internal Investigation, dated 02/20/23, indicated that on 02/19/23, during the 3:00 P.M. to 11:00 P.M. shift, Resident #1 sustained a right-hand skin after using the toilet, that Certified Nurse Aide (CNA) #1 informed Nurse #1 of the injury, and that it was alleged that when Nurse #1 went to Resident #1's room, she was rude and disrespectful to him/her. The Investigation indicated that when Nurse #1 went to Resident #1's room, she said to him/her, Do you realize as a result of you calling me in, I'm not going to get my dinner break. You will have to wait! During an interview on 03/15/23 at 2:40 P.M., Resident #1 said that on 02/19/23, CNA #1 assisted him/her to the toilet and that he/she asked CNA #1 for privacy. Resident #1 said that by accident, he/she cut the back of his/her right hand on the toilet paper holder. Resident #1 said CNA #1 noticed blood on his/her hand and told him/her she would get the nurse. Resident #1 said that when Nurse #1 came in, she was rude and said, Do you realize as a result of you calling me in, I'm not going to get my dinner break. You will have to wait! Resident #1 said Nurse #1 left the room, and did not return until sometime later (exact time unknown). Resident #1 said when Nurse #1 finally came back to put a bandage on his/her hand, that Nurse #1 had an attitude. Resident #1 said it was disrespectful and wrong for Nurse #1 to say what she said, and that it had not made him/her feel very good. During an interview on 03/21/23 at 10:20 A.M., Certified Nurse Aide (CNA) #1 said on 2/19/23, during the evening shift (exact time unknown) she notified Nurse #1 that Resident #1 had a skin tear and that she explained to Nurse #1 how Resident #1 sustained the skin tear. CNA #1 said, after she spoke to Nurse #1, she returned to Resident #1's room to assist him/her back to bed. CNA #1 said when Nurse #1 came into Resident #1's room, she did not seem pleased and that Nurse #1 let Resident #1 know that this was an inconvenient time for her to deal with him/her. During an interview on 03/27/23 at 9:35 A.M., Nurse #1 denied speaking to Resident #1 in a disrespectful or undignified way that night. Nurse # said she believed the Management Team wanted to terminate her, so she decided to resign. During an interview on 03/28/22 at 11:35 A.M., the previous Director of Nursing (DON) said that on 02/20/23, she received a call from Resident #1's daughter who reported that Resident #1 had a difficult night (on 2/19/23). The DON said she interviewed Resident #1, who reported that he/she had gotten a skin tear after using the toilet. The DON said CNA #1 who had been assisting Resident #1 with care that night, assured Resident #1 she would get the nurse, and that CNA #1 had notified Nurse #1 right away that Resident #1 had sustained a skin tear. The DON said Resident #1 told her that when Nurse #1 came to his/her room she said, Do you realize as a result of you calling me in, I'm not going to get my dinner break. You will have to wait!. The DON said when they met with Nurse #1 regarding the alleged incident, that Nurse #1 denied the allegation, refused to provide a written statement, and resigned immediately. The DON said that she believed that Nurse #1 was overwhelmed at the time, but said that Nurse #1 more than likely said those words to Resident #1 that night.

Based on interview, the facility failed to ensure its staff designated an Infection Preventionist (IP) who had completed specialized training in infection prevention and control prior to assuming the role of IP at the facility. Specifically, the facility designated an IP in November 2022 who had not completed specialized training in infection prevention and control before assuming the IP role, still had not completed the specialized training by the time survey began in February 2023 and continued to work as the designated IP at the facility. Findings include: During an interview on 2/22/23 at 7:52 A.M., the Director of Nurses (DON) said the facility's designated IP had not yet completed specialized training in infection prevention and control as required. During an interview on 2/24/23 at 11:07 A.M., the IP said she started working at the facility in November 2022, was designated as the facility's IP at that time, and that she continued to work in that role. The IP said she had not completed specialized training in infection prevention and control prior to starting at the facility and that she had not yet completed the training. The IP said there was a nurse consultant at the facility daily who had specialized training in infection prevention and control and assisted in overseeing processes at the facility, but that the nurse consultant was not the designated IP. During a follow-up interview on 2/27/23 at 10:30 A.M., the DON said the nurse consultant's role was to manage the facility and provide assistance as needed. The DON further said the designated IP was the employee who was hired and assumed the IP role in November 2022, but had not yet completed specialized training in infection prevention and control.

Based on observation, record review, and interview, the facility failed to ensure its staff implemented infection control practices relative to 1) the facility's water management program, to provide a safe, sanitary, and clean water supply, for all residents and staff, and 2) required hand hygiene practices during care of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) for one Resident (#54), out of a total sample of 18 residents. Specifically, the facility failed to ensure its staff: a) cleaned the ice machine every three months, as indicated in the facility's water management program, as an intervention to prevent waterborne pathogens, and b) implemented proper hand hygiene practices before and after glove use during a dressing change for Resident #54's pressure ulcer. Findings include: 1. The facility failed to ensure a safe, sanitary, and clean water supply for residents and staff when its staff failed to clean the ice machine every three months, as required, when the ice from the ice machine was used for resident and staff consumption. Review of the facility's Water Management Plan, dated May 2022, included the following: -The facility would establish a water management program that incorporated routine monitoring, inspection, and infection control measures to provide a safe, sanitary, and clean water supply. -The water management program would inhibit and decrease microbial growth and opportunistic pathogens in the facility's water supply. -The risk area assessment included the facility's ice machine. -The ice machine was to be cleaned every three months. During an interview on 2/24/23 at 1:08 P.M., the Infection Preventionist (IP) said she located no evidence the ice machine was cleaned every three months as required. On 2/24/23 at 1:17 P.M., the surveyor observed an ice machine in the facility's kitchen. At this time, the Food Service Director (FSD) said there was an ice machine in the staff break room, but it was not working. He said a new ice machine had been installed in the kitchen approximately nine to 10 months prior, in the spring of 2022. The FSD said the ice from this machine was used daily in: a) residents' daily water cups, b) coolers on both resident units for resident drinks, and c) a cooler in the staff break room for staff use. The FSD also said there had been discussion at the facility about cleaning the ice machine, but this had not been done since the ice machine was installed. 44222 2. For Resident #54 the facility staff failed to perform hand hygiene after doffing (removing) gloves and before donning (putting on) gloves while performing wound care treatment. Findings include: Review of the Department of Public Health Memorandum titled Comprehensive Personal Protective Equipment (PPE) Guidance, dated January 21, 2022, indicated that HCP (healthcare personnel) should perform hand hygiene prior to donning and after doffing gloves. Review of the facility policy titled Personal Protective Equipment: Glove Use, revised 10/2022, indicated: -Objective to prevent wounds from contamination -Wash hands after removing gloves. (Note: Gloves do not replace hand washing) Resident #54 was admitted to the facility in February 2022 with diagnoses including Osteomyelitis (an infection of the bone) of vertebra, sacral and sacrococcygeal (located at the bottom of the spine or tailbone) region, pressure area (skin damage caused by unrelieved pressure when soft tissue is compressed between a boney prominence and an external surface for a prolonged time) of sacral region. Review of the February 2023 Physician's orders indicated: Cleanse sacral wound with wound cleanser, apply Santyl (an ointment that removes dead tissue from wounds) Alginate (a substance that provides a moist environment and promotes wound healing), and border foam dressing daily and as needed (PRN). On 2/27/23 at 11:00 A.M., the surveyor observed Nurse #2 perform the wound care treatment for Resident #54's sacral area. After gathering supplies Nurse #2 doffed her gloves, did not perform hand hygiene, and donned new gloves. Nurse #2 then cleansed the sacral area, doffed her gloves, did not perform hand hygiene, and donned another pair of gloves. Nurse #2 completed the wound care treatment, doffed her gloves, did not perform hand hygiene, donned another pair of gloves, and rendered aid to the Resident. During an interview on 2/27/23 at 11:10 A.M., Nurse #2 told the surveyor that she should have washed her hands in between glove changes but there was no hand sanitizer handy. During an interview on 2/27/23 at 11:15 A.M., the Director of Nurses (DON) told the surveyor that the staff should always perform hand hygiene in between the donning and doffing of gloves.

Based on observation, policy review, and interview, the facility failed to ensure its staff maintained a clean and sanitary environment in the kitchen where food items were stored for resident consumption. The facility also failed to ensure its staff adhered to food storage requirements in the kitchen. Specifically, the facility failed to ensure its staff: 1) labeled and dated all open food stored for resident consumption, in the kitchen's reach-in refrigerator and freezer, 2) kept scoops from directly touching the ice and rice, 3) maintained a sanitary surface where clean dishes and pans were stored, and 4) maintained the microwave to be free of dried food and debris. Findings include: Review of the facility's policy, Food Use and Storage, dated 10/2022, indicated the following: It is the policy of the facility to provide safe and sanitary storage of all foods. The food service workers, cooks, dietary aides, dishwashers, food prep aides, and any person working in the kitchen is responsible to adhere to the food safety requirements. -Leftovers should be labeled, dated, and used within three days. 1. On 2/22/23 at 7:15 A.M., the surveyor observed the following in the kitchen: a) In the reach-in freezer: -a brown paper bag covered in clear plastic wrap, not labeled or dated. -an open package of chicken patties, not labeled or dated. -an open package of eggplant slices, not labeled or dated. b) In the reach-in refrigerator: -shelves with debris and crumbs -four separate slices of lemon pie, covered in plastic wrap, not labeled or dated -pan of jelly, not labeled or dated. c) The bin of rice was labeled rice but not dated. 2. The ice scoop was inside the ice machine, laying directly on the ice cubes. The rice scoop was inside the bin of rice, laying directly on the rice. 3. The bottom shelf on the food preparation table was dirty with crumbs, dried splatters, and debris. Clean dishes and pots were stored on top of the dirty surface. During an interview on 2/22/23 at 7:28 A.M., the Food Service Director (FSD) said all foods should have been labeled and dated, including the open bags of eggplant and chicken patties. He said the brown paper bag held tater tots and should have been labeled and dated, along with the lemon pie slices and pan of jelly. He further said the food should be used within three days. The FSD said all of the scoops should be on a hook and not touching ice or rice, he said the bin of rice should have been dated. He looked at the bottom shelf of the food prep tables that had visible crumbs, splatters, debris and said the shelf should have been clean. The surveyor asked the FSD if he had a cleaning schedule or maintained logs to ensure the cleaning was done. The FSD said he did not have a cleaning schedule or logs. 4. On 2/22/23 at 7:39 A.M., the surveyor observed the microwave in the food service area (between the kitchen and resident dining room) with dried splatters of food on the inside of the door and the rotating dish. Dietary Aide #1 said there was no set person to clean the microwave, the staff took turns. She said the microwave should be clean.

Based on record review and interview, the facility failed to ensure that its staff electronically submitted timely Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system for two Residents (#25 and #39), out of a sample of five applicable residents. Specifically, the facility failed to ensure its staff electronically submitted MDS data as required for: 1) Resident #25 relative to discharge tracking, and 2) Resident #39 relative to entry tracking within 14 days of completing the MDS assessments. Findings include: Resident #25 was admitted to the facility in June 2021. Resident #39 was admitted to the facility in March 2022. Review of the facility's MDS Transmission Report, dated 4/8/22, indicated: -discharge tracking MDS data, dated 3/10/22, for Resident #25, and -entry tracking MDS data, dated 3/16/22, for Resident #39 was not submitted to the CMS system until 4/8/22 (more than 14 days following the completion of both assessments). During an interview on 2/24/23 at 2:24 P.M., the MDS Nurse said the MDS data for Resident #25 and Resident #39 was not submitted within 14 days of the assessment completions, as required.

Based on record review and interview, the facility failed to ensure its staff notified the Physician/Non-Physician Practitioner (NPP) of unavailability and missed doses of an ordered medication for one Resident (#124), out of a total sample of 18 residents. Specifically, the facility failed to ensure its staff notified the Physician/NPP when ordered doses of Xarelto (anticoagulant-medication used to treat and prevent blood clots) was: a) unavailable for administration, and b) not administered to Resident #124 as ordered for three consecutive days. Findings include: Review of the undated facility protocol, titled What to do When Medication is Unavailable, included the following: - If the Pharmacy was out of a medication or did not deliver the medication, facility staff were required to: 1) contact the Physician/NPP, to advise on an alternative medication and 2) document this in a progress note. - If a medication dose was missed, facility staff were required to notify the Physician/NPP and a progress note needed to be completed. Resident #124 was admitted to the facility in February 2023 with diagnoses including COVID-19 and atrial fibrillation (a-fib: abnormal heart rhythm that can increase risk for blood clots). Review of the hospital Discharge Summary, dated 2/21/23, included the following: - Resident #124 was positive for COVID-19 and had a diagnosis of a-fib. - The Resident required 20 milligrams (mg) of Xarelto to be administered in the evenings with meals. - The Resident was not treated with a therapeutic for COVID-19 due to its interaction with Xarelto. - The last dose of Xarelto administered to the Resident in the hospital was on 2/20/23. Review of a Physician Order, dated 2/21/23, indicated: Xarelto tablet, 20 mg amount: one tablet-oral once an evening at 5:00 P.M (diagnosis: paroxysmal a-fib [when a rapid, erratic heart rate begins suddenly and then stops on its own]). Review of the February 2023 Medication Administration Record (MAR) indicated no evidence Xarelto had been administered to Resident #124 as ordered for three consecutive days as follows: 2/21/23, 2/22/23, and 2/23/23. Review of the clinical record included no evidence the Physician/NPP was notified that Xarelto was unavailable and not administered to Resident #124, as required, during the 2/21/23 through 2/23/23 timeframe. During an interview on 2/24/23 at 12:50 P.M., Nurse #4 said if an ordered medication was not available, the nurse was required to notify the Physician. At this time, Nurse #4 looked through the medications in the medication cart that were available for Resident #124. She said there was no Xarelto available for the Resident. When asked whether the Physician/NPP had been notified that the medication was unavailable, Nurse #4 said the surveyor should follow-up with Unit Manager (UM) #1 because she would know more about this. During an interview on 2/24/23 at 12:55 P.M., UM #1 said she was unaware of any medications not being available for Resident #124 or that any medications had not been administered. UM #1 said she would need to look into this and get back to the surveyor. During a follow-up interview on 2/24/23 at 1:25 P.M., UM #1 said if a medication was not administered because it was unavailable, the nurse was required to notify the Physician/NPP and take any new medication orders provided. UM #1 further said Xarelto had not been available for or administered to Resident #124 for three consecutive days because the Pharmacy had not delivered it yet, and that there was no evidence the Physician/NPP had been notified, as required. During an interview on 2/24/23 at 3:48 P.M., the Director of Nurses (DON) said if a medication was unavailable, the nurse was required to notify the Physician/NPP and take new medication orders. The DON said the Physician/NPP should have been notified as required that Xarelto was unavailable and not administered to Resident #124 on 2/21/23, 2/22/23, and 2/23/23. Please Refer to F760.

Based on observation, record review, and interview, the facility failed to ensure that its staff implemented the plan of care for two Residents (#26 and #36), out of a total sample of 18 residents. Specifically, the facility staff failed to implement: 1) the use of fall mats for Resident #26, and 2) the plan of care relative to meals for Resident #36. Findings Include: 1) Resident #26 admitted to the facility in December 2016 with diagnosis of Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life). Review of the facility policy for Updating and Revising Care Plans, last revised 12/2022, indicated that the facility will develop and implement a comprehensive person-centered care plan to meet each resident's preferences and goals, and address the resident's medical, mental and psychosocial needs. Review of Resident #26's Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident was unable to complete the Brief Interview of Mental Status (BIMS) Assessment as he/she was rarely/never understood. Further review of the MDS revealed that the Resident required extensive assistance for Activities of Daily Living (ADLS) and has had a fall with injury. Review of Resident #26's Event Reports indicated that the Resident sustained falls on: -10/30/22 at 12:00 P.M. -10/31/22 at 12:06 P.M. -10/31/22 at 5:00 P.M. -1/7/23 at 8:00 P.M. -1/21/23 at 10:17 P.M. Review of Resident #26's care plan for falls indicated an intervention for a fall mat to the right side of the bed every shift (days, evenings, and nights) with a start date of 2/17/23. On 2/22/23 at 12:44 P.M., the surveyor observed Resident #26 resting in bed. The floor mat was observed folded in half and placed against the wall. On 2/23/23 at 11:52 A.M., the surveyor observed Resident #26 resting in bed. The floor mat was folded in half and placed against the wall. On 2/23/23 at 1:39 A.M., the surveyor observed Resident #26 resting in bed. The floor mat was folded in half and placed against the wall. During an interview on 2/27/23 at 10:53 A.M., the Director of Nurses (DON) said that the floor mats should have been on the floor next to the Resident's bed. 37400 2. For Resident #36, the facility staff failed to ensure the Speech Language Pathologist (SLP-specialist who evaluates and treats swallowing disorders) recommendations and the Physician's Orders were implemented relative to providing two handled mugs and no straws during meals. Resident #36 was admitted to the facility in November 2022 with diagnoses including Dementia, Dysphagia (difficulty swallowing), Parkinson's Disease (progressive disease of the nervous system causing tremors, muscular rigidity and slow imprecise movements) and Pneumonia. Review of the Minimum Data Set (MDS) Assessment, dated 12/28/22, indicated Resident #36 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 9 out of 15, and required supervision with eating. Review of the SLP Discharge Summary, dated 1/10/23, included the following recommendation relative to swallowing: -upright posture during meals -rate modification -maintain current diet (ground), no straws Review of the February 2023 Physician's Orders included the following: -SLP recommends .thin liquids via a two handled mug only ., initiated 12/17/22 -Dietary: No Salt Packet, Ground, Special Instructions: no straws, initiated 1/19/23 On 2/24/23 at 12:31 P.M., the surveyor observed Resident #36 seated in a wheelchair in his/her room with a lunch tray positioned on an over bed table. The Resident was feeding him/herself the lunch meal. Two regular glasses of fluids were observed on the meal tray and were not in a two handled mugs. A regular coffee mug with a bent straw in place was also observed on the table. Review of the Resident's meal ticket indicated the following diet: No Salt Packet, Ground, no straws. There was no notation on the meal ticket that indicated Resident #36 was to have liquids in two handled mugs. During an observation and interview on 2/24/23 at 12:33 P.M., the surveyor asked Unit Manager (UM) #1 about the straw observed in the Resident's coffee cup and the lunch meal ticket which indicated no straws. UM #1 said that she would check into the matter and get back to the surveyor. At 12:35 P.M., UM #1 was observed to return to Resident #36's room and remove the straw while informing Resident #36 that he/she was not supposed to have straws. During a follow-up interview on 2/24/23 at 12:38 P.M., UM #1 said that she reviewed the SLP notes which indicated the Resident was not supposed to have straws, so she removed them. During an interview on 2/24/23 at 1:06 P.M., the Food Service Director (FSD) said that the hot and cold beverages were served on a separate cart during meals and that the nursing staff distributed the fluids to the resident during meals. He further said that each cart had a tray with different cups which included covered and handled cups for residents. The FSD said that if a two handled cup was to be used for a resident, nursing would obtain the order from the Physician and would notify him so that this information could be put on the resident's meal ticket. The FSD and the surveyor reviewed Resident #36's meal ticket for lunch and the FSD said that the only notation on Resident #36's ticket indicated that he/she should have no straws. He further said that there was no indication on the Resident's meal ticket that he/she should have two handled mugs for liquids. During an interview on 2/24/23 at 1:47 P.M., UM #1 said that any adaptive equipment recommended by rehabilitation staff, like specialized cups, should be listed on the Resident's meal ticket. She further said that the process for communicating the Resident's diet/meal information was not followed and the interventions for Resident #36 were not implemented as recommended by the SLP and as ordered by the Physician.

Based on observations, interview, and record review, the facility failed to ensure its staff re-evaluated positioning concerns timely for one Resident (#36), out of a total sample of 18 residents. Specifically, decline in Resident #36's positioning that did not receive timely treatment to address the decline. Findings include: Review of the facility policy titled Rehabilitation Screening & Referrals, revised 11/2022, indicated all residents will be screened by rehabilitation for possible therapy intervention. These screenings will be completed upon admission/readmission, upon facility request, or upon resident change in functional status. The policy also included the following: -all screens will consist of a brief review of the medical record, interview of the resident/staff/family and observation of the resident -residents . will be reviewed during the routine Medicare meeting regarding the results of the screen . -rehabilitation staff will be required to attend daily clinical meetings in order to remain aware of falls, new physician orders and changes in status such as confusion, difficulty in transfers/ambulation/Activity of Daily Livings (ADLs), hygiene, positioning and oral intake, a screen should occur. Resident #36 was admitted to the facility in November 2022 with diagnoses including Dementia, Parkinson's Disease (progressive disease of the nervous system causing tremors, muscular rigidity and slow imprecise movements), lack of coordination and generalized muscle weakness. Review of the Minimum Data Set (MDS) Assessment, dated 12/28/22, indicated: - Resident #36 exhibited moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 9 out of 15, -required extensive assistance of staff with bed mobility, activities of daily living (ADLs) and transfers, -was unsteady and required staff assistance with transitions and walking, -utilized a wheel chair, -had occasional pain and received as needed (PRN) medications for pain, -and had a fall with injury (not major) since admission. Review of the clinical record indicated Resident #36 received rehabilitation services and was discharged from Physicial Therapy (PT) on 1/9/23 and from Occupational Therapy (OT) on 1/10/23. Review of a Nurse's Progress Note, dated 2/14/23, indicated Resident #36 was observed on the floor in his/her room at 4:50 P.M., and sustained a bump to his/her right forehead. The Physician and Resident's family were updated and orders were obtained to monitor the Resident's status and send to the emergency room if indicated. Review of the Nursing/Rehab Communication Form, dated 2/15/23, indicted a rehabilitation referral (screen) was submitted requesting Occupational Therapy (OT) and Physicial Therapy (OT) to address the following: -fall -wheelchair positioning problems Further review of the screen indicated a Therapist completed the screen on 2/20/23 (five days later) and recommended OT evaluation and treatment orders to be obtained by the Physician. Review of the February 2023 Physician's Orders indicated no documented evidence that current active orders for OT evaluation and treatment had been requested following the completed therapy screen. On 2/22/23 at 11:24 A.M., the surveyor observed Resident #36 leaning to the right while seated in a wheelchair. On 2/23/23 at 12:04 P.M., the surveyor observed the Resident observed leaning to the right while seated in his/her wheelchair. The staff were observed to place a pillow on the Resident's right side. On 2/24/23 at 9:22 A.M., the surveyor observed Resident #36 seated in a wheelchair in his/her room at the entry to the bathroom. The Resident's body was leaning to the right and his/her right side and head was against the door jam of the bathroom. The Resident appeared unable to self propel his/her wheel chair into the bathroom. The surveyor knocked and entered the room at this time and asked the Resident if he/she needed assistance to use the bathroom. Resident #36 said yes and the surveyor alerted facility staff who responded. At 9:35 A.M., the surveyor observed the Resident seated in a wheel chair positioned near his/her bed and was leaning the right. At 9:48 A.M., Unit Manager (UM)#1 was observed to enter the room and tell the Resident that she was going to place a pillow on the Resident's right side to help with positioning his/her arm. At 10:05 A.M., the surveyor observed the Resident still seated in his/her wheelchair and was leaning to the right. The pillow was positioned on the Resident's lap. On 2/24/23 at 12:31 P.M., the surveyor observed Resident #36 in his/her room during lunch seated in the wheelchair and leaning to the right. During an interview, the Resident said that he/she had pain in his/her right side. During an interview on 2/24/23 at 12:33 P.M., UM #1 said that the Resident leans to the right when positioned in his/her wheelchair. She said that therapy had worked with the Resident and did not make any new recommendations relative to the wheelchair. UM #1 further said that a rehabilitation screen had been submitted after the Resident's fall which also requested assistance with the Resident's positioning when in the wheel chair but she did not know about the status of the screen. The surveyor informed UM #1 about the Resident's complaints of right sided pain at this time. During an interview on 2/24/23 at 1:17 P.M., Rehabilitation (Rehab) Staff #1 said that Resident #36 was not currently receiving OT or PT services. She further said that the Resident had previous admissions to the facility and was identified as having a right sided lean but was able to correct this when cued by staff. Rehab Staff #1 said that the Resident was issued a new wheel chair to help with his/her positioning upon admission and that a Rehab screen had been completed recently due to his/her fall and request to address wheelchair positioning. She said that she would locate the rehab screen and follow up with the surveyor. During a follow-up interview on 2/24/23 at 1:33 P.M., Rehab Staff #1 provided a copy of the Rehab Screen request submitted by nursing on 2/15/23. She said that the Therapist had reviewed and signed the screen on 2/20/23, five days later, and had recommended OT evaluation and treatment orders to address the screen. Rehab Staff #1 said that Resident #36 had not been evaluated yet to address the concerns. Rehab Staff #1 said that there is coverage for rehabilitation services six days a week, Monday through Saturday and that the expectation was that if a rehab screen was submitted, it would be addressed the next business day. She further said that if orders were recommended for rehabilitation services (OT, PT, SLP), those should be implemented within the next 24 to 48 hours. Rehab Staff #1 said that there was a delay in responding to the rehab screen for Resident #36, that it should have been completed sooner and that the evaluation and treatment should have already been completed prior to this date.

Based on record review and interview, the facility failed to ensure that its staff accurately completed a Minimum Data Set (MDS) Assessment for one Resident (#24) out of a total sample of 18 residents. Specifically, the facility staff failed to accurately code for an unplanned weight loss of 5% or more in one month for Resident #24. Findings include: Resident #24 was admitted to the facility in March 2018. Review of the Resident's monthly weights indicated the following: -1/5/2023 113 pounds -2/4/2023 107.2 pounds This represented a 5.13% weight loss over a one month period. Review of the MDS assessment dated [DATE] Section K, did not indicate an unplanned weight loss of 5% or more in the last month. During an interview on 2/27/23 at 2:35 P.M., the MDS nurse said that the Resident's unplanned weight loss of 5% or more in the last month should have been indicated on the MDS dated [DATE] but it was not.

Based on record review and interview, the facility failed to complete Quarterly Minimum Data Set (MDS) Assessment timely for two Residents (#5 and #48), out of a sample of five applicable residents. Specifically, the facility failed to ensure its staff completed the Quarterly MDS Assessments no later than 14 days following the assessment reference dates (ARDs) for each assessment. Findings include: 1) Resident #5 was admitted to the facility in December 2020. Review of the clinical record indicated a Quarterly MDS Assessment with an ARD of 3/16/22. 2) Resident #48 was admitted to the facility in June 2021. Review of the clinical record indicated a Quarterly MDS Assessment with an ARD of 3/16/22. Review of the facility's MDS Transmission Report, dated 4/8/22, indicated the Quarterly MDS Assessments with ARDs of 3/16/22 for Residents #5 and #48 were not completed until 4/3/22 (more than 14 days following the ARD for each Assessment). During an interview on 2/24/23 at 2:24 P.M., the MDS Nurse said the Quarterly MDS Assessments for Residents #5 and #48 were not completed within the required 14 day timeframe following the ARDs of 3/16/22.

Based on record review and interview, the facility failed to ensure its staff completed a Comprehensive Minimum Data Set (MDS) Assessment in a timely manner for one Resident (#39), out of a sample of five applicable residents. Specifically, the facility failed to ensure its staff completed a Comprehensive Admission MDS Assessment for Resident #39 within 14 days after the Resident's admission to the facility. Findings include: Resident #39 was admitted to the facility in March 2022. Review of the Resident's clinical record indicated a Comprehensive Admission MDS Assessment with an assessment reference date (ARD) of 3/16/22. Review of the MDS Transmission Report, dated 4/8/22, indicated Resident #39's Comprehensive MDS Assessment was not completed until 4/3/22 (more than 14 days following the Resident's admission to the facility). During an interview on 2/24/23 at 2:24 P.M., the MDS Nurse said Resident #39's Comprehensive Admission MDS Assessment, dated 3/16/22, was not completed within 14 days following the Resident's admission to the facility, as required.

Based on observation, record review, and interview, the facility failed to ensure its staff provided wound treatment and care in accordance with professional standards of practice for one Resident (#274), out of five sampled Residents. Specifically, the facility staff failed to ensure: 1) obtained wound treatment orders on admission to identify all wound areas and initiate treatment. 2) failed to implement wound treatment as ordered for several days to promote healing. 3) failed to implement an updated care plan for wound treatments. Findings include: Review of the facility policy, titled, Skin Integrity and Wound Care Policy, dated, January 2023, indicated the following: -Document all wounds initially on the admission assessment in MatrixCare (computer software for medical charting) by the admitting nurse. - The admitting nurse will document/ include: the anatomical part, site, staging if pressure ulcer, depth, drainage type and amount, odor, perimeter involvement and wound type. -Assessment will be prompt and orders will be in place. -The individual interventions will be reflected in the plan of care. -All wounds are assessed and measured weekly by the nursing staff and wound physician. If the wound physician is unavailable, the unit manager will coordinate nursing team to assess and measure accordingly. Wound condition and progress are documented in matrix care. -Document physician ordered treatments and the monitoring of wound status on treatment sheets. Resident # #274 was admitted to the facility in February 2023. Review of the Clinical Admission Documentation, dated 2/16/23, indicated Resident #274 had open areas to bilateral feet. No wound measurements were documented in the record. Review of the Norton Plus (an assessment that considers several factors to identify a pressure ulcer risk), dated 2/16/23, indicated Resident #274 had a high Norton Skin Risk (a Norton rating < 9 indicates very high risk, 10-13 indicates high risk, 14-17 indicates moderate risk and >18 indicates low risk) as evidenced by a score of 11. Review of the Baseline Care Plan, dated 2/16/23, indicated that there was a skin concern or wound with wound dressings to both feet. Review of the Physician Order Report, dated 2/17/23, indicated: -a right heel wound (other wound areas were not identified) -cleanse with house wound cleanser -apply Calcium Alginate (a highly absorbent dressing that interacts with the wound fluids to form a gel that provides a moist wound environment and facilitates auto debridement) -followed by a border foam dressing and kling (a non-Sterile absorbent gauze roll) once a day on the 3:00 P.M.-11:00 P.M.(evening) shift. Review of the February 2023 Treatment Administration Record (TAR) indicated treatment of right heel wound, cleanse with house wound cleanser, apply Calcium Alginate followed by border foam dressing and kling once a day on the 3:00 P.M.-11:00 P.M. shift, was initialed by nursing staff, indicating treatment as ordered and dressing changes on each shift from 2/17/23 through 2/23/23. Review of the Physician Order Report, dated 2/18/23, indicated: a) left heel wound -cleanse with house wound cleanser -apply Calcium Alginate to moist wound bed -followed by border foam dressing and kling once a day on the 3:00 P.M.-11:00 P.M. (evening) shift. b) right medial/heel foot wound -cleanse with house wound cleanser. -Apply Iodosorb (a gel that can kill bacteria, applied to the skin to treat wet ulcers and wounds) -followed by 2 X 2 gauze and kling once a day on the 3:00 P.M.-11:00 P.M. shift c) top of right foot wound -cleanse with house wound cleanser -apply xeroform (a sterile pad applied to a wound to promote healing and protect the wound from further harm) -followed by 2 x 2 gauze and kling once a day on the 3:00 P.M.-11:00 P.M. shift. Review of the February 2023 TAR indicated treatment to left heel wound, right medial foot wound and top of right foot wound, was initialed by nursing staff once a day on the 3:00 P.M.-11:00 P.M., shift from 2/18/23 through 2/23/23, indicating treatments as ordered and dressing changes. During an observation and interview on 2/24/23 at 9:36 A.M., Unit Manager (UM) #2, Nurse Practitioner, the Wound Physician, and the surveyor observed Resident #274 lying in bed with gauze dressings to both feet that were dated 2/20/23. UM #2 confirmed that the bilateral foot dressings were dated 2/20/23 and said she was not sure when they should have been changed or what treatment was ordered. Further review of the February 2023 TAR indicated from 2/21/23 through 2/23/23, that the bilateral wound treatment dressings had been signed off as being administered as ordered, when the treatment dressings had not been changed since 2/20/23. Review of the Wound Care Specialist Rounding Sheet, undated (rounds were completed 2/24/23), indicated Resident #274 was a new patient and had the following wound description and treatments ordered: -left heel measurement of 4.2 centimeters (cm) x 5 cm x 0.1 cm, 100 % slough (dead skin tissue that may have a yellow or white appearance) with odor, with erythema (redness of the skin that occurs with skin injury, infection, or inflammation) and maceration (the softening and breaking down of skin from being exposed to too much moisture). Further review indicated the Wound Physician recommended Doxycycline (antibiotic used to treat bacterial infections), and Augmentin (antibiotic used to treat a wide variety of bacterial infections) for 10 days. Additional Wound Physician Orders included: a) X-ray of the left heel, -pressure relieving boots -a new order for Flagyl (antibiotic used to treat a wide variety of infections) to be used at the wound site, -Santyl (an ointment that helps remove dead skin tissue and aid in wound healing) Alginate ABD (alginate wound dressing that is a highly absorbent dressings and used for large wounds or wounds requiring high absorbency)/gauze daily and as needed (PRN). b) Right heel measurements of 1.5 cm x 0.5 cm x 0.2 cm with 100 % granulation (the development of new tissue) with Wound Physician's Orders for: -Collagen (helps stimulates new tissue growth), -border foam, gauze daily and PRN c) Right foot distal measurements 1 cm x 1 cm with 100 % eschar (dead tissue that is typically tan, brown, or black, and may be crusty) with a Wound Physician's order for an antiseptic (used on the skin to treat or prevent skin infection) daily and as needed. Review of the Nurse Practitioner Notes dated 2/24/23 indicated concerns for infection of the left heel, will culture wound but in the meantime start PO (by mouth) Doxycycline and Augmentin, will need to follow up as soon as possible. During an interview on 2/24/23 at 2:44 P.M., UM #1 reviewed the clinical record for Resident #274 with the surveyor and said when a Resident is admitted into the facility with wounds the treatment orders come from the hospital in the discharge summary. She further said that if there are no orders present then the admitting nurse will complete a head-to-toe assessment and if there are wound areas identified, the size and description would be documented in the clinical observation area of MatrixCare and in the nursing notes. The nurse(s) would ask the Physician for any wound treatment orders. UM #1 reviewed the record and said that the size and description of the wounds was not done on admission. She further said that the hospital discharge summary did not have documentation on what treatment orders should be for wounds on Resident #274's feet. She said that the wound dressings to both feet were not changed on admission. UM #1 further said that she measured the wounds on 2/17/23, they appeared concerning and that she reached out to the Physician and received wound treatments orders. She said that some of the orders were not started until 2/18/23. She further said that the consent to see the Wound Physician should be obtained on admission, but that Resident #274 did not have a signed wound consent until 2/23/23. She further said that she was made aware that the dressings to Resident #274 bilateral feet were dated 2/20/23 and that when nurses initialed the TAR it indicated that the treatments and dressings were completed. UM #1 said she did not know why the nurses documented that the treatments were done, when they were not and that they were investigating. She said that when a Resident is admitted with a wound the expectation is to monitor the area and get treatment orders immediately. She said that should have been done for Resident #274 and it was not. She said that the baseline care plan was initiated but it was not updated with individual interventions and treatments for the wounds to Resident #274 bilateral feet and that it should have been. During an interview on 2/24/23 at 3:43 P.M., The Director of Nursing (DON) said that she was made aware that the dressings to Resident #274's feet were being signed off as being changed and that they were not changed from 2/21/23 through 2/23/23 as they should have been, and that she was currently investigating. Review of the statement dated 2/24/23, Nurse #5 indicated, I charted that dressing was changed, it was not related to fall (another resident). I had planned on changing what was charted-but was unable . Review of the statement dated 2/24/23, Nurse #6 indicated, I signed off a wound treatment before doing it. I then forgot to go do the wound dressing change .

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was free from a significant medication error. While at an outside provider appointment on 7/05/22, Resident #1 was assessed to have a change in mental status, and upon speaking to nursing staff at the Facility it was determined that Resident #1 had not been administered [MEDICATION(S)] as ordered for several days (missing a total of seven doses). Resident #1 was transferred to the Hospital Emergency Department for evaluation, and admitted related to mental status changes caused by the abrupt cessation in his/her [MEDICATION(S)]. Findings include: Review of Facility's Policy titled, Unavailable Medications, dated as revised 01/18, indicated that the pharmacy will notify nursing staff if a medication is unavailable. Nursing staff will notify the physician if a medication is unavailable. Resident #1 was admitted to the Facility in July 2022, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Physician Orders, dated 07/03/22, indicated for nursing to administer [MEDICATION(S)] 4 milligrams (mg) by mouth every 8 hours (three times a day) for 10 days. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . - 07/03/22, 2:00 P.M. and 10:00 P.M., MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - 07/04/22, 6:00 A.M., 2:00 P.M., and 10:00 P.M., MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - 07/05/22, 6:00 A.M. and 2:00 P.M., MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 08/11/22 at 9:41 A.M., Nurse #1 said she did not have [MEDICATION(S)] to administer to Resident #1. During an interview on 08/10/22 at 4:27 P.M., Nurse #2 said he did not have [MEDICATION(S)] to administer to Resident #1. During an interview on 08/10/22 at 4:44 P.M., Nurse #3 said he did not have [MEDICATION(S)] to administer to Resident #1. Review of Resident #1's medical record indicated there was no documentation by nursing to support the physician and/or nurse practitioner were notified, or that the Unit Manager was made aware. Review of a Nurse's Progress Note, dated 07/05/22 at 8:47 P.M., indicated the Facility was notified that Resident #1 was admitted to the Hospital with altered mental status. During an interview on 08/10/22 at 3:32 P.M., the Unit Manager said on 07/05/22 Resident #1 was at his/her [CONDITION(S)] appointment and she received a call from the oncology clinic looking to confirm that Resident #1 had been receiving his/her [MEDICATION(S)], because Resident #1 was more lethargic and did not like seem like him/herself. The Unit Manager said she reviewed Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility's Omnicell Medication Dispensing Machine (machine used to obtain medications that have not been delivered from the pharmacy) Inventory Report, indicated on 07/03/22, 07/04/22, and 07/05/22, there were twenty (20) [MEDICATION(S)] 1 milligram (mg) tablets available in the machine, that could have been dispensed and administered to Resident #1 by nursing. There was no documentation to support nursing staff accessed the Omnicell to obtain [MEDICATION(S)] to administer to Resident #1. When interviewed, the Unit Manager, Nurse #1, Nurse #2 and Nurse #3, all said they were unaware, until the day of survey, that the medication was available in the Omnicell. Review of Resident #1's Hospital Discharge Summary, dated 07/06/22, indicated that Resident #1 was admitted for altered mental status. The Summary indicated that Resident #1's altered mental status was caused by the abrupt cessation in his/her [MEDICATION(S)]. During an interview on 08/11/22 at 9:30 A.M., the Nurse Practitioner said she was notified on 07/05/22 that Resident #1 had not received his/her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 08/11/22 at 8:32 A.M., The Director of Nursing (DON) said she was made aware on 07/05/22 that Resident #1 had not received his/her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was non-ambulatory, had a diagnosis of [CONDITION(S)] (paralysis of the legs and lower body), and therefore had no control or feeling in his/her bilateral lower extremities (legs and feet), the Facility failed to ensure he/she was provided with assistive devices (bilateral leg/foot rests) for his/her wheelchair, in an effort to prevent incidents/accidents resulting in an injury. - On 05/29/22, Certified Nurse Aide (CNA) #1 transferred and repositioned Resident #1 in his/her wheelchair but did not attach leg/foot rests to the wheelchair to support his/her bilateral lower extremities. Resident #1's Family Member took Resident #1 outside in the wheelchair for a walk, and Resident #1's legs/feet (which he/she had no feeling or control over secondary to paralysis) were unsecured, unprotected, and dragged on the pavement causing extensive injuries to his/her feet. Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with Avulsion (wound that happens when skin is torn from your body during an accident or other injury) injuries to both feet. Findings Include: Review of the Facility's Policy titled, Wheelchair (Use Of), undated, indicated the purpose of the Wheelchair Policy was to provide mobility for the non-ambulatory resident with safety and comfort. The Policy indicated do not remove foot rests off of the wheelchair. The Policy indicated if the resident does not need the foot rests for staff to fold foot rests up out of the residents way for safety. The Policy indicated to lower foot rests, place residents feet on the foot rest, position his/her feet and legs in good body alignment while in the wheelchair. Review of Resident #1's Minimum Data Set (MDS) Admission Assessment, dated 05/10/22, indicated his/her diagnoses included [CONDITION(S)] (paralysis of the legs and lower body), and that he/she required total dependence of one staff member for wheelchair mobility. The MDS indicated that Resident #1 had functional limitations with impairments on both sides of his/her lower extremities (including hips, knees, ankles, and feet). Review of the Police Department Report, dated 05/29/22, indicated upon Officer arrival, Resident #1 was located at the outdoor front entrance of the Facility. The Report indicated Resident #1's feet were observed wrapped in white bandages and positioned on top of a white blanket. The Report indicated Resident #1's socks (which had been removed prior to Officer arrival) were located on the ground, there was a large amount of blood and toe nails observed within the socks, and Resident #1's feet were actively bleeding. The Report indicated there was a long trail of bloody tire marks from Resident #1's wheelchair around the property, on the sidewalk and in the parking lot. The Report indicated Resident #1's Family Member had asked permission from Facility staff to take Resident #1 outside for a walk in his/her wheelchair. The Report indicated Resident #1's feet had been dragged approximately ¼ of a mile around the Facility (duration of the walk) and that the Family Member was unaware. The Report indicated Resident #1 had been paralyzed from the waist down since November 2021 and was unable to feel his/her bilateral legs/feet. Review of the Hospital Emergency Department (ED) Report, dated 5/29/22, indicated Resident #1 sustained Avulsion injuries to both of his/her feet, abrasions to soles of his/her feet, and was missing toenails. The ED Report indicated Resident #1's new physician's orders included, [MEDICATION(S)] (oral antibiotic) 500 milligrams (mg) administer three times a day for 10 days, and [MEDICATION(S)] (antibiotic) 2% cream, apply topically three times a day for 10 days. During an interview on 06/15/22 at 1:02 P.M., Certified Nurse Aide (CNA) #1 said on 05/29/22 she transferred and repositioned Resident #1 in his/her wheelchair. CNA #1 said after she had repositioned him/her, Resident #1's Family Member said they were going for a walk. CNA #1 said she did not see leg/foot rests for Resident #1's wheelchair in his/her room. CNA #1 said she could not take leg/foot rests from another resident's wheelchair and said if the foot rests were not located in the residents room there usually was a reason why. During an interview on 06/15/22 at 10:06 A.M., the Unit Assistant said she helped CNA #1 transfer Resident #1 out of bed into his/her wheelchair and said there were no leg/foot rests attached to Resident #1's wheelchair or located in his/her room. During an interview on 06/15/22 at 1:55 P.M., Nurse #2 said on 05/29/22, Resident #1's Family Member was calling for help at the Facility's front entrance. Nurse #2 said she observed Resident #1 sitting in his/her wheelchair and then observed a pool of blood under Resident #1's feet. Nurse #2 said Resident #1 was wearing slipper socks on his/her feet and said the tops of the slipper socks were completely worn down and stuck to his/her feet from the friction of being dragged over the pavement. Nurse #2 said she had to apply saline solution (mixture of salt ad water) to the socks to remove them from Resident #1's feet. Nurse #2 said Resident #1's feet were actively bleeding and she applied a pressure dressing to try to stop the bleeding. During an interview on 06/15/22 at 9:13 A.M., Nurse #1 said Resident #1 was never assessed for the use of a wheelchair and/or leg/foot rests, because Resident #1 usually refused to get out of bed. Nurse #1 said if resident is unable to use his/her feet to propel the wheelchair independently, then leg/foot rests are used to support the residents legs and feet. Nurse #1 said Resident #1 was unable to use his/her feet to propel while in the wheelchair due to [CONDITION(S)], and would have required leg/foot rests to be in place when in the wheelchair. Nurse #1 said on 05/29/22, she was notified the Emergency Medical Services (EMS) were called to the Facility , and when she went to the front entrance to see what was going on, said she saw Resident #1 in his/her wheelchair, and observed a large amount of blood under Resident #1's wheelchair and his/her feet were bleeding. Nurse #1 said because Resident #1 was on an anticoagulant (blood thinner, inhibits clotting) medication, Nurse #2 had a hard time stopping the bleeding. Nurse #1 said there was a large blood trail from Resident #1's wheelchair half way around the building and back to the Facility's front entrance. During an interview on 07/5/22 at 8:27 A.M., the Physical Therapist said residents are assessed for wheelchair mobility upon admission to the Facility. The Physical Therapist said a resident who has a diagnosis of [CONDITION(S)], such as Resident #1 does, they would not have self-control of their lower extremities and would need support (leg/foot rests) for their legs and feet, to prevent an injury. During an interview on 06/15/22 at 5:00 P.M., the Director of Nursing said it is best practice for staff to assess all residents for wheelchair mobility and the need for leg/foot rests. The Director of Nursing said if a resident is unable to be mobile in his/her wheelchair, it is her expectation that the wheelchair will have leg/foot rests attached to support the residents lower extremities and prevent injury.

During a COVID-19 Focused Infection Control Survey conducted at Sunny Acres Nursing Care Center on October 28, 2020, it was determined that effective October 28, 2020, the Facility was found to be in Immediate Jeopardy for F880 and not to be in compliance with 42 CFR §483.80 Infection Control regulations and has not implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for and respond to COVID-19. Capacity: 93. Census: 67. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy to the Facility Administrator on 10/29/20, including the Immediate Jeopardy Templates. The Facility failed to: 1) Make timely efforts to separate COVID-19 positive and COVID-19 negative roommates after receiving positive test results; 2) Perform hand hygiene and change personal protective equipment (PPE) between entering rooms occupied by COVID-19 negative and COVID-19 positive residents; 3) Wear eye protection while in resident rooms; 4) Screen visitors on entry to the building. Failure to properly cohort COVID-19 positive and COVID-19 negative residents, perform hand hygiene or wear required PPE, and not screen potentially infectious visitors placed residents at a significant increased risk of exposure to and potential infection with [DIAGNOSES REDACTED]-CoV-2 (COVID-19) virus. Since 4/16/20, this 93 bed facility has had 70 positive resident cases, 37 positive staff cases and 11 resident deaths attributed to COVID-19. On 10/29/20, the facility submitted a letter indicating abatement of the Immediate Jeopardy would occur by 10/30/20 at 11:59 P.M. An extended Focused Infection Control onsite survey was conducted on 11/2/20 to review the facility's alleged abatement of Immediate Jeopardy as of 10/30/20 at 11:59 P.M. It was determined the facility did NOT comply with the requirements of the directed plan of correction and Immediate Jeopardy was NOT corrected. On 11/2/20, the facility submitted a letter indicating abatement of the Immediate Jeopardy would occur by 11/2/20 at 11:59 P.M. An extended Focused Infection Control onsite survey was conducted on 11/4/20 to review the facility's alleged abatement of Immediate Jeopardy as of 11/2/20 at 11:59 P.M. It was determined the facility did NOT comply with the requirements of the directed plan of correction and Immediate Jeopardy was NOT corrected. Findings include: 1) Centers for Disease Control (CDC) guidance titled Infection Control for Nursing Homes, dated 6/25/20, indicated Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. The Facility's policy titled Appropriate Personal Protective Equipment (undated), indicated Known COVID positives and known COVID negatives must be on separate units. And staffing teams should be separate. Review of the Facility's training materials (undated), indicated that all residents who are confirmed positive for or are recovering from COVID-19 are in either completely dedicated COVID-19 positive wings; or, if unavailable, residents are cohorted appropriately, either in a room alone or cohorted into a room with other confirmed cases. All residents who are not suspected to be infected with COVID-19 are in rooms or units that do not include confirmed or suspected cases. During an interview with the facility's Administrator and the Director of Nursing (DON) on 10/28/20 at 9:23 A.M., they said that COVID-19 had continued to spread through the facility since the surveyors were last there on 10/21/20. The Administrator, when asked about the decision to not separate COVID-19 negative from COVID-19 positive residents on the unit, said he did not want to move COVID-19 negative residents from their private rooms because they are in deluxe suites. The Administrator said that these COVID-19 negative residents were probably already exposed to [MEDICAL CONDITION] and could soon turn COVID-19 positive. The Administrator said it was fruitless to move these identified residents because doing so would not stop the spread of [MEDICAL CONDITION] among the resident population, and the exposed residents were likely to get COVID-19 eventually. On 10/28/20 at 8:33 A.M., during a tour of the 2D unit, which housed a mix of COVID-19 positive and COVID-19 negative residents throughout the unit layout, the following observations were made: At 8:37 A.M., the surveyor observed the section of the 2D unit which housed a mix of three COVID-19 negative residents and three COVID-19 positive residents. During an interview on 10/28/20 at 8:34 A.M. with CNA #2 , CNA #2 said that over the past week, several of the residents on the unit had converted from COVID-19 negative to COVID-19 positive and that the staff cared for both positive and negative residents throughout the shifts. During an interview on 10/28/20 at 8:37 A.M. with Nurse #1, she said that she was responsible to provide the treatment and medication to all the residents in this section. Nurse #1 said it's tricky, because I am the only nurse at this end, so I end up having to go back in to the negative rooms after positives. On 10/28/20 at 12:59 P.M., the surveyors met with the Administrator to review concerns with regard to the 2D unit, where the surveyors observed that COVID-19 negative and positive resident rooms were mixed throughout the unit. The Administrator said, there is no plan to separate or move the (COVID-19 negative) residents from that unit. At 1:23 P.M., the surveyor observed a resident room, that had been identified as COVID-19 negative in the morning, was now identified on the door sign as COVID-19 positive. During an interview on 10/28/20 at 1:23 P.M.with Nurse #2, she said that at approximately 9:00 A.M. that morning they had learned that one of the residents in the room was COVID-19 positive. Nurse #2 said that the resident's roommate was COVID-19 negative and has remained in the room with him/her since that time. Nurse #2 said she was not aware if there was a plan to separate the residents. During an interview with the Administrator on 10/28/20 at 3:30 P.M., he said that at approximately 9:15 A.M., the facility's Infection Preventionist Nurse had received lab results confirming a new COVID-19 positive resident on the 2D unit. The Administrator said that the COVID-19 negative resident continued to share a room with a COVID-19 positive roommate for at least 6 hours despite confirmation at approximately 9:15 A.M., the COVID-19 negative resident's labs results confirmed his/her negative status. The Administrator said staff were in the process of preparing to move the COVID-19 negative resident onto a COVID-19 negative/recovered unit. Review of the facility's floor plan and census indicated a total of 93 beds and occupancy of 67 residents. Twenty four beds were currently unoccupied in rooms shared by either COVID-19 negative or COVID-19 recovered residents, or were unoccupied by any residents. 2) Review of the Centers for Disease Control and Prevention guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated July 15, 2020 indicated: - HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. - Put on clean, non-sterile gloves upon entry into the patient room or care area. - Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. At 8:53 A.M., the surveyors entered the doffing station of the 2D unit to remove Personal Protective Equipment (PPE). CNA #4 entered the doffing station and the surveyors inquired if there was a disinfectant available to clean the face shields that had been worn on the 2D unit. CNA #4 looked around the room and out in the hallway but was unable to locate any disinfecting supplies. CNA #4 said there should be bleach wipes to clean your shield, I don't know why there aren't any. At 8:54 A.M., the surveyors assessed the doffing station on the 2C unit however there were no disinfectant wipes available. The Unit Secretary was interviewed and she said I think that they had them last night but I still need to replenish the supply today. The Unit Secretary said she did not know how staff were disinfecting their face shields in the absence of disinfectant supplies. At 8:57 A.M., the surveyors entered the 1A/B unit doffing station. There were no disinfectant supplies available. At 1:19 P.M., the surveyors arrived on the 2D unit (which housed both COVID -19 positive and COVID - 19 negative residents) and observed Housekeeper (HK) #1 exiting a designated COVID-19 positive room, wearing a gown and a glove on each hand, and carrying a bag of trash. HK #1 placed the bag of trash on the floor in the hallway, potentially contaminating the environment. Without performing hand hygiene, or removing her gown or gloves, HK #1 used her gloved hand to press a code on the wall keypad to unlock an emergency exit door, potentially contaminating the keypad. HK #1 placed the bag of trash in the stairwell landing then re-entered the unit. Still wearing the same gown and gloves, HK #1 walked the length of the unit and exited the unit through the main entranceway. At 1:30 P.M., the surveyors observed HK #1 standing in the hallway of the 2D unit, wearing a glove on each hand, and moving items on her cart with gloved hands . Without removing the gloves and without performing hand hygiene, HK #1 entered a room occupied by a COVID-19 negative resident, potentially exposing the resident to COVID-19 pathogens. At 1:33 P.M., the surveyors observed HK #1 exiting a resident room and remove her gloves. HK #1 did not perform hand hygiene or don new gloves and then proceeded to enter a room occupied by a COVID-19 positive resident. During an interview with Nurse #1, she said that she did not know why the housekeeping staff do their own thing. The surveyor shared the observations of HK #1, and Nurse #1 said nothing about what she did is okay, it is absolutely not okay to wear gloves in the hallway, particularly after exiting a COVID-19 positive room, or to neglect to perform hand hygiene. 3) CDC guidance titled Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, published by the Centers for Disease Control, dated 7/15/20, indicated when health care personnel (HCP) working in areas with minimal to no community transmission should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. The Facility's policy and procedure for residents with confirmed or suspected COVID-19, dated 6/2/20, indicated that in all clinical areas all staff must wear eye protection when there are COVID-19 positive cases in the building. On 10/28/20 at 8:20 A.M., during a tour of the section of the second floor unit, 2C, which housed a mix of COVID-19 recovered and COVID-19 negative residents, the following observations were made: At 8:23 A.M., Certified Nurse Aide (CNA) #1 exited a room, occupied by a COVID-19 recovered resident, wearing only a face mask, and no eye protection. A sign on the door indicated that a face shield and mask were to be worn at all times in the room. During an interview with CNA#1 on 10/28/20 at 8:25 A.M., she said that she was supposed to wear face shield and mask at all times when in resident rooms. CNA #1 said there was an ample supply of face shields available in the facility. Following the interview with CNA #1, the surveyors continued to observe CNA #1 enter bedrooms occupied by residents, and continued to not wear eye protection. - At 8:27 A.M., CNA #1 entered room [ROOM NUMBER] without wearing eye protection. - At 8:29 A.M., CNA #1 re-entered room [ROOM NUMBER] without wearing eye protection. - At 8:31 A.M., CNA #1 entered room [ROOM NUMBER] without wearing eye protection. - At 9:48 A.M., CNA #1 entered room [ROOM NUMBER] without wearing eye protection. - At 1:23 P.M., CNA #1 entered room [ROOM NUMBER] without wearing eye protection. - At 1:45 P.M., CNA #1 entered room [ROOM NUMBER] without wearing eye protection. During an interview with the 2C unit Nursing Supervisor on 10/28/20 at 1:50 P.M., she said that all staff were required to wear eye protection when in a resident bedroom, regardless of their COVID-19 status. 4) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated July 15, 2020, indicated: screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection and ensure they are [MEDICATION NAME] source control. Actively take their temperature and document absence of symptoms consistent with COVID-19. Upon arrival to the facility the surveyors observed the following: On 10/28/20 at 8:03 A.M., the surveyors entered through the front door of the building into the main lobby. There were COVID-19 screening forms and a pen available at the main desk counter, however no staff were present to screen the surveyors. Several of the screening forms on the counter had names written at the top and the COVID-19 questions were answered, however no temperatures were filled in. At 8:08 A.M., one of the facility's infection control nurses walked by and saw the surveyors. She said that she was not sure where the screener was located. At 8:58 A.M., the screener approached the surveyors and said that she had been out on a smoke break when the surveyors arrived at the building. The screener said that normally someone covered for her when she was away from the main entrance, but that this did not happen today. On 11/2/20, based on observation, interview and policy review, the facility staff failed to ensure staff wore appropriate personal protective equipment (PPE) while in clinical areas occupied by COVID-19 positive and quarantined residents. Findings include: Review of the Centers for Disease Control and Prevention guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated July 15, 2020 indicated: - HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. - Put on clean, non-sterile gloves upon entry into the patient room or care area. - Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. CDC guidance titled Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, published by the Centers for Disease Control, dated 7/15/20, indicated when health care personnel (HCP) working in areas with minimal to no community transmission should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. The Facility's policy and procedure for residents with confirmed or suspected COVID-19, dated 6/2/20, indicated that in all clinical areas all staff must wear eye protection when there are COVID-19 positive cases in the building. On 11/2/20 at 7:20 A.M., the surveyors observed the COVID-19 positive Unit 2D. A certified nurse aide (CNA) #3 exited a resident room carrying a soiled brief in one ungloved hand, and dirty linen in his other ungloved hand. CNA #3 did not wear a protective gown. CNA #3 pushed the exit door from the wing open with his hip and exited the with the brief and linen. On 11/2/20 at approximately 7:20 A.M., the surveyors observed Nurse #1 on the COVID-19 positive Unit 2D. Nurse #1 did not wear eye protection. Nurse #1 stood by the medication cart, next to two other staff members, in the hallway and next to a bedroom occupied by COVID-19 positive residents. There were approximately 5 staff in the hallway near Nurse #1 and no one intervened to address the lack of eye protection. At approximately 7:35 A.M., Nurse #1 still did not wear eye protection. During an interview with Nurse #1 on 11/2/20 at 7:35 A.M., she said she was unaware that staff were required to wear eye protection while on the COVID-19 positive unit. Nurse #1 said she thought eye protection was only required inside the bedrooms. The Infection Control Nurse interjected during the interview and told Nurse #1 to put on eye protection. The Infection Control Nurse exited the wing and then returned with eye protection for Nurse #1. On 11/2/20 at 7:30 A.M., the surveyors observed CNA #5 enter the COVID-19 positive Unit 2D. CNA #5 did not wear a protective gown or eye protection. CNA #5 walked to a precaution bin located in the hallway and retrieved plastic bags then exited the unit. On 11/2/20 at 7:42 A.M., the surveyors observed the Assistant Director of Nursing (ADON) on Unit 2C, which was occupied by COVID-19 negative, recovered and quarantined residents. The ADON stood in the hallway outside a room which was occupied by a quarantined resident, accompanied by another staff member. The ADON did not wear eye protection and the other staff member did not intervene. During an interview with the ADON on 11/2/20 at 9:15 A.M., she said staff should wear eye protection while on any of the units. Review of the PPE in-service sign-in list, dated 10/30/20, indicated approximately 30 staff who had been working since 10/28/20, including Nurse #1, had not been in-serviced on PPE use. During an interview on 11/2/20 at 9:21 A.M. with the ADON and Management Consultant they said that not all the staff have been in-serviced since the last survey on 10/28/20, but they hoped to complete in-servicing by 11/3/20. The ADON and Management Consultant said that staff would not work in the building until they had been in-serviced on PPE use. During an observation at 10:04 A.M., on Unit 2C the surveyors observed CNA #6 enter Unit 2C. CNA #6 did not wear eye protection. CNA #6 then entered Unit 2D without wearing eye protection. The surveyor observed the Infection Control Nurse tell CNA #6 to put on eye protection. During an interview with CNA #6 on 11/2/20 at 10:06 A.M., she said she thought eye protection was not required unless she was on the COVID-19 positive unit. During an observation on 11/2/20 at 10:50 A.M. on the 2C Unit, the surveyors observed the Administrator exiting from Unit 2D and into Unit 2C. The Administrator was not wearing eye protection. On 11/4/20, the surveyors conducted a second onsite partially extended Focused Infection Control survey. Based on observation, interview and policy review, the facility staff failed to: 1) In-service all staff on personal protective equipment (PPE) and infection control since the last survey on 11/2/20, and contrary to the Immediate Jeopardy Directed Plan of Correction. Two certified nurse aides (CNAs) continued to work their shifts in the building on 11/3/20 without this education; 2) Perform proper hand hygiene and change PPE appropriately. Findings include: 1) Review of the memo titled Facility's Immediate Jeopardy Enforcement Recommendation Request that Allegation of Jeopardy may be Removed, dated 11/2/20, indicated: This facility has started a new Education and Training program to ensure that all staff clearly understand the proper usage of PPE, proper hand hygiene and prevention of Covid-19. This education program began on 10/28/2020 and will continue to through 11/2/2020. No staff will be able to work after 11/2/2020 at 11:59 pm, unless they receive the documented proper education presented by the facility Infection Control Coordinator, Staff Development Coordinator or Supervisor. Review of the Facility's working staff schedule, dated 11/3/20, indicated that Certified Nurse Aid (CNA) #7 was assigned to Unit 2D (COVID-19 positive unit) for the 7:00 A.M. to 3:00 P.M. shift. Review of the working staff schedule dated 11/3/20, indicated CNA #8 was assigned to Unit 1 (mixed quarantined and COVID-19 recovered) for the 3:00 P.M. to 11:00 P.M. shift. Review of the COVID-19 personal protective equipment and infection control in-service sign-in sheets, and the master education spreadsheet, indicated that CNA #7 and CNA #8 had not taken this in-servicing, as required by the memo Facility's Immediate Jeopardy Enforcement Recommendation Request that Allegation of Jeopardy may be Removed. During an interview with the Assistant Director of Nursing on 11/4/20 at approximately 10:00 A.M., she said that it was difficult to ensure that agency staff had received their in-servicing on PPE and infection control before working on the units. 2. Review of the Centers for Disease Control and Prevention guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated July 15, 2020 indicated: - HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. - Put on clean, non-sterile gloves upon entry into the patient room or care area. - Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. On 11/4/20 at 7:22 A.M., the surveyors observed Unit 2C, a COVID-19 mixed unit (quarantined and COVID-19 recovered). Diet Aide (DA) #2 entered the unit, wearing a glove on each hand and pushing a cart of beverages. DA #2 placed the cart against a wall, walked down the corridor to briefly speak to another staff member, then walked back up the corridor to the exit doors, pushed opened the door with her gloved hands, and without removing the gloves or performing hand hygiene, exited the unit. On 11/4/20 at 7:24 A.M., Certified Nursing Assistant (CNA) #5 entered Unit 2D, the COVID-19 positive unit, wearing eye protection and a gown. CNA #5 touched a linen cart, a bed side table and a PPE bin drawer with ungloved hands. CNA #5 then put on gloves without first cleaning his hands, contaminating the gloves. CNA #5 then, with the contaminated gloved hands, grabbed clean towels and 2 face clothes from a clean linen cart. The two face clothes fell from his hands to the floor. CNA #5 picked up the contaminated face cloths with a contaminated gloved hand and carried these dirty and clean linens into a designated COVID-19 positive room. During an interview with CNA #5 on 11/4/20 at 7:25 A.M., he said that he washed his hands before he entered the unit. CNA #5 said he intended to put the dirty face cloths in a soiled linen bin. On 11/4/20 at 7:25 A.M., the surveyor observed the Unit 2C doffing station. There were no disinfectant supplies available to clean contaminated eye protection. On 11/4/20 at 7:26 A.M., the surveyor observed KA #3, with a glove on each hand, enter Unit 2C, pushing an additional cart of beverages. DA#3 pushed the cart on the unit and then, without removing the gloves and without performing hand hygiene, DA #3 pushed the exit door open with the gloved hands and left the unit. On 11/4/20 at 7:29 A.M., the surveyor observed Nurse #3 exit Unit 2D (COVID-19 positive unit). Nurse #3 entered the Unit 2C restroom. A sign on the restroom door indicated this restroom was for C-Side staff only. Nurse #3 potentially cross-contaminated the Unit 2C restroom. At 7:31 A.M., upon exiting the restroom, Nurse #3 walked over to Unit 2C's nurse's station, leaned on the counter top, and spoke to a Unit 2C staff member, potentially cross contaminating the counter. Nurse #3 then returned to the Unit 2D doffing station. A sign on the entryway door directed Unit 2D staff to use a bathroom in the hallway assigned to Unit 2D staff. During an interview with Nurse #3 at 7:32 A.M., she said that she is the nurse for the Unit 2D COVID-19 positive unit. Nurse #3 said that she was supposed to use a bathroom designated for the staff working on the COVID-19 positive unit, but that she had not done so. During an interview with the Assistant Director of Nurses (ADON) on 11/4/20 at 7:40 A.M., the surveyor informed her of CNA #5's infection control breaches. The ADON said that CNA #5 was an agency staff. The ADON said it was difficult to ensure agency staff adhered to proper infections control practice because they are scheduled irregularly on the floors, and she does not know who from the agency will show up to the facility on a particular day. The ADON said CNA #5 should have cleaned his hands after entering Unit 2D and before putting on gloves. The ADON said that CNA #5 should have disposed of the dirty face cloths in the hallway. The ADON said that CNA #5 should not have entered the bedroom with dirty gloves, and that he should have performed hand hygiene and changed gloves after touching the contaminated face cloths.

Based on record review and interview the facility staff failed to ensure adequate supervision and assistance devices to prevent accidents for 2 sampled residents (#6 and #84) in a total sample of 18 residents. Findings include: Review of the Falls Prevention Policy, date revised 4/20/17 indicated the following; -When the resident is admitted to the facility, the admission nurse also does a brief assessment .If the resident is at risk of falling the resident is referred to the Physical Therapy department for a screen and possible evaluation, that they are put on alarms for at least the first 24 hours then to be assessed as if they need to be continued as well, and they are started on the 4 P's program. -With 14 days of admission to the facility, after any fall and /or quarterly each resident will be assessed for falls -Based on the outcome of the Falls Risk Assessment, interventions are to be put in place to reduce or eliminate hazards/risks associated with the fall or anticipated fall or decrease the injury due to unavoidable fall. -A careplan will be written to address each intervention put in place. -Any new intervention will be placed in the Certified Nursing Assistant (CNA) communication book. Additionally, the policy indicates the following procedures after any fall: -Immediately put in place new interventions that will prevent further falls or reduce the risk of injuries secondary to fall. -Document in detail in the resident's chart; A. Nurses note should contain any information regarding the fall, any injuries and interventions put in place. B. Update Care Plan regarding fall and interventions and/or preventative action taken. Notify staff of any change. 1. For Resident #84 the facility staff failed to ensure adequate supervision and assistance was provided to prevent a fall that resulted in significant injuries. Resident #84 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], indicated the resident had moderate cognitive impairment as evidenced by a BIMS score of 10 out of 15 and required extensive assistance of 2 for transfers. Review of a fall risk assessment, dated 11/20/17, indicated the resident was at moderate risk for falls as evidenced by a score of 11. Review of the Event Report, dated 12/6/17, indicated the resident sustained [REDACTED]. The resident had reached down to pick a Bingo chip off of the floor and fell out of the wheelchair. Further review indicated the resident sustained [REDACTED]. The resident was sent to the emergency room for evaluation and returned to the facility later that evening. Review of a progress note, dated 12/7/17, indicated the resident had a moderate size laceration to the top of the head, no sutures or staples, but did require a daily dressing change. Review of the care plan for falls, initially created 8/30/17, indicated there were no new fall interventions added to the care plan after the fall on 12/6/17. Review of the Quarterly MDS dated [DATE] indicated the resident had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, required extensive assist of 2 for transfers, and had one fall with major injury. Review of the fall assessment, dated 5/24/18, indicated the resident was at high risk for fall as evidenced by a score of 18, (a score of over 13 indicated high risk). Review of a progress note, dated 6/12/18, indicated the resident sustained [REDACTED]. Review of the Event Report, dated 6/12/18, indicated the resident had been sitting in the wheelchair in his/her room. The resident dropped a piece of candy and when he/she attempted to pick it up off of the floor he/she fell out of the wheelchair and sustained a laceration to the the head and complained of right hip pain. The resident was sent to the emergency room for evaluation. Review of a progress note, dated 6/26/18, indicated the resident returned from the hospital (following the fall on 6/12/18) with [DIAGNOSES REDACTED]. Review of the care plan for falls indicated interventions, dated 6/26/18, for skilled Physical and Occupational Therapy, and to provide the resident a reacher (an adaptive device used to reach objects out of reach). Review of the clinical record indicated the resident sustained [REDACTED]. The resident was found on the floor next to the bed and had been sitting in the wheelchair prior to the fall (third fall out of the wheelchair). The resident did not sustain an injury. On 8/21/18 at 10:05 A.M., the resident was observed to be up and dressed seated in the wheelchair in his/her room with bilateral sneakers on and a cushion to the wheelchair. During an interview on 8/21/18 at 1:34 P.M., the QA nurse said that following the first fall the resident was on neurological checks for 3 days, then he/she bounced back and was good, very much aware. She said the staff monitored him/her to not bend over. The DON said the second fall occurred when Resident # 84 was reaching and once again fell out of the wheelchair and landed on his/her head again, which resulted in a brain hemorrhage. She said the resident was issued a reacher which he/she never used. The QA nurse said the staff made sure there was no extra clutter in the resident's room and made sure the call bells were always within reach. The surveyor reviewed the care plan for falls and the QA nurse said neurological checks were done but she didn't see any other interventions. The QA Nurse said she saw what the surveyor concerns were but since they couldn't restrain anyone there wasn't much else to do. During an interview on 8/21/18 at 2:01 P.M. with the Director of Nurses (DON), QA nurse, and MDS nurse, the third fall was reviewed and the DON said the resident fell out of the wheelchair in his/her room and the intervention added was to keep the resident visible when in the wheelchair. The QA Nurse said they always give the residents call bells even if they don't know how to use them (which makes it an ineffective intervention). The DON said some residents were hard to find interventions for and sometimes it was to keep the resident safe and not to prevent falls (resident had multiple significant injuries from the second fall). When the surveyor asked if the resident's care plan was updated when he/she went from a moderate risk for falls to high risk the MDS nurse said no. When the surveyor asked if the anticoagulant (blood thinner) medication was care planned the MDS nurse said no and they didn't usually care plan for that. The surveyor pointed out that at the time of the 12/2017 fall it was identified by the facility staff that the resident had recently started on an anticoagulant, and would that have been referenced anywhere. The DON said that it wasn't on the care plan but probably should have been given that the resident has been a high risk for falls and also has had injuries. When asked where the evidence was that alternatives or trial interventions for falls prevention were done, no one answered. The DON said they didn't want to trial a seatbelt because they were afraid of more injury, when asked if rehab assessed the resident for appropriateness (or not) of any safety device the DON said no. 2. For Resident #6, the facility staff failed to utilize alarms as care planned for 2 falls the resident sustained [REDACTED]. Resident #6 was admitted to the facility in 11/2015 with [DIAGNOSES REDACTED]. Review of the Fall Care Plan, start date 12/7/15 and edit date 11/28/17, indicated the following intervention; -Equip him/her with device that monitors rising, sensor pad to wheelchair. -Give verbal reminders no to ambulate/transfer without assistance. -Keep call light in reach at all times. -One assist with all transfers and ambulation with rolling walker. -Provide toileting assistance 2-3 times a shift and upon request. Review of the CNA Assignment Card 2 Sheet, undated, indicated the following; -Safety Devices/transportation: sensor alarm in chair and bed, -Transfers/Activities of Daily Living (ADLs): 1 assist ADLs in bathroom, 2 assist with transfers and ambulation. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 5/17/18, indicated the resident had severe cognitive impairment as evidenced by a score of 6 out of 15 on the Brief Interview For Mental Status (BIMS), required extensive assistance with bed mobility, transfers, walking, dressing, toileting hygiene and bathing, and no falls. Review of the Fall Risk Assessment, dated 5/17/18, indicated a score of 13. A score of 6-13 points equals a moderate fall risk. Review of the Safety Event Report, dated 6/20/18, indicated the resident had an unwitnessed fall in the bathroom at 10:57 P.M. The report indicated the resident was heard by staff calling out for help. The resident was found lying on his/her right side, complaining of left leg and hip discomfort. The report indicated that prior to the fall the resident had been sitting in his/her wheelchair beside the bed, in the room. The report indicated the resident was transferred to the hospital for evaluation. No additional interventions/immediate measures were indicated on the report. Review of the facility's Resident Alarm Sheet indicated a bed and chair alarm were listed for the resident. They were only checked on the 3:00 P.M. to 11:00 P.M. shift on 6/20/18, and did not indicate what time the alarm was checked during the shift or whether or not it was functioning. Review of the Safety Event Report, dated 7/11/18, indicated the resident had an unwitnessed fall in the bedroom at 3:00 A.M. The report indicated the resident was heard calling for help and was found sitting on the floor, leaning against the wall with his/her right leg folded under him/her. A witness statement included with the report indicated that the resident was heard screaming and the staff went to check on the resident. The report indicated the resident complained of right leg pain with the slightest movement. The resident was transferred to the hospital for further evaluation. A Nurse's note, dated 7/11/18, indicated the resident was admitted to the hospital with [REDACTED]. A Nurse's note, dated 7/19/18 indicated the resident was readmitted to the facility after having surgery. Review of the facility's Resident Alarm Sheet indicated a bed and chair alarm were listed for the resident. They were checked on the 11:00 P.M. to 7:00 A.M. shift on 7/10/18, but did not indicate what time the alarm was checked during the shift or whether or not it was functioning. During an interview on 8/22/18 at 9:10 A.M., CNA #1 said the resident has an alarm on when in the wheelchair. Nurse #2 said the resident has a pressure alarm when in bed. CNA #1 said at times the resident would wheel him/herself to the bathroom and attempted to use the toilet alone, and so he/she needed the alarm. CNA #1 said the resident had not attempted to stand up alone since the fall of 7/11/18. During an interview on 8/22/18 at 10:15 A.M., the Quality Assurance (QA) Nurse said the fall reports do not indicate an alarm was sounding at the time of either fall and she had to assume they were not in place at the time of the fall. She said the alarms should have been on and nothing indicated they were on and sounding at the time of the falls. At 11:03 A.M., the QA Nurse said the resident had always had alarms to the bed and chair since he/she was admitted . She was unsure why the bed alarm was not listed as an intervention on the Fall Care Plan, but was listed on the CNA assignment sheets, and the CNA alarm check sheets.

Based on interview and record review the facility staff failed to revise the comprehensive care plan for falls for one sampled Resident # 84 out of a total sample of 18 residents. Findings include: Review of the facility's policy for Falls Prevention, with a revision date of 4/2017, indicated the following: - .after any fall and/or quarterly each resident will be assessed for falls using the Johns Hopkins Fall Risk Assessment Tool. -Based on the outcome of the Falls Risk Assessment, interventions are to be put in place to reduce or eliminate hazards/risks associated with the fall or anticipated fall or decrease the injury due to an unavoidable fall. - A care plan will be written to address each intervention put in place. - After a fall has occurred, a Post Fall observation .will be completed to consider any new interventions and preventative strategies to make sure this type of fall does not re-occur. Resident #84 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], indicated the resident had moderate cognitive impairment as evidenced by a BIMS score of 10 out of 15 and required extensive assistance of 2 for transfers. Review of a fall risk assessment, dated 11/20/17, indicated the resident was at moderate risk for falls as evidenced by a score of 11. Review of the Event Report, dated 12/6/17, indicated the resident sustained [REDACTED]. The resident had reached down to pick a Bingo chip off of the floor and fell out of the wheelchair. Further review indicated the resident sustained [REDACTED]. The resident was sent to the emergency room for evaluation and returned to the facility later that evening. Review of a progress note, dated 12/7/17, indicated the resident had a moderate size laceration to the top of the head, no sutures or staples, but did require a daily dressing change. Review of the care plan for falls, initially created 8/30/17, indicated there were no new fall interventions added to the care plan after the fall on 12/6/17. Review of the Quarterly MDS dated [DATE] indicated the resident had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, required extensive assist of 2 for transfers, and had one fall with major injury. Review of the fall assessment, dated 5/24/18, indicated the resident was at high risk for fall as evidenced by a score of 18, (a score of over 13 indicated high risk). Review of a progress note, dated 6/12/18, indicated the resident sustained [REDACTED]. Review of the Event Report, dated 6/12/18, indicated the resident had been sitting in the wheelchair in his/her room. The resident dropped a piece of candy and when he/she attempted to pick it up off of the floor he/she fell out of the wheelchair and sustained a laceration to the head and complained of right hip pain. The resident was sent to the emergency room for evaluation. Review of a progress note, dated 6/26/18, indicated the resident returned from the hospital (following the fall on 6/12/18) with [DIAGNOSES REDACTED]. Review of the care plan for falls indicated interventions, dated 6/26/18, for skilled Physical and Occupational Therapy, and to provide the resident a reacher (an adaptive device used to reach objects out of reach). Review of the clinical record indicated the resident sustained [REDACTED]. The resident was found on the floor next to the bed and had been sitting in the wheelchair prior to the fall (third fall out of the wheelchair). The resident did not sustain an injury. On 8/21/18 at 10:05 A.M., the resident was observed to be up and dressed seated in the wheelchair in his/her room with bilateral sneakers on and a cushion to the wheelchair. During an interview on 8/21/18 at 1:34 P.M., the QA nurse said that following the first fall the resident was on neurological checks for 3 days, then he/she bounced back and was good, very much aware. She said the staff monitored him/her to not bend over. The DON said the second fall Resident #84 was reaching and once again fell out of the wheelchair and landed on his/her head again, which resulted in a brain hemorrhage. She said the resident was issued a reacher which he/she never used. The QA nurse said the staff made sure there was no extra clutter in the resident's room and made sure the call bells were always within reach. The surveyor reviewed the care plan for falls and the QA nurse said neurological checks were done but she didn't see any other interventions. The QA Nurse said she saw what the surveyor concerns were but since they couldn't restrain anyone there wasn't much else to do. During an interview on 8/21/18 at 2:01 P.M. with the Director of Nurses (DON), QA nurse, and MDS nurse, the third fall was reviewed and the DON said the resident fell out of the wheelchair in his/her room and the intervention added was to keep the resident visible when in the wheelchair. The QA nurse said they always give the residents call bells even if they don't know how to use them (which makes it an ineffective intervention). The DON said some residents were hard to find interventions for and sometimes it was to keep the resident safe and not to prevent falls (resident had multiple significant injuries from the second fall). When the surveyor asked if the resident's care plan was updated when he/she went from a moderate risk for falls to high risk the MDS nurse said no. The surveyor pointed out that at the time of the 12/2017 fall it was identified by the facility staff that the resident had recently started on an anticoagulant, and would that have been referenced anywhere. The DON said that it wasn't on the care plan but probably should have been given that the resident has been a high risk for falls and also has had injuries. When asked where the evidence was that alternatives or trial interventions for falls prevention were done, no one answered. The DON said they didn't want to trial a seatbelt because they were afraid of more injury, when asked if the rehabilitation department assessed the resident for appropriateness (or not) of any safety device the DON said no. Please refer to F 689

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to perform a pain assessment or obtain Physician orders [REDACTED].#1's pain when he/she showed signs of increased left leg pain during care from 11:59 P.M. on 10/22/16 through 11:59 P.M. on 10/24/16, when the Physician was notified and an order was given to obtain an x-ray the following day. Resident #1 continued to show signs of pain with restricted leg movement and received Tylenol with little to no effect. On 10/25/16, at 10:07 A.M. (approximately 10 hours after Resident #1's first sign of increased leg pain) an x-ray was reported positive for a left [MEDICAL CONDITION] and Resident #1 was transferred to the Hospital for evaluation and treatment. Findings Include: The Facility's Policy titled Pain Assessment and Management, dated July 2013, indicated the pain of all residents is recognized and addressed appropriately and it's the responsibility of each licensed nurse to recognize the effectiveness or ineffectiveness of the treatment and to report to the Physician and/or Nurse Practitioner any changes that need to be made. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had a [DIAGNOSES REDACTED]. A Nurse Progress Note, dated 10/22/16 and timed at 3:38 A.M., indicated Resident #1 was moaning out frequently at the start of the 11:00 P.M. shift, he/she was medicated with Tylenol ([MEDICATION NAME] medication used to treat pain) which had some effect, however, Resident #1 had increased moaning with any care provided. There was no documentation to indicate that a comprehensive pain assessment that identified the characteristics of Resident #1's pain was performed and no new Physician order [REDACTED]. This was not consistent with the Facility Policy titled Pain Management. A Nurse Progress Note, dated 10/22/16 and timed at 3:22 P.M., indicated Resident #1 was heard moaning out for several hours during the 7:00 A.M.-3:00 P.M. shift and Tylenol was given with no change in behavior. There was no documentation to indicate that a comprehensive pain assessment that identified the characteristics of Resident #1's pain was performed and no new Physician order [REDACTED]. This was not consistent with the Facility Policy titled Pain Management. A Nurse Progress Note, dated 10/23/16 and timed at 6:28 A.M., indicated Resident #1 was heard moaning out frequently during the 11:00 P.M. to 7:00 A.M. shift and was medicated with Tylenol with little to no effect, and Resident #1 had increased moaning with any care provided. There was no documentation to indicate that a comprehensive pain assessment was completed which identified the characteristics of Resident #1's pain was performed and no new Physician order [REDACTED]. This was not consistent with the Facility Policy titled Pain Management. A Nurse Progress Note, dated 10/23/16 and timed at 2:51 P.M., indicated Resident #1 continued to moan out during the 7:00 A.M.-3:00 P.M. shift and Tylenol was given with no change in behavior. There was no documentation to indicate that a comprehensive pain assessment that identified the characteristics of Resident #1's pain was performed and no new Physician order [REDACTED]. There was no indication that Resident #1's care plan was updated to include interventions in response to Resident #1's symptoms of untreated pain. This was not consistent with the Facility Policy titled Pain Management. A Nurse Progress Note, dated 10/24/16 and timed at 10:59 P.M., indicated Resident #1 was noted to have increased moaning with movement of his/her left hip and a physician's orders [REDACTED]. A Nurse Progress Note, dated 10/25/16 and timed at 4:51 A.M., indicated Resident #1 moaned frequently throughout the 11 P.M. to 7 A.M. shift with little to no effect from Tylenol and he/her leg movement was restricted until the x-ray was performed. A Radiology Report dated, 10/25/16 and timed at 10:07 A.M., indicated Resident #1 had a left [MEDICAL CONDITION]. Nurse #2 was interviewed at 1:45 P.M. on 12/1/16. Nurse #2 said on 10/24/16 Resident #1 was crying and appeared to have hip pain when they put him/her on his/her left side so she called the Physician and obtained an order for [REDACTED]. Nurse #1 was interviewed at 3:45 P.M. on 11/30/16. Nurse #1 said on 10/22/16 Resident #1's moaning increased. Nurse #1 said she suspected there was more going on, or words to that effect, and she advised the certified nurse's aides to position Resident #1 on his/her right side. Nurse #1 said she did not conduct a comprehensive pain assessment on Resident #1. Nurse #1 said she did not call the Physician to report Resident #1's pain or obtain orders to treat his/her pain. The Director of Nursing (DON) was interviewed at 11:36 A.M. on 11/22/16. The DON said staff should have completed a comprehensive pain assessment on Resident #1 and should have notified Resident #1's Physician when his/her pain medications were not effective.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to promptly notify Resident #1's Physician and Health Care Proxy (legal representative) when on 10/22/16 Resident #1 showed signs of increased left leg pain which continued for approximately 69 hours, during which Resident #1 moaned and screamed when repositioned, until 10:59 P.M. on 10/24/16 when staff notified the Physician and an order was obtained for a left hip x-ray which was reported on 10/25/16 as positive for a left [MEDICAL CONDITION]. Findings Include: The Facility's Policy titled Resident Change in Condition, undated, indicated that unexpected changes in a Resident's status are promptly assessed and reported to the attending physician in a timely fashion with notification of the Resident's legal representative within 24 hours and be noted in the medical record. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had a [DIAGNOSES REDACTED]. A Nurse Progress Note, dated 10/22/16 and timed at 3:38 A.M. indicated Resident #1 moaned out frequently at the start of the 11:00 P.M.-7:00 P.M. shift, he/she was medicated with Tylenol ([MEDICATION NAME] medication used to treat pain) which had some effect. The note indicated Resident #1 had increased moaning with any care provided. There was no documentation to indicate Resident #1's Physician or Health Care Proxy was notified of Resident #1's change in condition. This was not consistent with the Facility Policy titled Resident Change in Condition. A Nurse Progress Note, dated 10/22/16 and timed at 3:22 P.M., indicated Resident #1 was heard moaning out for several hours during the 7:00 A.M.-3:00 P.M. shift and Tylenol was given with no change in behavior to indicate it was affective in treating Resident #1's pain. There was no documentation to indicate the Physician or Health Care Proxy was notified of Resident #1's pain. This was not consistent with the Facility Policy titled Resident Change in Condition. A Nurse Progress Note, dated 10/23/16 and timed at 6:28 A.M., indicated Resident #1 was heard moaning out frequently during the 11:00 P.M. to 7:00 A.M. shift and was medicated with Tylenol which had little to no effect, and Resident #1 had increased moaning with any care given. There was no documentation to indicate the Physician or Health Care Proxy was notified of Resident #1's increased pain. This was not consistent with the Facility Policy titled Resident Change in Condition. A Nurse Progress Note, dated 10/23/16 and timed at 2:51 P.M., indicated Resident #1 continued to moan out and Tylenol was given with no change in behavior. There was no documentation to indicate the Physician or Health Care Proxy was notified of Resident #1's continued moaning. This was not consistent with the Facility Policy titled Resident Change in Condition. A Nurse Progress Note, dated 10/24/16 and timed at 10:59 P.M., indicated Resident #1 was noted to have increased moaning with movement of his/her left hip and a physician's orders [REDACTED]. A Nurse Progress Note, dated 10/25/16 and timed at 3:42 P.M., indicated Resident #1's x-ray results were positive for a left [MEDICAL CONDITION] and Resident #1 was transferred to the Hospital for further evaluation. Nurse #1 was interviewed at 3:45 P.M. on 11/30/16. Nurse #1 said on 10/22/16 she advised the certified nurse's aides she worked with on the 11:00 P.M.-7:00 A.M. shift to make sure Resident #1 was positioned on his/her right side because he/she was in too much pain when positioned on his/her left side. Nurse #1 said she did not notify the Physician of Resident #1's pain during the 11:00 P.M.-7:00 A.M. shift on 10/22/16 or on 10/23/16 when Resident #1 demonstrated increased moaning with care. C.N.A. #1 was interviewed at 2:35 P.M. on 12/1/16. C.N.A. #1 said several days before Resident #1's hip x-ray was performed Resident #1 was moaning and screaming with care and while sitting in his/her recliner. The Director of Nursing (DON) was interviewed at 11:36 A.M. on 11/22/16. The DON said staff did not but should have notified Resident #1's Physician about his/her increased pain and the ineffectiveness of Resident #1's pain medication.

Based on record review, interviews, and observations, the Facility failed for 11 of 26 sampled residents (Resident #1, #2, #4, #6, #10, #12, #13, #19, #20, #23, and #26), and 3 of 3 non-sampled residents (Resident A, Resident B and Resident C), to ensure injuries of unknown source were comprehensively investigated in an effort to determine their cause, and failed to ensure they were reported to the State Agency (Department of Public Health). The Director of Nurses (DON) and Quality Assurance Nurse said the Facility did not report to the Department of Public Health injuries of unknown origin unless the injuries consisted of a laceration requiring sutures to close or a fractured bone. The DON and Quality Assurance Nurse said the Facility abuse policy did not include information regarding how the Facility investigated and reported to the Administrator and Department of Public Health injuries of unknown origin. Findings include: The Facility Incident and Accident Policy, dated 10/2012, indicated the purpose of the incident report was to document the events of an accident or incident. The policy indicated a statement would be obtained from the person who witnessed the accident or who found the resident. There was no process within the policy to indicate how the Facility managed injuries of unknown source (origin). The Facility Abuse Prevention Policy, dated 10/2010, indicated no procedure for investigation of injuries of unknown origin or reporting injuries of unknown origin with investigation results to the Department of Public Health. There was no indication that as part of personnel training requirements that staff were educated regarding what constituted an injury of unknown source. The policy indicated under the Identification Section of the Abuse Prevention Policy whenever there was an actual or suspected abuse, mistreatment, neglect, comprehensive timely notification to the appropriate agency would occur. The policy indicated incidents of injuries of unknown origin such as bruises, skin tears, and lacerations required a report and supervisory follow-up. The Surveyor interviewed the Quality Assistance (QA) Nurse at 4:15 P.M. on 9/28/12. The QA Nurse said she worked at the Facility for three years prior to date of survey, and it was her responsibility to collect information regarding all injuries such as, bruises and skin tears, residents' falls, and resident to resident altercations, as well as allegations of abuse, mistreatment, neglect, or misappropriation. The QA Nurse said she was responsible for obtaining statements from staff when an investigation was to be completed, including investigations regarding injuries of unknown origin. The QA Nurse stated she normally obtained information from the staff who provided care to the resident during the 16 hours before an incident or allegation was received. The QA Nurse said all information which was collected, related to a specific incident, was attached to the Incident Notification Form. The QA Nurse said although she attempted to obtain statements from staff as part of the investigation, she did not always receive the requested information from staff. The QA Nurse said this would account for the difference in number of staff she spoke with from incident to incident, in an effort to determine cause. The DON and the QA Nurse said it was not the Facility's practice to report injuries of unknown origin unless those injuries consisted of a fractured bone or a laceration which required sutures to close. The QA Nurse said she could think of no time when an injury of unknown origin such as a hematoma, contusion, or bruise was reported to the Department of Public Health. The DON and QA Nurse said the Facility's abuse prevention policy did not include any information regarding investigation of injuries of unknown source and the reporting of those injures to the Department of Public Health. 1. The [DIAGNOSES REDACTED]. Resident #1's Heath Care Proxy Form, dated 11/6/08, indicated Resident #1 authorized a family member to make all health care related decisions in the event Resident #1 be unable to do so. The Health Care Proxy Activation Form indicated that on 2/5/11, a physician activated the proxy because Resident #1 was unable to make decisions due to cognitive loss related to [MEDICAL CONDITION]. The quarterly Minimum Data Set (MDS) assessment, dated 8/15/12, indicated Resident #1 had moderately impaired hearing, Resident #1's ability to understand was limited to making concrete requests, and responded to direct, simple conversation only. The assessment indicated Resident #1 had impaired recall and orientation. The physician orders, dated 9/25/12, indicated Resident #1's plan of care included aspirin 81 milligrams daily, [MEDICATION NAME] (anticoagulant with a narrow therapeutic index), dosing based on the INR (international normalized ratio). The plan of care indicated Resident #1 was to wear protective arm sleeves when out of bed. a. The nurse's note, dated 6/3/12, indicated at 11:00 A.M., a certified nursing assistant (CNA) noted a large hematoma (localized collection of blood) on Resident #1's right wrist, and when assessed the area was documented as being dark blue/purple in color, measured 7.5 by 9 (no unit of measurement within the note), and was sensitive to the touch. The note indicated the physician was informed; and an x-ray was obtained of the arm, which was negative for a fracture. The radiology report, dated 6/3/12, indicated Resident #1 had no fracture. The Investigation Notification Form, dated 6/3/12, indicated during A.M. care, what was described as large hematoma, was found on Resident #1's right wrist. The report indicated Resident #1 cried out when the area was touched, and was unable to provide any information regarding how the injury occurred. A Witness Statement Form, dated 6/3/12, was attached to the Investigation Form. The statement indicated Resident #1's alarm sounded and when staff responded, staff found Resident #1 in bed with the right wrist bruise. The name and title of the staff member who completed the statement was not legible. Two Investigation of Bruise/Skin Tear Forms, dated 6/4/12; and another, dated 6/6/12, were attached to the Investigation Notification Form. The Investigation of Bruise/Skin Tear Forms consisted of a series of typed questions and spaces for the staff to fill in the answers. The form included instructions for them to be completed prior to returning to the Quality Assurance (QA) Nurse. There was no indication additional staff or relevant witnesses were interviewed in an effort to determine the cause of Resident #1's injury. The Investigation Report (a typed summary of the incident), dated 6/3/12, indicated two CNAs and one Nurse were interviewed regarding Resident #1's right wrist bruise. The Surveyor interviewed Nursing Supervisor #3, at 4:46 P.M. on 9/27/12. Nursing Supervisor #3 said she was the staff member who found Resident #1's 6/3/12 hematoma, which was measured in centimeters (cm). Nursing Supervisor #3 said Resident #1 was unable to provide her with any information regarding how the injury occurred, but told Nursing Supervisor #3 he/she had pain in the wrist. Nursing Supervisor #3 said no staff member observed how the injury occurred. The Surveyor interviewed Nurse #1 at 10:02 A.M. on 9/27/12. Nurse #1 told the Surveyor she recalled the June 2012 hematoma on Resident #1's right wrist. Nurse #1 said the area that was described as quite large, encompassing the back of the wrist, and was purple in color, and sensitive to the touch. Nurse #1 said a x-ray was obtained of the right wrist, which was negative for a fracture, and ice was applied to the limb. Nurse #1 said Resident #1 was unable to provide any information regarding how the bruise occurred due to cognitive impairment. b. The nurse's note, dated 8/1/12, indicated that some time during the afternoon on this date, Resident #1 was noted to have a 4 cm by 6 cm bruise on the left hand. The note indicated the bruise was not present during A.M. care. The Incident Notification Form, dated 8/1/12, indicated at 1:00 P.M., a CNA noted Resident #1 was seated in the hallway and at that time, had a 4 by 5 cm bruise on the back of the left hand. The Form indicated the area was not present during care earlier, and Resident #1 was unable to provide any comment on the bruise, due to cognitive impairment. An Incident Witness Statement, dated 8/1/12, was attached to the Incident Notification Form. The statement indicated a staff member noted the bruise while Resident #1 was seated in the hallway. The name and title of the staff member who completed the statement was not legible; and no other statements were collected from staff or other relevant witnesses in an effort to determine the cause of the injury. The Investigation report, dated 8/1/12, indicated one staff member was interviewed as part of the investigation regarding Resident #1's left wrist bruise. Nurse #1 said she remembered Resident #1's 8/1/12 bruise, but did not know how the injury occurred. c. The Investigation Report, dated 9/12/12, indicated Resident #1 was seated in a recliner in the hallway when the CNA called for the nurse to check Resident #1's left hand. The Report indicated Resident #1 was noted to have a 9 cm, purple colored bruise covering Resident #1's entire hand. The Report indicated when assessed, Resident #1's left hand was swollen and warm to the touch. The Report indicated Resident #1 had no recollection regarding how the injury occurred. The Investigation Report (summary), dated 9/12/12, indicated the QA Nurse interviewed two CNAs and one nurse as part of the investigation regarding Resident #1's left wrist bruise. The nurse's note, dated 9/13/12, indicated during the 11:00 P.M. shift, on 9/12/12, to the 7:00 A.M., on 9/13/12 shift, Resident #1 was noted to have what was documented as a large, purple bruise covering the entire top of Resident #1's left hand. The note indicated Resident #1 was unaware of how the injury occurred. The nurse's note, dated 9/13/12, indicated at 11:00 A.M., the Nurse Practitioner examined Resident #1's left hand and wrist hematoma. The note indicated the Nurse Practitioner ordered an x-ray for Resident #1's left arm; and the arm was to be elevated; staff were to apply ice twice a day, for one week; and apply ace wraps during the night, for one week. The radiology report, dated 9/13/12, indicated Resident #1 had no fracture, but had moderately diffuse swelling and [MEDICAL CONDITION] changes to the left hand. The Surveyor interviewed Nursing Supervisor #1 at 9:00 A.M. on 9/27/12. Nursing Supervisor #1, Nursing Supervisor #3, and Nurse #1 said the 9/12/12 bruise was a large, raised, deep purple in color, and spread half-way up Resident #1's left arm and into the finger tips of Resident #1's left hand. Nursing Supervisor #1 said the bruise was found at 11:30 P.M. on 9/12/12 and was not present during the day on 9/12/12 when Nursing Supervisor #1 saw Resident #1. Nursing Supervisor and Nurse #1 said they had no idea how Resident #1 sustained the injury, and Resident #1 was not able to provide any information regarding the injury due to cognitive impairment. Nursing Supervisor #1, Nursing Supervisor #3, and Nurse #1 said Resident #1 was prescribed [MEDICATION NAME] and in response to the bruise, Resident #1's INR was obtained, which was elevated at 4.2 (normal between 2.0 and 3.0). Nursing Supervisor #1 and Nursing Supervisor #3 said Resident #1 had no other injuries, bruises, or symptoms of bleeding on 9/13/12. The Nurse Practitioner's progress note, dated 9/13/12, indicated the Nurse Practitioner was asked to evaluate Resident #1 because he/she had a large hematoma, etiology was unknown. The report indicated Resident #1 was a poor historian, but told the Nurse Practitioner the injury may have been a result of his/her hand being caught in a door. The Nurse Practitioner indicated that when assessed, Resident #1 had swelling and an "extensive" bruise" on the left hand, which extended to the tips of the fingers and left wrist. The Surveyor interviewed the Nurse Practitioner at 12:10 P.M. on 10/1/12. The Nurse Practitioner said the cause of Resident #1's 9/13/12 bruise was not known. The Nurse Practitioner said the use of Resident #1's [MEDICATION NAME] and the elevated INR may have contributed to how extensive the bruise was, but was not the cause of the injury itself. The Nurse Practitioner said Resident #1 had no other symptoms of bleeding or other injuries of unknown origin on 9/13/12, when the INR was elevated. The Surveyor interviewed the Director of Nurses (DON) at approximately 1:00 P.M. and 4:30 P.M., on 9/27/12. The DON said the etiology of the bruising on Resident #1's hands and arms on 6/3/12, 8/4/12, and 9/13/12 was not known. There was no indication the Facility completed a comprehensive investigation regarding Resident #1's injuries of unknown origin, and did not obtain information from the staff who provided care to the resident during the 16 hours before an incident or allegation was received. The DON said Resident #1's injuries of unknown origin, noted on 6/3/12, 8/1/12, and 9/12/12, were not reported to the Department of Public Health because the x-rays completed for two of the injuries indicated no [MEDICAL CONDITION] limb. 2. Resident #2's quarterly MDS, dated [DATE], indicated Resident #2 had disorganized thinking; and required assistance with transfers, bed mobility; and was dependent for bathing and personal hygiene. The Incident/Accident Report and Incident Notification Form, both dated 4/7/12, indicated at 7:15 P.M. on this date, Resident #2 was noted to have blood on his/her leg protectors. The report indicated upon removal of the leg protectors, Resident #2 was noted to have 3 cm crescent-shaped skin tear surrounded by a 15 cm long, by 7 cm wide purple/maroon colored bruise on the left leg, and two small bruises above the skin tear and larger bruise. The report indicated four steri strips were required to close the skin tear. The report indicated Resident #2 was unable to recall how the injury occurred. Two Incident Witness Statements, both dated 4/7/12, were attached to the Form. The statements indicated they were from the two staff who found the skin tear and bruises. There was no indication additional staff or relevant witnesses were interviewed in an effort to determine the cause of Resident #2's injury. 3. Resident #4's annual MDS assessment, dated 9/12/12, indicated Resident #4 had severely impaired decision making ability, required extensive assistance from two staff for bed mobility, transfers; and was dependent upon staff for bathing, dressing, and grooming. The assessment indicated Resident #4 was non-ambulatory and was able to self-propel in the wheelchair. The physician orders [REDACTED]. a. The nurse's note, dated 4/12/12, indicated the CNA who performed one-to-one with Resident #4 noted Resident #4 had a "large hematoma" on the left forearm while providing Resident #4 with a shower. The note indicated the etiology of the hematoma was not known. There was no indication the staff were aware of how the injuries occurred despite being under direct one-to-one supervision The Investigation Report, dated 4/12/12, indicated at 7:00 P.M. on this date, Resident #4 was in the shower with a CNA, when the CNA removed Resident #4's protective sleeves, and observed a large hematoma on Resident #4's left forearm. The report indicated the hematoma measured 12 cm by 13 cm in size. The report indicated Resident #4's plan of care included one-to-one supervision of staff 24 hours a day; Resident #4 was unable to provide any information regarding how the injury occurred. The nurse's note, dated 4/13/12, indicated Resident #4's physician evaluated Resident #4's left forearm and ordered that the arm be ace wrapped with ice applied twice a day. Review of the Investigation Report (summary), dated 4/13/12, indicated three CNAs and one nurse were interviewed as part of the investigation. There was no indication the staff were aware of how the injuries occurred despite being under direct one-to-one supervision b. The nurse's note, dated 4/30/12, indicated Resident #4's companion reported Resident #4 had a bruise on the top of the left foot which extended into the toes. There was no indication the staff were aware of how the injuries occurred despite being under direct one-to-one supervision c. The nurse's note, dated 5/10/12, indicated the CNA noted during a shower that Resident #4 had dried blood on the left wrist, and when cleansed had a small skin tear of unknown cause. There was no indication the staff were aware of how the injuries occurred despite being under direct one-to-one supervision d. The nurse's note, dated 5/13/12, indicated the companion reported Resident #4 had a 2 cm by 2 cm bruise on the top of the second toe on Resident #4's left foot. The note indicated the origin of the bruise was not known. There was no indication the staff were aware of how the injuries occurred despite being under direct one-to-one supervision e. The nurse's note, dated 6/10/12, indicated at 1:50 P.M., the companion reported Resident had a small cut on the outer side of the 5th digit on Resident #4's left hand. The note indicated the area was cleansed and two steristrips were applied. The note indicated the origin of the injury was not known. The note indicated bruises were also noted as 1 cm on the base of third digit of left hand; one circular (less than dime sized) between the third and the fourth digit of Resident #4's left hand; and what was documented as a, "much larger linear shaped bruise" along the side of the fifth digit on Resident #4's left hand. There was no indication the staff were aware of how the injuries occurred despite being under direct one-to-one supervision f. The nurse's note, dated 8/19/12, indicated at 5:10 P.M., the companion found a laceration on the bridge of Resident #4's nose which measured 0.25 cm by 0.25 cm in size, and was found when the companion adjusted Resident #4's glasses. The note indicated Resident #4 had no recollection of the incident. The note indicated the area was cleansed with normal saline solution and steristrips were applied. There was no indication the staff were aware of how the injuries occurred despite being under direct one-to-one supervision The Investigation Report, dated 8/19/12, indicated one CNA and one nurse were interviewed as part of the investigation. g. During observations completed on 10/1/12, the Surveyor noted dark blue and purple colored bruises on Resident #4's left hand, extending into the index finger. Nursing Supervisor #3 and Nurse #1 said they had no knowledge of the areas prior to being asked by the Surveyor. Nurse #1 and Nursing Supervisor #3 measured the areas in the presence of the Surveyor; and were measured to be 2.25 inches (5.71 cm) by 1.5 inches (3.81 cm); a bruise which measured 2.0 cm by 2.0 cm, and a 1 cm in diameter dark purple/red bruise on the index finger. There was no indication the Facility completed a comprehensive investigation regarding the bruises of unknown origin found on Resident #4 on 4/12/12, 4/30/12, 5/10/12, 5/13/12, 6/10/12, 8/19/12, and 10/1/12 in an effort to determine their cause, and failed to ensure they were reported to the Department of Public Health. 4. The Incident Notification Form, dated 3/20/12, indicated at 7:00 A.M., Resident #6 was noted to be seated with his/her legs over the side of the bed, with a 3 inch (7.62 cm) skin tear on the left shin. The Form indicated the etiology was unknown. A witness statement, dated 3/20/12, was attached to the Form and indicated Resident #6 was in bed attempting to get up and when the CNA attempted to put on Resident #6's shoes the CNA noted the skin tear. There were no statements from any other staff who provided care to Resident #6 prior to when the skin tear was noted. 5. Resident #10's quarterly MDS, dated [DATE], indicated Resident #10 had impaired orientation and recall. The care plan, dated 3/6/12, indicated Resident #10 was dependent upon staff for bathing, dressing, and grooming. The Incident Notification Form and Report, both dated 8/13/12, indicated at 8:00 A.M., during A.M. care, the CNA noted Resident #10 had a 6 cm by 5 cm bruise on the left wrist and a dried skin tear on the left leg. The Form and Report both indicated the etiology of the bruise and skin tear was not known. The Investigation Report, dated 8/13/12, indicated one CNA and one nurse were interviewed as part of the investigation in an effort to determine the cause of Resident #10's injuries. 6. The Incident Notification Form, dated 5/15/12, indicated at 10:00 A.M., Resident #12 was noted to have a large bruise over the first knuckle of Resident #12's left hand. The Form indicated Resident #12 was combative with care on 5/14/12 and on 5/15/12, prior to when the bruise was noted. The Form indicated when questioned, Resident #12 was quoted as saying words to the effect of, " 'they must have hit me'.(sic)" The Investigation of Bruise/Skin Tear Form, dated 5/23/12, indicated the CNA assigned to provide care to Resident #12 during the 3:00 P.M. to 11:00 P.M. shift on 5/14/12, was left a questionnaire to complete and return to the QA Nurse. The Investigation Report, completed by the QA Nurse, was dated 5/15/12 and indicated, two CNAs and one nurse were interviewed as part of the investigation. There was no indication all staff who provided care to Resident # 12 during the 24 hours prior to when the bruise was noted and when Resident #12 said the "they" may have hit her, in accordance with Facility policy. 7. Resident #19's quarterly MDS assessment, dated 6/27/12, indicated Resident #19 had severely impaired decision making ability; required assistance with ambulation; and was dependent upon staff from bathing, dressing, and hygiene. a. The Incident Notification Form, dated 8/13/12, indicated that at 8:30 A.M. Resident #19 was found by a CNA with blood on his/her face, when the CNA brought Resident #19 a food tray. The form indicated when assessed, Resident #19 was noted to have a 3 cm round area with a 2 cm skin tear on Resident #19's mid-line side edge of the chin. A Incident Witness Statement, dated 8/13/12, was attached to the Form and indicated it was from the staff member who found the injury. There was no indication any additional staff or relevant witnesses were interviewed in an effort to determine the cause of the injury. b. The Incident Notification Form and Report, both dated 8/25/12, indicated at 7:00 P.M. when staff performed care on Resident #19, they noted a 3 cm by 2 cm bruise on Resident # 19's inner right wrist. The report indicated the etiology of the bruise was not known, and Resident # 19 was unable to provide any information regarding the injury due to dementia. An Incident Witness Statement, dated 8/25/12, was attached to the Form and indicated it was completed by the staff member who found the injury. There was no indication any additional staff or relevant witnesses were interviewed in an effort to determine the cause of the injury. The Investigation Report, dated 8/25/12, indicated one CNA was interviewed as part of the investigation. 8. The Incident Notification Form and Report, both dated 4/2/12, indicated at 10:00 A.M., Resident A was noted to have what was documented as a large bluish/purple colored bruise on the top of the left hand, of which the etiology was unknown. The Form indicated Resident A was unable to comment due to being non-verbal. Attached to the Incident Notification Form were three statements. The witness statement, dated 4/2/12, from the physical therapist indicated that at the time the bruise was noted Resident A was previously seated in the dining room in a gerichair. The report indicated Resident A was wearing protective sleeves at the time, and the bruise was noted after the sleeves were removed. The witness statement, dated 4/3/12, indicated the CNA who provided care to Resident A the day the bruise was noted documented Resident A had no bruise when care was provided. The Investigation Report (summary), dated 4/3/12, indicated two CNAs, one nurse, and the physical therapist were interviewed as part of the investigation in an effort to determine the cause of the injury. There was no indication the Facility completed a comprehensive investigation regarding the bruises of unknown origin found on Resident A on 4/2/12, in an effort to determine their cause, and failed to ensure they were reported to the Department of Public Health. 9. The Incident Notification Form and Investigation of Bruises Report, both dated 7/23/12, indicated at 8:15 P.M., Resident B was noted to have a 3 cm by 6 cm, dark purple bruise on right, lower leg. The Form indicated the etiology of the bruise was not known, and Resident B was unable to comment about the bruise due to cognitive impairment. The Incident Witness Statement, dated 7/23/12, indicated the staff member who found the injury provided a statement regarding the injury. There was no indication that any other statements were obtained from staff or relevant witnesses in an effort to determine the cause of the injury. There was no indication the Facility completed a comprehensive investigation regarding the bruises of unknown origin found on Resident B on 7/23/12 in an effort to determine their cause, and failed to ensure they were reported to the Department of Public Health. 10. The Incident Notification Form and Investigation of Bruise and Skin Tear Form, both dated 8/17/12, indicated Resident #26 was noted to have a 5 cm by 6 cm bruise on the left upper arm, which was found by the CNA during A.M. care. The Form indicated the bruise was not present during the previous days when care was provided; and Resident #26 was unable to state how the bruise occurred. The Incident Witness Statement, dated 8/17/12, indicated the staff member who found the injury provided a statement regarding the injury; and two Investigation of Bruises questionnaires, one dated 8/27/12 and the other dated 8/29/12 were attached to the Incident Notification Form. The name and title of the staff members who completed the 8/27/12 questionnaire were not legible. There was no indication the Facility completed a comprehensive investigation regarding the bruises of unknown origin found on Resident #26 on 8/17/12 in an effort to determine their cause, and failed to ensure they were reported to the Department of Public Health. 11. The Incident Notification Form, dated 8/19/12, indicated a CNA found Resident C with "old" bruising which measured, 7 cm by 6.5 cm on the right upper arm, and a second bruise which measured 7.5 cm by 8 cm, which was documented as being rose in color, slightly raised, and non-tender to the touch. The Form indicated Resident C was unaware of how the injuries occurred and had short-term memory issues. The Incident Witness Statement, dated 8/19/12, indicated it was completed by the staff member who found the injury. The Investigation Report, dated 8/19/12, indicated one CNA and one nurse were interviewed as part of the investigation in an effort to determine the cause of Resident C's injury. There was no indication the Facility completed a comprehensive investigation regarding the bruises of unknown origin found on Resident C on 8/19/12 in an effort to determine their cause, and failed to ensure they were reported to the Department of Public Health. 12. Resident #20 was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified the Resident as having some cognitive deficits, requiring total care in transfers via Hoyer lift and being non-ambulatory. The Resident did not have any skin issues and he/she did not have any falls. Review of an incident report dated 6/28/12 indicated the following: The aide was performing care with the Resident that evening at 7:00 P.M. and noted dry blood down the Resident's right leg. Nursing cleansed the area and noted a small 1 cm skin tear to the Resident's right knee with scant amount of bleeding. The Resident was unable to recall what happened. A statement was obtained from the aide who made the observation of the Resident. The aide indicated that prior to transferring the Resident via Hoyer-lift, the aide found dry blood down the Resident's right leg. Prior to the observation, the Resident was seated in his/her chair. The Resident was noted to have no recollection of the incident. Further review of this incident report indicated there were no interviews conducted with staff working prior shifts who cared for this Resident. On 10/16/12 at 9:00 A.M., an interview was held with the QA nurse. She stated that she conducts investigations regarding incidents pertaining to Residents. She also stated that it was the facility's practice to interview direct staff for 2 shifts as part of the investigation process. There was no written evidence that this was done, therefore, making this an incomplete investigation. 13. For Resident #13, the facility failed to conduct a thorough investigation to determine the cause of bruises of unknown etiology. Resident #13 was admitted to the facility in 7/2012 with a [DIAGNOSES REDACTED]. An Initial MDS dated [DATE] indicated the resident had severe cognitive impairment, was independent with transfers and ambulation and needed assistance with hygiene and bathing. According to an incident report dated 8/1/12, on 8/1/12 at 7:00 A.M. the resident was found with 2 bruised areas on the right lower extremity during morning care. The etiology was unknown. The witness statement dated 8/1/12 was completed by the CNA who discovered the bruises. There were no other interviews conducted to determine the possible cause of the bruises. On 10/16/12 at 9:00 A.M., an interview was conducted with the QA nurse, who conducts the investigations. She stated when she conducts an investigation of an injury of unknown etiology, she obtains statements from staff who cared for the resident from the previous 2 shifts in an attempt to determine the cause. When asked if there were any interviews for this investigation, she stated there was not. 14. For Resident #23, the facility failed to conduct a thorough investigation to determine the cause of bruises and skin tears of unknown etiology. Resident #23 was admitted to the facility with a [DIAGNOSES REDACTED]. An annual MDS dated [DATE] indicated the resident continued with severe cognitive impairment and was dependent on staff for transfers toilet use, hygiene and bathing. An incident report dated 2/8/12 at 11:30 P.M. indicated a 3 cm oval ecchymotic area was found on the left lateral shin. The only statement provided was a witness statement completed by the CNA that discovered the bruise. A thorough investigation was not conducted to determine the cause of the bruise. An incident report dated 3/25/12 indicated that on 3/25/12 at 6:30 A.M., during morning care, the aide noted a purple bruise on the resident's 2nd toe, right foot. Etiology unknown. Review of the investigation documentation revealed there was a witness statement from the CNA who discovered the bruise and a statement from the CNA who cared for the resident on the previous 3:00 P.M. - 11:00 P.M. shift. There was no further investigation conducted to determine the possible cause of the bruise. According to an incident report dated 4/26/12, on 4/26/12 at 9:00 A.M., the aide performing morning care noted the resident had a Band-Aid on the left forearm. The charge nurse removed the Band-Aid found a 1 cm round skin tear. The only statement included in the investigation documentation was the witness statement by the CNA that discovered the skin tear. A quarterly MDS dated [DATE] indicated the resident had no changes since the prior assessment. An incident repor

Based on observation, record review and interviews, the facility failed to ensure that 16 residents (#1, #2, #4, #5, #6, #7, #10, #11, #12, #13, #19, #21, #22, #23, #25 and #26) in a total of 26 sampled and 3 nonsampled residents, were provided adequate supervision and effective interventions to prevent injuries and accidents. Findings include: 1. For Resident #5 the facility failed to provide supervision and effective interventions to prevent falls with injuries (fracture) and skin tears. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) dated 12/4/11, indicated the resident had short and long term memory problems, required no assistance with transfers, ambulation and toileting, was occasionally incontinent of urine and had no falls in the last 90 days. A care plan for "Falls Risk" had the following problem statement: (Resident) ambulates independently with a rolling walker. He/She has a history of falls prior to admission. He/She has a [DIAGNOSES REDACTED]. Approaches included: - Keep room free of clutter. - Encourage participation in exercise program 3 times a week. - Remind him/her to use walker at all times and keep it within reach. - Monitor for signs of discomfort and encourage rest periods. According to an incident report dated 1/21/12, the resident fell on [DATE] at 4:45 A.M. The resident was found sitting on the floor near the bed. The resident stated he/she was going to the bathroom. The resident had his/her walker and the bed was wet at that time. The resident complained of pain to the left knee and tailbone. The left hip was reddened and tender to the touch. An X-ray was ordered by the nurse practitioner, which turned out to be negative for fractures. The intervention put into place to prevent further falls was: Urinal at bedside, resident reminded to ask for assistance, re-oriented to call light. A quarterly MDS dated [DATE] continued to assess the resident as having short and long term memory problems, requiring no assistance with transfers and ambulation, but now needed limited assistance with toilet use and was frequently incontinent of urine. In addition, the resident had a fall with a minor injury since the previous assessment. Further review of the facility's incident reports indicated the following: On 4/11/12 at 6:16 P.M. the resident's roommate called out for help. The resident was found leaning on roommate's footboard. The resident stated he/she went to the bathroom and lost his/her balance and slipped. The resident scraped his/her right forearm on the footboard sustaining a skin tear. The intervention put in place was: Resident encouraged to use walker instead of cane. On 5/5/12 at 11:00 A.M., the resident was calling out and was found seated on the floor at the bottom of the bed. The resident stated "I slipped". The resident did not have the walker when he/she was found. There were no injuries noted. The intervention put into place was: Resident placed on safety checks and encouraged to use his/her walker. On 5/13/12 at 4:15 A.M. during rounds, an aide heard a loud noise and went to the resident's room and found the resident lying on the floor on the right side. The resident complained of pain to the right shoulder and the right hip. The aide believed the resident was returning from the bathroom when he/she fell . An order was obtained to send the resident to the hospital for an evaluation. The resident was admitted to the hospital with [REDACTED]. Interventions put into place were: non skid socks at all times, pressure alarm in bed, chair alarm in wheelchair. A significant change MDS dated [DATE] identified the resident as now being totally dependent on staff for ADLs (activities of daily living) and having a fall with a major injury (fracture) since the previous assessment. Further review of the incident reports indicated the following: On 6/20/12 at 2:45 A.M., staff heard the resident yelling and found the resident hanging out of bed with the left leg still in bed. The rest of his/her body was on the floor. The bed alarm was not sounding. The resident complained of right shoulder pain and an order was obtained for an X-ray of the right shoulder. At 7:00 A.M., the charge nurse checked on the resident to find the resident with a hematoma to the right side of the forehead. The resident was restless and hallucinating. The Nurse Practitioner was updated and an order was obtained to send the resident to the hospital for a Cat Scan of the head. The intervention put in place was: low bed provided with half siderails, mat to floor and bed against the wall. On 8/1/12 at 6:00 P.M., the resident was in the hallway in a gerichair when another resident ran over the resident's left lower extremities causing a skin tear to the second toe on the left foot. Intervention: Isolated incident. No intervention. Staff aware to keep halls free of congestion with wheelchairs. On 8/16/12 at 1:00 P.M., staff heard the resident yelling and upon investigation found resident with skin tear to the right forearm below the elbow with frank bleeding. Resident's roommate states resident hit his/her elbow on door frame as resident transferred through it. Intervention: No intervention at this time. The resident was observed during the survey. On 10/1/12 at 10:30 A.M., the resident was observed seated in a scoot chair. The resident was self propelling around the halls of the nursing unit. On 10/2/12 from 9:00 A.M. until 12:30 P.M. the resident was observed again sitting in the scoot chair. The resident was wandering around the nursing unit. On 10/4/12 at 11:00 A.M., the resident was observed in the scoot chair. The resident was using the handrails on the walls to move down the hallway. On 10/9/12 at 4:45 P.M., during interview with the DON (Director of Nurses), she said that supervision and effective interventions were not provided to prevent the resident from sustaining falls and skin tears. 2. For Resident #7, the facility failed to provide supervision and effective interventions to prevent falls. This resident fell 9 times in an 8 month period. One fall resulted in a laceration to the scalp that required 6 staples. Resident #7 was admitted to the facility on [DATE]. The resident's first fall occurred on 1/20/12 at 1:30 A.M. According to an incident report dated 1/20/12, the resident's roommate called out to staff stating the resident was sitting on the floor. The resident was found sitting on the floor against the bed. The resident sustained [REDACTED]. The resident stated he was going to the bathroom. The intervention put in to place was: educate resident to use call light, ask for help and keep urinal at bedside. An initial MDS dated [DATE] assessed the resident as having severe cognitive impairment and needing extensive assistance with transfers, ambulation and toileting. In addition, the resident was continent of bowel and bladder and had 1 fall since admission with no injury. A care plan for falls, with a start date of 2/2/12, had the following problem statement: Ambulates with assist only. He/She has a history of falls prior to admission and is at risk. The care plan for falls included the following interventions: - 1 assist with all transfers and ambulation. - Keep personal items and call light within reach at all times, especially the urinal to decrease risk of self transferring in the bathroom. - Tabs alarm in bed and chair to alert staff to independent transfers. Review of the facility's incident reports indicated the following: On 2/18/12 at 10:40 P.M., the resident was heard calling out for help and was found on the floor next to the bed. The alarm was sounding. No injury was noted at that time. The intervention put into place was: 30 minute checks. On 2/20/12 at 9:30 A.M., the resident was found on the floor next to the bed. The resident stated he/she was trying to get onto the bed when he/she realized he/she couldn't do it and sat down on the floor. The resident's tabs alarm was not sounding. The facility felt the resident's significant other (who is also a resident at the facility) removed the tabs alarm from the resident. There was no injury. The intervention put into place was: change the tabs alarm to a pad alarm in the wheelchair and a pad alarm on the bed. On 2/22/12 at 11:40 A.M., the resident's significant other called out for help. The resident was found lying on his/her right side on the bathroom floor with a laceration to the right side scalp. The resident stated he/she slipped off the toilet. The resident's alarm was not sounding due the resident's significant other turning off the alarm and assisting the resident to the bathroom. The resident was sent out to the hospital for an evaluation. The resident returned to the facility with 6 staples to the right side of the scalp. The intervention put into place was: Velcro alarm belt. On 3/17/12 at 11:20 A.M., the resident's alarm was heard sounding and the resident was found seated on the floor beside the resident's personal recliner. The resident stated he/she attempted to get up into the wheelchair to get away from the noise in the hallway. No injury was noted. The intervention put into place was: a Velcro alarm belt in personal recliner. In addition, on 3/26/12, an alarm was installed on the bathroom door. On 4/12/12 at 4:45 A.M., the resident was heard yelling for help. When the staff responded, the resident was found on the floor outside the bathroom door. The resident was incontinent at the time of the fall. No alarms were sounding. Staff stated the batteries were dead in the mattress alarm and the alarm on the bathroom door was malfunctioning at the time. Further investigation revealed the bathroom door alarm was in the off position. The interventions put into place were: staff education and make sure alarms are working. No injuries were noted at the time of the fall, although 5 days later, on 4/17/12, bruises were noted on the right side of the resident's abdomen, which the facility attributed to this fall. A quarterly MDS dated [DATE] indicated that the resident continued to need extensive assistance with transfers, ambulation and toileting. The resident also had falls with and without injuries since the previous assessment. Further review of the facility's incident reports indicated the following: On 5/23/12 at 1:30 A.M., the resident's alarm was sounding. The resident was found on the floor. The resident's significant other was also laying on the floor. The resident stated "I asked my (significant other) to take me to the bathroom. I guess we both couldn't help each other." The resident was assessed and sent to the hospital for an evaluation due to the resident hitting his/her head. The resident returned to the facility the same day without injury. The intervention put into place was: re-orient resident with each contact. On 6/6/12 at 2:00 P.M., a staff member was walking past the resident's room and heard a chair alarm sounding. The resident's significant other was calling for help. The resident was seated on the bathroom floor. A small pink area was noted on the resident's buttocks. The resident stated "I slipped in my own bathroom". The resident was attempting to transfer to the toilet. The bathroom door alarm was not sounding at the time. The resident's significant other has a history of turning off the bathroom door alarm. Intervention is for maintenance to replace bathroom door alarm on the inside of the bathroom doorway. A quarterly MDS dated [DATE] indicated that the resident did not have any changes in the area of ADLs, but did experience falls since the previous assessment. An incident report dated 8/20/12 at 2:15 P.M. indicated that staff found the resident on his/her back on the bathroom floor. The resident fell backwards as he/she tried to toilet himself/herself. The chair alarm was sounding, but the bathroom door alarm was not. The intervention put in place was: the door alarm now has the on/off button taped in a permanent "ON" position so that everyone is reminded to leave the alarm on at all times. A nurse's note dated 9/25/12, 3:00 P.M. to 11:00 P.M., indicated the resident was found on his/her bathroom floor in a sitting position. There were no injuries noted. The resident's wheelchair alarm did not sound because it was turned off. The resident was observed daily during the survey. On 10/1/12 at 10:00 A.M., the resident was observed sitting in the activity lounge with his/her significant other. The resident was seated in a wheelchair with a Velcro seatbelt on. On 10/2/12 at 1:00 P.M., the resident was observed in his/her wheelchair being pushed by his/her significant other into their room. During interview on 10/9/12 at 3:00 P.M., the DON said that this resident had a high number of falls since admission to the facility and supervision and effective interventions were not provided prevent the falls. 3. For Resident #11, the facility failed to provide supervision and effective interventions to prevent falls. This resident fell 18 times in an 8 month period. Resident #11 was admitted to the facility on [DATE] and was identified on admission as being a high risk for falls with numerous falls at home. In addition, the resident utilized a wheelchair for mobilization and has a bed and chair alarm. The first fall for this resident occurred on 1/23/12 at 11:00 A.M. The incident report indicated the resident was being assisted by a physical therapist, when resident became weak, knees buckled and the physical therapist was unable to pull the chair close enough to the resident. The resident was safely lowered to the floor without injury. The intervention put into place was: Physical Therapist to have stand-by when resident is out of chair. The second fall occurred on the same day, 1/23/12, at 12:30 P.M. According to the incident report, the resident was in bed at 12:00 P.M. for some tests. At 12:30 P.M., the resident was heard yelling for help and was found on the bathroom floor. The alarm was not sounding. The resident stated "I had to go and I fell ". The resident had self transferred from the bed to the wheelchair. The resident stated he/she turned off the bed alarm. There was no injury. The intervention put in place was: wireless alarm on bed as well as alarmed floor mat inside bathroom door to alert staff if resident enters the bathroom alone. The third fall occurred on the same day, 1/23/12, at 7:30 P.M. The incident report indicated an aide responded to an alarm sounding in the resident's room and found the resident on the bathroom floor in a seated position. There were no injuries. An admission MDS dated [DATE] indicated that the resident was severely impaired cognitively, had behaviors of wandering daily, needed extensive assistance with transfers and toilet use, and was continent of bowels and occasionally incontinent of urine. The resident also had falls since admission to the facility. A "Falls Risk" care plan initiated on 2/2/12 contained the following problem statement: (Resident) is non ambulatory and transfers with 2 assist. He/She has a history of falls prior to admission and is at high risk. He/She constantly attempts to self transfer. Approaches included: - Cordless mattress alarm in bed, seat alarm in wheelchair, floor alarm in bathroom and he/she is on 30 minute checks as he/she will use other bathrooms as well as his/her own. - Keep personal items and call light within reach at all times. On 2/22/12 at 1:35 A.M., the resident was calling out for help and was found sitting on the floor at the end of the bed. The resident sustained [REDACTED]." The intervention put into place was: wireless alarm box permanently moved to nurses station for staff to observe. On 3/7/12 at 6:45 P.M., the resident was heard calling for help. The resident was found sitting on the floor in the handicap bathroom. The resident stated "I tried to transfer myself, I thought I could do it". Resident also states he/she shut off the alarm box prior to transferring. Intervention put in place: Urology appointment. On 4/3/12 at 6:15 P.M., the resident was heard calling for help and was found seated on the floor in front of his/her wheelchair. Resident stated he/she shut off the alarm. Intervention put into place was: Resident's alarm will be changed to wireless sensor and alarm box is to be kept at nurses station. A quarterly MDS dated [DATE] indicated that the resident continued to have severely impaired cognition, behaviors of wandering daily and required extensive assistance with transfers and toilet use. The resident was continent of bowels and occasionally incontinent of bladder. In addition, the resident continued to have falls, with and without injuries. Further review of the facility's incident reports indicated the following: On 4/25/12 at 7:30 P.M., the resident was in the bathroom with an aide but refused the assistance of the aide. The resident lost balance and slid from the toilet seat onto his/her knees. The intervention put into place was: encouraged family to follow up with neurologist. On 5/9/12 at 10:40 A.M., the resident attempted to toilet self and fell . Resident stated he/she forgot that he/she had a catheter in place. The resident was found on the bathroom floor when the aide responded to the resident's seat alarm sounding. The intervention put into place was: Physical Therapy/Occupational Therapy 3 - 4 times weekly and low bed. On 5/13/12 at 7:00 A.M., the resident's alarm sounded. An aide responded to find the resident seated on the floor beside the bed and holding onto the siderail. The resident stated "I slid". Interventions put into place: Resident to have a floor mat on door side of low bed. On 5/17/12 at 3:50 P.M., the resident was attempting to self transfer from the wheelchair to the bathroom and fell , landing on his knees. The resident was found on his/her knees in front of the tub area. Resident had alarmed mat at the entrance to the bathroom, but it was not working at the time. Intervention: Resident will now have bathroom door alarm to be placed behind the door where resident is unable to find it. On 5/23/12, a Significant Change MDS was conducted. The resident now was assessed as being totally dependent on staff for transfers and toilet use. The resident was identified as being incontinent of bowel and utilizing an indwelling catheter. In addition, the resident continued to have falls since the previous assessment. The resident continued to experience falls as evidenced by the following incident reports: On 5/25/12 at 9:50 P.M., the resident was found on the floor in a sitting position in the handicap bathroom. The resident was attempting to get on the toilet. The alarm was sounding at the time of the fall. The resident stated "I was trying to go to the bathroom." Intervention: Resident to be monitored for signs/symptoms of UTI (urinary tract infection). On 5/28/12 at 9:30 A.M., the housekeeper heard the resident call for help from the bathroom across from the nurses' station. The resident was found on the floor. The resident was attempting to self toilet. No alarm was sounding at the time. Intervention: Resident to have Velcro belt to wheelchair. Door alarm placed on handicap bathroom. On 6/24/12 at 10:15 A.M., the resident was heard calling for help. An aide responded and found the resident seated on the floor of the resident's bathroom. The resident had attempted to self transfer to the toilet. The alarms were not sounding. Intervention: Resident is being treated for [REDACTED]. On 7/2/12 at 12:30 P.M., the resident attempted to self transfer to the toilet and was found sitting on the floor in front of the toilet. At the time of the fall, the resident's clip belt was fastened on the wheelchair seat. The resident has in the past unclipped the belt and fastened it behind him/her prior to transferring himself/herself. Also, the resident's bathroom door alarm was not sounding at the time of the fall. Question whether staff or housekeeping turned alarm back on after using the bathroom with another resident or cleaning the bathroom. Intervention: Staff education - All staff members, please do not turn off bathroom door alarms when assisting residents or cleaning bathrooms. Alarms have been left in the off position and increasing the risk of falls to residents. On 7/8/12 at 1:45 P.M., the resident's bed alarm was sounding. The resident was found with both lower extremities between 2 bars on the bed frame and was sliding off the wheelchair. Intervention: Bed to be in the lowest position when resident is out of bed. On 8/16/12 at 6:45 P.M., the resident was heard yelling for help in the bathroom on the B side hall. The resident was found down on his right knee unable to get up. No injury was noted. The resident has a Velcro seat belt alarm that had been removed and refastened on the seat. The bathroom door alarm did not sound at the time of the fall. Intervention: Staff has forgotten in the past to turn the bathroom door alarm back on after use. The bathroom door alarm has now been taped into the "ON" position to serve as a reminder to leave the alarm on at all times. A quarterly MDS conducted on 8/22/12 indicated that the resident has moderate cognitive impairment, totally dependent for transfers and toilet use and was continent of bowels and had an indwelling catheter. The resident also had falls since the previous assessment. The resident continued to fall. Facility incident reports revealed the following falls: On 8/24/12 at 7:30 P.M., the resident was calling for help and found on the floor on his back of the upstairs handicap bathroom. The resident stated he wanted to use the bathroom, while trying to sit, he/she missed the toilet and landed on his/her buttocks. Intervention: New wedge cushion on order with OT (occupational therapy) for residents wheelchair. Also spoke with maintenance regarding a coded door release for all handicap bathrooms. On 9/11/12 at 6:30 P.M., the nurse heard the resident yelling for help. The resident was found on the floor of the handicap bathroom. The resident had shut off alarmed belt to transfer. Intervention: Nursing continues with recommendations for family to bring in resident's computer to help with appropriate activities. The resident was observed on 10/2/12 at 4:30 P.M. entering the handicap bathroom. The bathroom door alarm sounded and a staff member responded to assist the resident. On 10/9/12 at 3:00 P.M., the DON said that this resident had a high number of falls since admission to the facility and supervision and effective interventions were not provided to prevent the falls. 4. For Resident #1, the facility failed to provide supervision and effective interventions to ensure the resident was free from injuries sustained during personal care and of unknown etiology and to prevent resident to resident altercations. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated the resident had short and long term memory problems, severely impaired decision making skills and had experienced delusions in the last seven days. The resident was totally dependent for bed mobility, transfers, hygiene and bathing. In addition the resident had no skin problems. A care plan for "ADL" had the following problem statement: (Resident) is dependent for bathing, grooming and dressing. Interventions include: - Provide one assist in the A.M. and P.M. for bathing, grooming and dressing. - Provide two assist for all transfers and ambulation. Review of the facility's incident report indicated the following: On 6/3/12 at 10:45 A.M., during morning care, an aide noticed a large hematoma which measured 7.9 cm (centimeters) by 9 cm on the resident's right forearm. The resident cried out when the area was touched. When asked what happened, the resident stated "I don't know". An order was obtained for an X-ray to the resident's right wrist/forearm, which was negative for a fracture. After an investigation, the conclusion was: It appears as though the resident may have been assisted from the wheelchair by the right wrist. The resident is on coumadin therapy and has a history of bruising. Staff is frequently reminded via communication book as well as inservices about the use of gait belts for transfers and draw sheets for repositioning. Intervention: Nursing will continue to monitor area until area is reabsorbed. On 6/21/12 at 10:00 A.M., the resident was being assisted with a shower by 2 aides when the resident became combative, swinging and punching at staff and being verbally abusive. The resident continued with behaviors throughout the shower and was noted with a bruise to the left wrist area after ADLs. The resident is on coumadin and has a history of bruising. Intervention: Staff reminded and given counseling regarding resident rights. Staff educated on reading increased behaviors as a sign of refusal and reminded to maintain resident's safety and return for care at another time. The resident is up late nights and is often sleepy in the morning. The resident's shower time will be changed to the 3:00 -11:00 P.M. shift. On 6/22/12 at 1:30 P.M., the resident was in the wheelchair in the hallway when he/she was observed slapping and arguing with another resident . No injury occurred. Intervention: Residents were redirected with activity. On 6/23/12 at 6:30 P.M., the resident came up behind another resident and slapped him/her in the back. Intervention: Residents were separated and monitored throughout the remainder of the shift. On 7/2/12 at 9:30 A.M., during a transfer from the toilet to the wheelchair, the resident struck out at aide and hit her arm on the aide's name tag. The resident sustained [REDACTED]. Intervention: The area was cleansed and 3 steristrips were applied. On 8/1/12 at 1:00 P.M., the resident was sitting in the wheelchair in the hallway when an aide noted a bruise to the left posterior hand measuring 4 cm by 6 cm. The bruise was not present during morning care. There was no investigation to determine how the bruise occurred, but it was felt perhaps the resident may have gotten the bruise when he/she was pushed up to the lunch table. Intervention: Gerisleeves when out of bed. On 8/6/12 at 3:15 P.M., the resident was sitting in the wheelchair by the reception desk. Another resident approached the resident. A conversation ensued followed by the residents grabbing and hitting each other. Resident #1 stated the other resident dug his/her nails into the resident's left forearm. A slight red area was noted. Intervention: Residents were separated and resident's were reassured and easily directed. A quarterly MDS dated [DATE] indicated the resident had severe cognitive impairment, physical behavioral symptoms directed towards others and wandering within the last seven days, needing extensive assistance with transfers and ambulation and being totally dependent for hygiene and bathing. Further review of the incident reports indicated the following: On 9/12/12 at 11:30 P.M., the resident was in a recliner in the hall when an aide called the nurse to come check on the resident. Resident was noted with a 9 cm bruise to the entire top of the hand. The area was swollen and tender to touch. The resident had no recollection of the incident. Intervention: Area was elevated with ice. The resident had gerisleeves on at the time the bruise was noted. On 10/2/12 at 6:30 A.M., the resident was found with bruising on bilateral arms during morning care. The right elbow area bruise was red/purple in color and measured 6 cm by 4.5 cm. The left upper arm by the elbow was red in color and measured 4.5 cm by 3.5 cm. Intervention: Staff education. The resident was observed on 10/1/12 at 9:15 A.M. The resident was sleeping in a gerichair outside his/her room. The resident was wearing gerisleeves. On 10/2/12 at 2:00 P.M., the resident was observed sleeping in his/her bed. On 10/4/12 at 11:00 A.M., the resident was observed sitting in the gerichair outside his/her room with gerisleeves on. An interview was conducted with the DON on 10/9/12 at 5:00 P.M., and she said supervision and interventions were not provided to prevent bruising sustained during care and to protect the resident from being involved in resident to resident altercations. 5. For Resident #10, the facility failed to ensure the resident was safe and free from injuries sustained from an unsafe environment, resident to resident altercations and unknown etiologies. Resident #10 was admitted to the facility on [DATE] with dementia. A quarterly MDS dated [DATE] indicated the resident had severe cognitive impairment and displayed behaviors of rejecting care. The resident needed extensive assistance with transfers and bed mobility and was totally dependent for dressing, hygiene and bathing. A care plan developed for "ADL" contained the following problem statement: (Resident) is dependent for bathing, grooming and dressing. Can be resistive at times. Approaches include: - Provide one assist in A.M. and P.M. for bathing, grooming and dressing. - Assist with all transfers and ambulation. - Gerichair for comfort and safety. - Tabs alarm in chair, mattress alarm in bed. Review of the facility's incident reports indicated the following: On 3/8/12 at 9:35 P.M., the resident was sitting in a wheelchair in the hall when another resident propelled past the resident and bumped above the resident's left outer foot. No redness or edema was noted. Intervention: Isolated incident, no intervention at this time. On 4/15/12 at 6:00 P.M., the resident was in the hallway when the resident bumped her left front shin against the food truck as he/she was self propelling the wheelchair. The resident sustained [REDACTED]. Intervention: Staff to keep hallway less congested. On 4/16/12 at 8:00 P.M., the charge nurse was walking by the resident and noticed the resident with a red/purple circular area to the posterior right forearm and below the elbow. Intervention: Aides reminded via communication book to keep the halls less congested with wheelchairs and Hoyer lifts for the safety of the residents. A quarterly MDS dated [DATE] indicated the resident continued with severe cognitive impairment, displayed behaviors of physical and verbal symptoms directed towards others and rejecting care. In addition, the resident needed extensive assistance with transfers and bed mobility and was totally dependent for dressing, hygiene and bathing. Further review of the incident reports indicated the following: On 6/14/12 at 9:00 A.M., the resident was in the wheelchair screaming. The supervisor witnessed another resident back their wheelchair into the resident's left leg. The resident sustained [REDACTED]. Intervention: Appears to be an isolated incident. No intervention at this time. On 6/20/12 at 11:25 P.M., the resident self propelled through the nursing station door and hit the right elbow on the door sustaining a skin tear. The resident was not provided assistance by the staff for ambulation as required per the resident's care plan. Intervention: Incident appears isolated. Nursing to monitor area until resolved. No intervention at this time. Nursing to utilize lock inside door as needed. On 6/22/12 at 6:30 P.M., the resident was sitting in the wheelchair at the nurses' station when another resident approached the resident and slapped him/her. The residents were separated and redirected without further incident. No injury noted. Intervention: Redirected with activity. On 6/23/12 at 6:30 P.M., the resident was sitting in the hall by the nurses' station when another resident came up behind him/her and slapped him/her on the back. Intervention: The residents were separated and continuously monitored throughout the shift. On 7/31/12 at 5:00 P.M., it was reported by a nurse that the resident was slapped in the face by

Based on record review and staff interviews, the facility failed to provide supervision and assistance to prevent falls with injury for 1 resident (#27), who needed assistance to use the bathroom, in a total sample of 14 residents. Findings are: Resident #27 was admitted to the facility with hypertension and coronary heart disease. A quarterly MDS (minimum data set) dated 8/15/12 indicated the resident had moderately impaired cognition, needed extensive assistance with transfers and toileting, limited assistance with ambulation and was frequently incontinent of bladder. A care plan for falls included the following interventions: - Assist with all transfers and ambulation. - Mattress alarm in bed. - Tabs alarm in chair. - Non skid strips to bedside and in front of chair. Review a nursing note dated 10/27/12, 7:00 A.M. - 3:00 P.M., indicated the resident was very confused and was experiencing visual hallucinations. A urine culture was pending. According to the nurse's note dated 10/28/12, 7:00 A.M.- 3:00 P.M., the urine culture was returned indicating the resident had a UTI (urinary tract infection) and was started on an antibiotic. In addition, the resident had nasal and chest congestion and a productive cough. A chest x-ray was ordered by the physician, which showed the resident also had pneumonia. The resident was placed on a second antibiotic for the pneumonia according to a nurse's note dated 10/29/12, 7:00 A.M. - 3:00 P.M. Review of the facility incident report indicated the resident fell on [DATE] at 9:30 A.M. Further review of the incident report indicated on 11/1/12 at 9:25 A.M., the resident's roommate called out to Nurse #1 who was passing by the doorway to the room. Nurse #1 entered the room to find Resident #27 seated in the wheelchair in the bathroom. Nurse #1 pulled the call light in the bathroom for the resident, and the resident agreed to wait for someone to help him/her in the bathroom. Nurse #1 left the bathroom door open and left the room. At approximately 9:30 A.M., Resident #27's roommate was calling for help, when a Certified Nursing Assistant (CNA) responded. The roommate told the CNA that a noise came from the bathroom. Upon entering the bathroom, Resident #27 was found on the floor in the bathroom. The resident's tab alarm was attached to the resident's sweater, but the resident's sweater was found on the side of the weight chair in the bathroom. The resident stated he/she was standing at the sink washing his/her hands, lost his/her balance and fell . The resident was sent to the hospital and admitted with a left hip fracture. On 12/11/12 at 2:00 P.M., during interview, Nurse #1 stated on 11/1/12 at 9:25 A.M., she was passing by Resident #27's room, when the resident's roommate called her to report Resident #27 was in the bathroom. Resident #27 told Nurse #1 that he/she had to go to the bathroom. Nurse #1 stated she pulled the call light for the resident because the resident could not reach it and left the bathroom. Nurse #1 stated she does not do hands on care. Nurse #1 stated, in hindsight, maybe I should have stayed with the resident.

Based on record review and staff interview, the facility failed to provide services in accordance with the plan of care for 1 resident (#2) to prevent falls with injuries by not providing assistance as required, in a total sample of 14 sampled residents. Findings include: Resident #27 was admitted to the facility with hypertension and coronary [MEDICAL CONDITION]. A quarterly MDS (minimum data set) dated 8/15/12 indicated the resident had moderately impaired cognition, needed extensive assistance with transfers and toileting, limited assistance with ambulation and was frequently incontinent of bladder. A care plan for falls included the following interventions: - Assist with all transfers and ambulation. - Mattress alarm in bed. - Tabs alarm in chair. - Non skid strips to bedside and in front of chair. Review a nursing note dated 10/27/12, 7:00 A.M. - 3:00 P.M., indicated the resident was very confused and was experiencing visual hallucinations. A urine culture was pending. Review of the facility incident report indicated the resident fell on [DATE] at 9:30 A.M. Further review of the incident report indicated on 11/1/12 at 9:25 A.M., the resident's roommate called out to Nurse #1 who was passing by the doorway to the resident's room. Nurse #1 entered the room to find Resident #27 seated in the wheelchair in the bathroom. Nurse #1 pulled the call light in the bathroom for the resident, and the resident agreed to wait for someone to help him/her in the bathroom. Nurse #1 left the bathroom door open and left the room. Assistance was not provided as required per the resident's assessment and care plan. At approximately 9:30 A.M., Resident #27's roommate was calling for help, when a Certified Nursing Assistant (CNA) responded. The roommate told the CNA that a noise came from the bathroom. Upon entering the bathroom, Resident #27 was found on the floor in the bathroom. The resident's tab alarm was attached to the resident's sweater, but the resident's sweater was found on the side of the weight chair in the bathroom. The resident stated he/she was standing at the sink washing his/her hands, lost his/her balance and fell . The resident was sent to the hospital and admitted with a left [MEDICAL CONDITION]. On 12/11/12 at 2:00 P.M., during interview, Nurse #1 stated on 11/1/12 at 9:25 A.M., she was passing by Resident #27's room, when the resident's roommate called her to report Resident #27 was in the bathroom. Resident #27 told Nurse #1 that he/she had to go to the bathroom. Nurse #1 stated she pulled the call light for the resident because the resident could not reach it and left the room. Nurse #1 stated she does not do hands on care. Nurse #1 stated, in hindsight, maybe I should have stayed with the resident. Please refer to F323.

Based on record review and staff interview, the facility failed to provide services in accordance with the plan of care for 3 residents (#7, #11 and #25) to prevent falls with injuries, in a total sample of 26 sampled residents and 3 non-sampled residents. Findings include: 1. For Resident #7, the facility failed to follow the care plan for "Fall Risk" by not ensuring alarms were functioning properly. This resident fell 9 times in an 8 month period. One fall resulted in a laceration to the scalp that required 6 staples. Resident #7 was admitted to the facility in 1/2012. The resident's first fall occurred on 1/20/12 at 1:30 A.M. According to an incident report dated 1/20/12, the resident's roommate called out to staff stating the resident was sitting on the floor. The resident was found sitting on the floor against the bed. The resident sustained [REDACTED]. The resident stated he was going to the bathroom. The intervention put in to place was: educate resident to use call light, ask for help and keep urinal at bedside. An initial MDS (minimum data set) dated 1/31/12 assessed the resident as having severe cognitive impairment and needing extensive assistance with transfers, ambulation and toileting. In addition, the resident was continent of bowel and bladder and had 1 fall since admission with no injury. A care plan for "Falls Risk", with a start date of 2/2/12, had the following problem statement: Ambulates with assist only. He/She has a history of falls prior to admission and is at risk. The care plan for falls included the following interventions: - 1 assist with all transfers and ambulation. - Keep personal items and call light within reach at all times, especially the urinal to decrease risk of self transferring in the bathroom. - Tabs alarm in bed and chair to alert staff to independent transfers. A care plan for "ADL' with a start date of 2/2/12, had the following problem statement: (Resident) is assisted with bathing, grooming and dressing secondary to memory loss and decreased mobility. Approaches included: - Set up for grooming and assist as needed. - Assist with all transfers and ambulation. - Assist with toileting 2-3 times a shift and if he/she requests. Provide urinal when in bed. Review of the facility's incident reports indicated the following: On 2/18/12 at 10:40 P.M., the resident was heard calling out for help and was found on the floor next to the bed. The alarm was sounding. There was no indication as to why the alarm was not working. No injury was noted at that time. The intervention put into place was: 30 minute checks. On 2/20/12 at 9:30 A.M., the resident was found on the floor next to the bed. The resident stated he/she was trying to get onto the bed when he/she realized he/she couldn't do it and sat down on the floor. The resident's tabs alarm was not sounding. The facility felt the resident's significant other (who is also a resident at the facility) removed the tabs alarm from the resident. There was no injury. The intervention put into place was: change the tabs alarm to a pad alarm in the wheelchair and a pad alarm on the bed. On 2/22/12 at 11:40 A.M., the resident's significant other called out for help. The resident was found lying on his/her right side on the bathroom floor with a laceration to the right side scalp. The resident stated he/she slipped off the toilet. The resident's alarm was not sounding due the resident's significant other turning off the alarm and assisting the resident to the bathroom. The resident was sent out to the hospital for an evaluation. The resident returned to the facility with 6 staples to the right side of the scalp. The intervention put into place was: Velcro alarm belt. On 3/17/12 at 11:20 A.M., the resident's alarm was heard sounding and the resident was found seated on the floor beside the resident's personal recliner. The resident stated he/she attempted to get up into the wheelchair to get away from the noise in the hallway. No injury was noted. The intervention put into place was: Velcro alarm belt in personal recliner. In addition, on 3/26/12, an alarm was installed on the bathroom door. On 4/12/12 at 4:45 A.M., the resident was heard yelling for help. When the staff responded, the resident was found on the floor outside the bathroom door. The resident was incontinent at the time of the fall. No alarms were sounding. Staff stated the batteries were dead in the mattress alarm and the alarm on the bathroom door was malfunctioning at the time. Further investigation revealed the bathroom door alarm was in the off position. The interventions put into place were: staff education and make sure alarms are working. No injuries were noted at the time of the fall, although 5 days later, on 4/17/12, bruises were noted on the right side of the resident's abdomen, which the facility attributed to this fall. A quarterly MDS dated [DATE] revealed the resident continued to need extensive assistance with transfers, ambulation and toileting. The resident also had falls with and without injuries since the previous assessment. Further review of the facility's incident reports indicated the following: On 5/23/12 at 1:30 A.M., the resident's alarm was sounding. The resident was found on the floor. The resident's significant other was also laying on the floor. The resident stated "I asked my (significant other) to take me to the bathroom. I guess we both couldn't help each other." The resident was assessed and sent to the hospital for an evaluation due to the resident hitting his/her head. The resident returned to the facility the same day without injury. The intervention put into place was: re-orient resident with each contact. On 6/6/12 at 2:00 P.M., a staff member was walking past the resident's room and heard a chair alarm sounding. The resident's significant other was calling for help. The resident was seated on the bathroom floor. A small pink area was noted on the resident's buttocks. The resident stated "I slipped in my own bathroom". The resident was attempting to transfer to the toilet. The bathroom door alarm was not sounding at the time. The resident's significant other has a history of turning off the bathroom door alarm. Intervention is for maintenance to replace bathroom door alarm on the inside of the bathroom doorway. A quarterly MDS dated [DATE] indicated the resident did not have any changes in the area of ADLs, but did experience falls since the previous assessment. An incident report dated 8/20/12 at 2:15 P.M. revealed staff found the resident on his/her back on the bathroom floor. The resident fell backwards as he/she tried to toilet himself/herself. The chair alarm was sounding, but the bathroom door alarm was not. The intervention put in place was: the door alarm now has the on/off button taped in a permanent "ON" position so that everyone is reminded to leave the alarm on at all times. A nurses note dated 9/25/12, 3:00 P.M. to 11:00 P.M., indicated the resident was found on his/her bathroom floor in a sitting position. There were no injuries noted. The resident's wheelchair alarm did not sound because it was turned off. The resident was observed daily during the survey. On 10/1/12 at 10:00 A.M., the resident was observed sitting in the activity lounge with his/her significant other. The resident was seated in a wheelchair with a Velcro seatbelt on. On 10/2/12 at 1:00 P.M., the resident was observed in his/her wheelchair being pushed by his/her significant other into their room. On 10/9/12 at 3:00 P.M., the DON said that this resident had a high number of falls since admission to the facility and the alarms were not always working. 2. For Resident #11, the facility failed to follow the care plan for "Falls Risk" by not ensuring alarms were functioning properly. The resident fell 18 times in an 8 month period. Resident #11 was admitted to the facility on [DATE] and was identified on admission as being a high risk for falls with numerous falls at home. In addition, the resident utilized a wheelchair for mobilization and has a bed and chair alarm. The interim care plan for falls dated 1/18/12, had the following interventions: - Low bed against wall with mat on floor. - Grab bar. - Bed sensor alarm. The first fall for this resident occurred on 1/23/12 at 11:00 A.M. The incident report indicated the resident was being assisted by a physical therapist, when resident became weak, knees buckled and the physical therapist was unable to pull the chair close enough to the resident. The resident was safely lowered to the floor without injury. The intervention put into place was: Physical Therapist to have stand-by when resident is out of chair. The second fall occurred on the same day, 1/23/12, at 12:30 P.M. According to the incident report, the resident was in bed at 12:00 P.M. for some tests. At 12:30 P.M., the resident was heard yelling for help and was found on the bathroom floor. The alarm was not sounding. The resident stated "I had to go and I fell ". The resident had self transferred from the bed to the wheelchair. The resident stated he/she turned off the bed alarm. There was no injury. The intervention put in place was: wireless alarm on bed as well as alarmed floor mat inside bathroom door to alert staff if resident enters the bathroom alone. The third fall occurred on the same day, 1/23/12, at 7:30 P.M. The incident report indicated an aide responded to an alarm sounding in the resident's room and found the resident on the bathroom floor in a seated position. There were no injuries. An admission MDS dated [DATE] assessed the resident as having severely impaired cognition, having behaviors of wandering daily, needing extensive assistance with transfers and toilet use, and being continent of bowels and occasionally incontinent of urine. The resident also had falls since admission to the facility. A "Falls Risk" care plan initiated on 2/2/12 contained the following problem statement: (Resident) is non ambulatory and transfers with 2 assist. He/She has a history of falls prior to admission and is at high risk. He/She constantly attempts to self transfer. Approaches included: - Cordless mattress alarm in bed, seat alarm in wheelchair, floor alarm in bathroom and he/she is on 30 minute checks as he/she will use other bathrooms as well as his/her own. - Keep personal items and call light within reach at all times. On 2/22/12 at 1:35 A.M., the resident was calling out for help and was found sitting on the floor at the end of the bed. The resident sustained [REDACTED]." The intervention put into place was: wireless alarm box permanently moved to nurses station for staff to observe. On 3/7/12 at 6:45 P.M., the resident was heard calling for help. The resident was found sitting on the floor in the handicap bathroom. The resident stated "I tried to transfer myself, I thought I could do it". Resident also states he/she shut off the alarm box prior to transferring. Intervention put in place: Urology appointment. On 4/3/12 at 6:15 P.M., the resident was heard calling for help and was found seated on the floor in front of his/her wheelchair. Resident stated he/she shut off the alarm. Intervention put into place was: Resident's alarm will be changed to wireless sensor and alarm box is to be kept at nurses' station. A quarterly MDS dated [DATE] indicated the resident continued to have severely impaired cognition, behaviors of wandering daily and requiring extensive assistance with transfers and toilet use. The resident was continent of bowels and occasionally incontinent of bladder. In addition, the resident continued to have falls, with and without injuries. Further review of the facility's incident reports indicated the following: On 4/25/12 at 7:30 P.M., the resident was in the bathroom with an aide but refused the assistance of the aide. The resident lost balance and slid from the toilet seat onto his/her knees. The intervention put into place was: encouraged family to follow up with neurologist. On 5/9/12 at 10:40 A.M., the resident attempted to toilet self and fell . The resident stated he/she forgot that he/she had a catheter in place. The resident was found on the bathroom floor when the aide responded to the resident's seat alarm sounding. The intervention put into place was: Physical Therapy/Occupational Therapy 3 - 4 times weekly and low bed. On 5/13/12 at 7:00 A.M., the resident's alarm sounded. An aide responded to find the resident seated on the floor beside the bed and holding onto the siderail. The resident stated "I slid". Interventions put into place: Resident to have a floor mat on door side of low bed. On 5/17/12 at 3:50 P.M., the resident was attempting to self transfer from the wheelchair to the bathroom and fell , landing on his knees. The resident was found on his/her knees in front of the tub area. Resident had alarmed mat at the entrance to the bathroom, but it was not working at the time. Intervention: Resident will now have bathroom door alarm to be placed behind the door where resident is unable to find it. On 5/23/12, a Significant Change MDS was conducted. The resident now was assessed as being totally dependent on staff for transfers and toilet use. The resident was identified as being incontinent of bowel and utilizing an indwelling catheter. In addition, the resident continued to have falls since the previous assessment. The resident continued to experience falls as evidenced by the following incident reports: On 5/25/12 at 9:50 P.M., the resident was found on the floor in a sitting position in the handicap bathroom. The resident was attempting to get on the toilet. The alarm was sounding at the time of the fall. The resident stated "I was trying to go to the bathroom." Intervention: Resident to be monitored for signs/symptoms of UTI (urinary tract infection). On 5/28/12 at 9:30 A.M., the housekeeper heard the resident call for help from the bathroom across from the nurses' station. The resident was found on the floor. The resident was attempting to self toilet. No alarm was sounding at the time. Intervention: Resident to have Velcro belt to wheelchair. Door alarm placed on handicap bathroom. On 6/24/12 at 10:15 A.M., the resident was heard calling for help. An aide responded and found the resident seated on the floor of the resident's bathroom. The resident had attempted to self transfer to the toilet. The alarms were not sounding. Intervention: Resident is being treated for [REDACTED].(pain, potty, position and periphery) indefinitely and an attempt to increase the resident's activities will be made. On 7/2/12 at 12:30 P.M., the resident attempted to self transfer to the toilet and was found sitting on the floor in front of the toilet. At the time of the fall, the resident's clip belt was fastened on the wheelchair seat. The resident has in the past unclipped the belt and fastened it behind him/her prior to transferring himself/herself. Also, the resident's bathroom door was not sounding at the time of the fall. Question whether staff or housekeeping turned alarm back on after using the bathroom with another resident or cleaning the bathroom. Intervention: Staff education - All staff members, please do not turn off bathroom door alarms when assisting residents or cleaning bathrooms. Alarms have been left in the off position and increasing the risk of falls to residents. On 7/8/12 at 1:45 P.M., the resident's bed alarm was sounding. The resident was found with both lower extremities between 2 bars on the bed frame and was sliding off the wheelchair. Intervention: Bed to be in the lowest position when resident is out of bed. On 8/16/12 at 6:45 P.M., the resident was heard yelling for help in the bathroom on the B side hall. The resident was found down on his right knee unable to get up. No injury was noted. The resident has a Velcro seat belt alarm that had been removed and refastened on the seat. The bathroom door alarm did not sound at the time of the fall. Intervention: Staff has forgotten in the past to turn the bathroom door alarm back on after use. The bathroom door alarm has now been taped into the "ON" position to serve as a reminder to leave the alarm on at all times. A quarterly MDS conducted on 8/22/12 indicated that the resident had moderate cognitive impairment, was totally dependent for transfers and toilet use and was continent of bowels and had an indwelling catheter. The resident also had falls since the previous assessment. The resident continued to fall. Facility incident reports indicated the following falls: On 8/24/12 at 7:30 P.M., the resident was calling for help and was found on the floor on his back of the upstairs handicap bathroom. The resident stated he wanted to use the bathroom, while trying to sit, he/she missed the toilet and landed on his/her buttocks. Intervention: New wedge cushion on order with OT (occupational therapy) for residents wheelchair. Also spoke with maintenance regarding combination locks for all handicap bathrooms. On 9/11/12 at 6:30 P.M., the nurse heard the resident yelling for help. The resident was found on the floor of the handicap bathroom. The resident had shut off alarmed belt to transfer. Intervention: Nursing continues with recommendations for family to bring in resident's computer to help with appropriate activities. The resident was observed on 10/2/12 at 4:30 P.M. entering the handicap bathroom. The bathroom door alarm sounded and a staff member responded to assist the resident. On 10/9/12 at 3:00 P.M., the DON acknowledged this resident had a high number of falls since admission to the facility and the alarms were not always working. 3. For Resident #25, the facility failed to follow the "Falls Risk" care plan by not ensuring a tabs alarm worked properly and a dycem was placed correctly on the resident's wheelchair, resulting in the resident falling, hitting his/her head and sustained a laceration. Resident #25 was admitted to the facility with hospice services in 8/2012. [DIAGNOSES REDACTED]. The resident's interim care plan for falls dated 8/28/12 had the following interventions in place: * two assists pivot transfers/or hoyer (lift to assist the resident out of a bed or chair) prn (as needed) per level of lethargy, bed to wheelchair * PT (physical therapy) screen * Clutter free environment * Orient to new environment * Keep call light and personal items within reach * Encourage activities * Two assist stand pivot transfer The Initial Fall Risk Assessment was conducted on 9/4/12. The resident was a high fall risk (13 out of 15). Review of the nurses' notes and incident report dated 9/6/12, indicated that the resident was heard screaming from his/her room and was found sitting in front of his/her straight chair. On 9/6/12, bed and chair tabs alarms were added to the care plan. The Initial MDS dated [DATE], indicated the resident's cognition status was unable to be evaluated due to his/her physical and mental status. It also indicated that the resident required extensive assistance with bed mobility and eating and was totally dependent in ambulation, dressing, bathing and hygiene. The MDS indicated that the resident had falls prior to admission. The admission falls care plan dated 9/17/12, indicated that a dycem map was to be placed under and on top of the cushion on chair or wheelchair. This was in addition to the the other interventions. The nursing notes and the incident report dated 9/23/12, indicated that the resident was found during rounds on the floor. The alarm was not sounding and the dycem mat was under the seat cushion, but not on top of the seat cushion under the resident as per the care plan. The resident apparently slid out of the wheelchair hitting his/her head on the back of wheelchair. This caused a small laceration at the base of the head and a small red mark on the back of the right shoulder. The resident stated that he/she hit his/herself on the wheelchair. The incident report indicated that the alarm was not sounding due to the cord being too long. It was also documented that the care plan was not followed as the dycem mat was under the seat cushion, not between the cushion and resident. The resident did not use the call light near him/her due to being legally blind. The resident was observed in an easy chair on 10/15/12 at 5:35 P.M., in his/her easy chair with his/her legs elevated on a pillow. The tab alarm was on, but the call light was on the bed not in reach of the, as per care plan. During an interview with the Director of Nurses, Nursing Supervisor #2, and Nursing Supervisor #3 on 10/9/12 at 5:00 P.M., they said that the resident's care plan was not followed. Please see F323.