Every finding on record at The Center at Blue Hills

Based on interviews and records reviewed, for one of the three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff for care, the Facility failed to ensure Resident #1 was free from physical abuse when, on 01/14/26 around 7:30 A.M., Certified Nurse Aide (CNA) #1 slapped Resident #1 in the face, which was witnessed by another staff member. Resident #1 was observed to have red marks on his/her face, told staff his/her face hurt and that he/she had been slapped. Based on the reasonable person concept, a cognitively impaired resident would experience emotional upset after being slapped by a caregiver.Findings include:Review of the Facility Policy titled Abuse, Neglect, and Exploitation, dated as last revised 01/2025, indicated the Facility is to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The Policy indicated the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The Policy further indicated that physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 01/14/26, indicated that a Certified Nurse Aide (CNA, later identified as CNA #1) had been witnessed slapping Resident #1 in the face. The Report indicated that CNA #1 denied the allegation of slapping Resident #1, however CNA #1 had stated that she had pushed Resident #1. The Report indicated that Resident #1 had red markings to the right side of his/her face, reported pain to his/her face, and received pain medication.The Report indicated that the Police were notified, statements were obtained by the officer and CNA #1 was transported to the Police Department.Resident #1 was admitted to the Facility in September 2025, diagnoses include dementia with behavioral disturbances, major depression, and he/she is legally blind. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 12/09/25, indicated he/she scored a three (3) out of 15 on his/her Brief Interview for Mental Status (BIMS) (13-15 cognitively intact, 8-12 moderate cognitive impairment and 0-7 severe cognitive impairment), indicating he/she had severe cognitive impairment.During an interview on 01/29/26 at 3:31 P.M., Nurse #1 said while putting Resident #1's clothes away in his/her room, she heard someone say, why did you do that? Nurse #1 said she immediately left the room and went to the area of the incident (small alcove directly to the right of Resident #1's room) to see what was going on.Nurse #1 said when she got there, she observed Resident #1 holding his/her face with both hands, noted a red area on the right side of his/her face, and a scratch near his/her right eyebrow. Nurse #1 said CNA #2 was with Resident #1 and reported to her that CNA #1 had slapped Resident #1 in the face. Nurse #1 said she asked Resident #1 what happened and that Resident #1 said I got hurt. Nurse #1 said that CNA #1 had already left the scene.Nurse #1 said she immediately reported the incident to the Staff Development Coordinator (SDC), who was on Resident #1's Unit at the nurse's station at that time.During an interview on 01/29/26 at 12:51 P.M., the SDC said that she immediately called the Director of Nurses (DON, who was on her way to the Facility) to inform her of the incident, said she also instructed CNA #1 to remain off the resident units, and to wait for the DON to arrive to speak with her.The SDC said she went to assess Resident #1, and he/she was holding his/her head with both hands. The SDC said asked him/her what had happened and Resident #1 said that someone hit him/her in the face. The SDC said she observed a small pink scratch on the right side of his/her face.The SDC said she then interviewed CNA #1. The SCD said that CNA #1 said that Resident #1 was reaching for her glasses, so she pushed him/her away. During an interview on 01/29/26 at 2:28 P.M., the Medical Records employee said on 01/14/26 around 7:35 A.M., she was walking down the corridor on Resident #1's unit, overheard some commotion near the dirty utility room and said she heard what sounded like a slap. During an interview on 01/29/26 at 1:28 P.M., CNA #2 said on 01/14/26 around 7:30 A.M. she was going to the linen closet, located in a small alcove next to the dirty utility room on Resident #1's unit, to get linen for her assignment. CNA #2 said she turned into the alcove and witnessed CNA #1 slap Resident #1 in the face. CNA #2 said I saw her slap him/her so hard. CNA #2 said Resident #1 held his/her face with both hands, and she saw a red mark and little cut on the right side of his/her face. CNA #2 said she had never seen anything like that before and told CNA #1 that she cannot put her hands on any resident like that and that it was abuse. CNA #2 said Nurse #1 arrived almost immediately after the incident occurred and that she told Nurse #1 what she saw.During a telephone interview on 01/29/26, CNA # 1 said she was attempting to put dirty linen in the solid utility room (located in an alcove next to Resident #1's room) and Resident #1 was in front of her not allowing her to move forward to enter the dirty utility room.CNA #1 said Resident #1 refused to move and was grabbing for her face/glasses and she said that she pushed him/her away, with her hands on his/her shoulders.Review of the Police Report, dated 01/14/26, indicated that Resident #1 said that he/she had got into a tussle. The Police Report indicated that Resident #1 pointed to his/her right eye and stated he/she was hit in the eye. The Police Report indicated that Resident #1 said he/she was just sore and did not wish to go to the Hospital for evaluation.The Police Report indicated the Police Officer observed on the right side of Resident #1's head, near his/her eye that there were two (2) small red marks. The Police Report indicated that CNA #1 said that she had pushed Resident #1 on his/her shoulders.The Police Report further indicated that CNA #1 was placed under arrest and charged with assault and battery on a disabled person over the age of 60. During an interview on 01/29/26 at 2:59 P.M., the Director of Nurses (DON) said when she arrived at the Facility on 1/14/26, she immediately went to interview CNA #1, and that CNA #1 stated Resident #1 was trying to reach for her glasses and she had pushed him/her away.The DON said she also assessed Resident #1, and he/she reported to her that someone had slapped him/her in the face but could not remember who it was. The DON said she observed a red scratch mark on the right side of his/her face.The DON said it is the Facility's expectation that all residents remain free from any type of abuse, including physical, and all staff had been educated per the Facility Abuse Policy.On 01/29/26, the Facility presented the Surveyor with a plan of correction with an effective date of 01/26/26 that addressed the area of concern identified in this survey, as follows:A) Resident #1 was immediately assessed following the incident and was observed to have a small scratch and red marks to the right side of his/her face, and B) The Resident #1, declined offer to be transferred to the Hospital ED for evaluation, was administered medication for complaints of pain as needed for comfort and continues to be monitored and provided emotional supported by staff.C) Resident #1's Physician and Health Care Agent (HCA) notified and were made aware of the incident and injury.D) The Administrator and the Director of Nurses (DON) reviewed/submitted an internal investigation and personnel record review indicated that CNA #1 was immediately suspended following the alleged incident and subsequently terminated.E) On 01/14/26, the DON and other management staff began interviewing all residents able to be interviewed to elicited feedback regarding care and treatment provided by facility staff members. F) On 01/14/26, the DON and other management staff began monitoring residents that are unable to be interviewed for signs and symptoms of behavior, physical and/or functional changes for indicators of potential concerns of abuse.G) On 01/16/26 the Staff Development Coordinator (SDC) initiated mandatory staff training on the Facility Patient Abuse Policies and Caring for residents with Dementia.H) The Facility Educator and/or designee will conduct random validation quizzes for up to ten (10) employees to ensure comprehension of the Abuse Policy three times per week for three (3) weeks, then monthly for two (2) months to ensure compliance. I) The Facility Staff Educator and/or designee will conduct random interviews for residents able to be interviewed for up to 10 residents to ensure satisfaction and safety three times per week for three weeks, then for two months to ensure compliance. J) The areas of concerns were discussed by administration and management staff, related to the need for an Ad [NAME] Quality Assurance and Performance Improvement (QAPI) meeting to implement immediate corrective action.K) The results/data from the staff training and the resident's interviews will be presented at the next monthly QAPI meeting and quarterly reporting will continue.L) The DON and/or designee are responsible for overall compliance.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Maintain the resident kitchenette in a clean and sanitary condition, and to ensure all food was properly labeled and dated and removed after three days in one of one kitchenette reviewed; and 2. Ensure the ceiling in the main kitchen was maintained in a safe sanitary condition to prevent flaking with potential to contaminate food and clean dishes below. Findings include: 1. Review of the facility's policy titled Use and Storage of Food Brought in by Family or Visitors, dated 2024, indicated but was not limited to the following: -It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. -All food items that are already prepared by the family or visitor brought in must be labeled with the content and dated. -The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. -The food must be consumed by the resident within 3 days. -If not consumed within 3 days, food will be thrown away by facility staff. On 10/10/24 at 8:44 A.M., the surveyor made the following observations in the only resident kitchenette: Freezer compartment: -There was an open box of unsealed Jamaican Hot beef Patties, not labeled or dated. Refrigerator: -Orange bag which contained a plastic container of a meal consisting of rice, meat, and gravy, dated 9/30/24. -On the top shelf there was a plastic container of rice, meat, and gravy, not labeled or dated. -Clear plastic pitcher of orange juice, dated 10/3/24. - [NAME] bag containing a take-out container, labeled with a resident's name but not dated. -There was a water bottle stuck to the floor of the refrigerator in a red dried liquid. The red liquid was also splattered of the side wall and the inside bottom of the door. During an interview on 10/10/24 at 3:05 P.M., the surveyor and the Food Service Manager (FSM) observed the kitchenette and all the observation listed above were observed, except the Frozen Jamaican Hot Beef Patties box had been removed. The FSM said her staff stock and check the refrigerator a couple times a day. FSM said all the resident's food brought in from home should be labeled, dated, and all foods should be removed after three days. 2. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: 6-101.11 Surface Characteristics. Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned. 6-2 Design, Construction, and Installation 6-201 Cleanability: 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. Indoor areas 6-101.11 Surface Characteristics. On 10/11/24 at 8:32 A.M., the surveyor observed the ceiling above both sides of the dishwasher (including right side where the clean dishes exit the dish machine) and above the milk refrigeration chest located outside the walk-in refrigerator to be in disrepair with large areas of the ceiling flaking off and a large brown water stain in the area above the milk chest. There were clean pots and pans stored to right of the flaking ceiling by the milk chest. During an interview on 10/11/24 at 8:45 A.M., the FSM said the ceiling has been like this for several months. She said the Maintenance Director already worked on the area above the milk chest, but it is flaking off again. The surveyor viewed the ceiling over the milk chest to be actively flaking off and containing a large brown water damaged area. During an interview on 10/11/24 at 9:32 A.M., the Maintenance Director said he tried to patch the area above the milk chest a while ago. During an interview on 10/11/24 at 10:33 A.M., the Administrator said he thought some work had been done on the kitchen ceiling already and was not aware the ceiling was still flaking. During an interview on 10/11/24 at 11:24 A.M., with the Maintenance Director and the Administrator present, the Maintenance Director said the ceiling flaking and water stain have been there for a while. He said he started on the ceiling over the milk chest, but there was a leak in the bathroom above which left a water stain on the ceiling, and it started flaking again.

Based on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit of three units in the facility. Specifically, the facility failed to ensure a utility room with hazardous items stored in it was not easily accessible to wandering residents on a Dementia Special Care Unit. Findings include: On 10/9/24 at 9:14 A.M., the surveyor observed an unlocked utility room with the door ajar, the surveyor was easily able to enter the room with just a gentle push of the door. Inside the room the surveyor observed: -Two open four-gallon bottles of no-rinse floor stripper -A pair of unsecured and unlabeled dentures -Four full containers of used sharps being stored -A four-gallon bottle of concentrated degreaser cleaner with approximately half of the liquid remaining in the bottle. On 10/9/24 at 10:24 A.M., the surveyor observed on the South unit of the Dementia Specialty Care facility, a resident walking without direction independently past the unlocked utility room. On 10/9/24 at 11:19 A.M., the surveyor observed Housekeeper #2 putting trash and a dirty linen cart inside of the unsecured utility room and leaving the door unlocked and ajar upon exiting. On 10/9/24 at 4:10 P.M., the surveyor observed the utility room door unlocked and ajar with staff and residents walking by the utility room. On 10/10/24 at 8:02 A.M., the surveyor observed the door of the utility room unlocked and ajar; the door was able to be pushed open without force. On 10/10/24 at 8:30 A.M., the surveyor observed the Director of Maintenance walking past the unlocked ajar utility room door and stopped to talk with a resident in the room across the hall. On 10/10/24 at 8:34 A.M., the surveyor observed a resident ambulating independently in the hallway with no direction. The surveyor observed him/her looking around and entering a room three doors down from the unlocked ajar utility room. The surveyor also observed another resident ambulating in the hallway independently. On 10/10/24 at 8:38 A.M., the surveyor observed a resident going behind the curtain next to the utility room door where Hoyer lift equipment was kept. The surveyor observed this resident attempt to take down a stop sign in front of an exit door at the end of hallway. The resident sat in another resident's wheelchair at the end of the hall after staff redirected the resident away from exit door. During an interview on 10/10/24 at 8:40 A.M., Certified Nursing Assistant (CNA) #1 said there are about five or six residents who wander up and down the hallway on this unit. She said some go in and out of other residents' rooms and that is why most rooms have a stop sign banner to deter residents from wandering where they shouldn't be. During an interview on 10/10/24 at 8:43 A.M., Nurse #1 said the stop signs are up to prevent the residents who wander into rooms they shouldn't. She said there are a lot of residents who wander (walk without direction) and attempt to go in rooms they should not. On 10/10/24 at 9:24 A.M., the surveyor observed a resident in a wheelchair self-propelling down the hallway past the unlocked and ajar utility room door. On 10/10/24 at 9:28 A.M., the surveyor observed CNA # 1 push the door open and push the dirty linen cart in the room and exit the room without ensuring the door was closed and locked. CNA #1 said they must put everything away because the residents will take things. On 10/10/24 at 10:42 A.M., the surveyor observed Housekeeping staff #2 exit the utility room and did not ensure the door was locked or secured behind her. The surveyor observed that the door to the utility room remained unlocked and ajar. On 10/10/24 at 9:32 A.M., the surveyor observed the door to the utility room unsecured and ajar while a resident was walking in the hallway attempting to enter a room with a Velcro stop sign banner which was next to the utility room. During an interview on 10/10/24 at 11:30 A.M., the Director of Nurses (DON) said the door to the utility room should be closed and secured at all times. She said her expectation is that staff ensure the door is closed and the room is secured so no residents can wander into the utility room and have access to hazardous materials.

Based on record review and interview, the facility failed to ensure Advance Directives were formulated and signed by the clinician (Physician, Nurse Practitioner, or Physician Assistant) making them valid for one Resident (#18), out of a total sample of 16 residents. Findings include: Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated 8/10/13, indicated but was not limited to the following: Instructions: -This form should be signed based on goals of care discussions between the patient (or patient's representative signing below) and the signing clinician. -Sections A through C are valid orders only if sections D and E are complete. If any section is not completed, there is no limitation on the treatment indicated in that section. Section D: Patient or patient's representative signature is required. Section E: Clinician signature required. Review of Resident #18's MOLST indicated section D and section E were both signed by Resident #18's Healthcare proxy (HCP) on 9/18/21. Resident #18 indicated advanced directives to be: Do not resuscitate (DNR), Do not intubate (DNI), Do not hospitalize (DNH), no dialysis. -Section E was not signed by the clinician making Resident #18's MOLST form not valid. Review of Resident #18's care plan indicated but was not limited to: -Advanced Directives DNR, DNI, DNH, no dialysis, HCP invoked. -My advanced directives will be honored through the next 90 days. -Please note, my wishes are clearly marked and identified in my medical record. -Please review my code status quarterly at my intra-disciplinary care plan meeting. During an interview on 10/10/24 at 3:20 P.M., the Director of Nurses (DON) said the MOLST should be signed by the physician to be valid. The DON said she will check in overflow to see if there is a MOLST signed by the clinician. During an interview on 10/10/24 at 4:40 P.M., the DON said there is no MOLST signed by the physician.

Based on record review and staff interview, the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it was appropriate to extend beyond 14 days for one Resident (#3), out of a total sample of 16 residents. Specifically, the facility failed to ensure a rationale was documented in the medical record for extending the use of Trazodone (anti-depressant) used for anxiety/agitation/insomnia. Findings include: Review of the facility's policy titled Use of Psychotropic Medications, dated as last revised 3/4/24, indicated but was not limited to the following: -A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. -PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnoses' specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). -If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Resident #3 was admitted to the facility in December 2023 with diagnoses which included insomnia, psychotic disorder with delusions, mood disorder, falls, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/15/23, indicated he/she scored 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had severe cognitive impairment. Additionally, he/she was taking an antidepressant. Review of the Physician's Orders from admission indicated but were not limited to the following: -Trazodone 25 milligrams (mg) by mouth two times a day for antidepressant (12/11/23) -Trazodone 25 mg by mouth every 6 hours as needed for anxiety/agitation for 14 days (12/11/23) -Trazodone 50 mg by mouth at bedtime for insomnia (12/11/23) -Trazodone 50 mg by mouth every 24 hours as needed for insomnia for 14 days (12/11/23) Review of the physician and psych progress notes indicated the following: -12/12/23, Resident #3 was seen by the Attending, the progress note indicated he/she was in no apparent distress and the plan was to provide supportive care and follow up with psych services routinely. Additionally, the note indicated to monitor sleep habits and adjust accordingly. The note failed to indicate a plan to extend the newly ordered PRN medications for Resident #3. -12/13/23, Resident #3 was seen by Psychiatry for an initial consult, the progress note indicated he/she was appearing pleasant with baseline confusion. He/she is tolerating the current psych med regime which I will recommend to maintain for now in order to obtain a longer baseline to avoid instability. Attempt gradual dose reduction (GDR) next exam if deemed necessary. RECOMMENDATION: MEDICATION CHANGES: Extend both PRN Trazodone orders for 90 days. The note failed to indicate a rationale to extend the newly ordered PRN medications for Resident #3. Review of the nursing notes (12/11/23-12/13/23) failed to indicate Resident #3 had experienced anxiety, agitation, or insomnia since admission. Review of the Medication Administration Record (MAR) (12/11/23-12/13/23) failed to indicate either PRN medication had been administered. Review of the physician progress note, dated 12/14/23, failed to indicate a rationale to extend the newly ordered PRN medications for Resident #3. Review of subsequent progress notes for December 2023 failed to indicate a rationale to extend the newly ordered PRN medications for Resident #3. Review of the Physician's Orders indicated the following changes were made on 12/13/23: -Trazodone 50 mg by mouth every 24 hours as needed for insomnia for 14 days (12/11/23-Discontinued 12/13/23) -Trazodone 50 mg by mouth every 24 hours for insomnia for 90 days (12/13/23) During an interview on 10/11/24 at 9:49 A.M., the Assistant Director of Nurses (ADON)/Staff Development Coordinator (SDC) said PRN psychotropic medications are to be limited to 14 days unless the Doctor writes an order to extend it and documents a rationale as to why they want to keep it longer. The ADON/SDC said she was not sure why the Trazodone was extended right after admission to the facility and was unable to provide the surveyor with a documented rationale in the medical record. During an interview on 10/11/24 at 12:20 P.M., the Director of Nurses (DON) and Corporate Nurse #1 said the provider should document a rationale to extend the PRN psychotropic and they were unable to locate a documented rationale in the medical record for extending the PRN Trazodone from 14 days to 90 days. During a follow up interview on 10/11/24 at 2:36 P.M., Corporate Nurse #1 said she thinks psych wanted to extend the Trazodone given his/her history of behaviors prior to admission and to ensure the medication didn't drop off after 14 days if he/she did need it. However, she was unable to provide a documented clinical rationale from the provider in the medical record.

Based on record review and interviews, the facility failed to ensure one Resident (#37), out of a total sample of 16 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to address wound physician's recommendations timely for care and treatment of two Stage 3 pressure ulcers (full thickness tissue loss that extends through the skin into the fat and deeper tissue, but does not expose bone, tendon, or muscle) to the coccyx (tailbone) and right buttock. Findings include: Review of the facility's policy titled Pressure Ulcer Prevention and Management, dated as last revised 3/4/24, indicated but was not limited to the following: -The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. -Licensed nurses will conduct full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. -The staging of pressure injuries will be clearly documented. -The RN Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression toward healing, and compliance at least weekly, and document a summary of findings in the medical record. -The attending physician will be notified of progression towards healing, or lack of healing, of any pressure ulcers weekly. Resident #37 was admitted to the facility in August 2024 with diagnoses which included unstageable pressure ulcer (the base of the wound bed is covered by a layer of dead tissue often yellow, green, grey, brown, or black therefore the wound cannot be accurately staged) of the sacral region (back of the pelvis at the base of the spine above the coccyx/tailbone). (Note: Sacrum and Coccyx are often inadvertently used interchangeably due to the proximity of the two areas.) Review of the Minimum Data Set (MDS) assessment for Resident #37 indicated he/she scored 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had severe cognitive impairment. Additionally, he/she had an unstageable pressure injury. Review of the Admission Nursing Assessment skin check indicated a pressure ulcer to the coccyx but failed to indicate a stage or description of the wound. Review of the Discharge Summary, dated 8/14/24, indicated but was not limited to the following: -Diagnosis: Pressure Ulcer of Sacral region, unstageable. -Wound Care Treatment Daily: Wound recommendations for buttocks: Treatment Plan: Opticel (gelling fiber wound dressing providing optimal moist wound healing environment) 1. Remove old dressing (moisten dressing with normal saline prior to removal if adhered to wound bed). 2. Cleanse wound with wound wash to peri wound, let it dry. 3. Apply skin prep. 4. Cut Opticel to fit wound base. Apply into wound bed dry. 5. Cover with foam dressing. Change dressing daily. -Ascorbic Acid 500 milligrams (mg) give one tablet by mouth twice a day. Review of the Physician's Orders from admission failed to indicate wound care was ordered as recommended. Review of the physician and nursing notes failed to indicate the recommendations for the dressings were reviewed with the Attending Physician and declined. Further review of the Physician's Orders indicated but were not limited to the following: -Silver Sulfadiazine External 1% Cream: Apply to burrock (sic) topically every shift for wound (8/14/24- Discontinued 8/15/24) -Silver Sulfadiazine External 1% Cream: Apply to buttocks/coccyx topically every shift for wound (8/15/24) -Ascorbic Acid 500 milligrams (mg) give one tablet by mouth two times a day for supplement (8/14/24) Further review of the medical record indicated Resident #37 was seen by the Wound Physician on 8/15/24. Review of the Initial Wound Evaluation and Management Summary, dated 8/15/24, indicated the following: -Patient presents with wound on coccyx and right buttock. -Site 1: Stage 3 Pressure Wound Coccyx Full Thickness measures 1.4 x 0.3 x 0.2 centimeters (cm) -Site 2: Stage 3 Pressure Wound of the Right Buttock Full Thickness measures 0.8 x 0.5 x 0.2 cm Dressing Treatment Plan: Calcium Alginate and Gauze Island with border dressing daily. Recommendations: Cleanse with normal saline at time of dressing change. Vitamin C 500 mg twice daily and Zinc Sulfate 220 mg once daily for 14 days. Review of the Physician's Orders failed to indicate the Wound Care Physician's recommendations were ordered as recommended. Review of the physician and nursing notes failed to indicate the recommendations for the dressings or the Zinc Sulfate were reviewed with the Attending Physician and declined. Review of the Wound Care Evaluation & Management Summary, dated 8/22/24, indicated the same recommendations were made from 8/15/24. Review of the Physician's Orders failed to indicate the Wound Care Physician's recommendations were ordered as recommended. Review of the physician and nursing notes failed to indicate the recommendations for the dressings or the Zinc Sulfate were reviewed with the Attending Physician and declined. Review of the Physician's Orders indicated the following: (12 days after initially recommended by the Wound Doctor) -Coccyx: Cleanse area with normal saline or wound cleanser. Apply skin barrier wipe to peri wound area. Apply Calcium Alginate and cover with border gauze as needed for skin impairment and every evening shift for skin impairment. (8/27/24) -Right Buttock: Cleanse area with normal saline or wound cleanser. Apply skin barrier wipe to peri wound area. Apply Calcium Alginate and cover with border gauze as needed for skin impairment and every evening shift for skin impairment. (8/27/24) -Zinc 50 mg by mouth one time a day for supplement for 14 days. (8/27/24) Review of the Wound Care Evaluation & Management Summary, dated 8/29/24, indicated the following: -Site: 1 Coccyx wound was macerated with increased moisture after Foley catheter discontinuation. -Site: 2 Right Buttock was at goal. No changes were made to either treatment and the recommendations remained the same as the orders implemented on 8/27/24. -Site: 3 Sacrum (New Area) measured 2.2 x 2.1 x not measurable cm (depth not measurable due to the presence of nonviable tissue and necrosis (death of body tissue)). Wound was surgically debrided to remove the necrotic tissue down to the healthy tissue. Dressing Treatment Plan: Calcium Alginate and Gauze Island with border dressing daily. Review of the Physician's Orders failed to indicate the Wound Care Physician's recommendations for Site 3: Sacrum were ordered as recommended. Review of the physician and nursing notes failed to indicate the recommendation for the Sacral wound was reviewed with the Attending Physician and declined. Review of the Physician's Orders indicated the following: (5 days after initially recommended by the Wound Doctor) -Sacrum: Cleanse area with normal saline or wound cleanser. Apply skin barrier wipe to peri wound area. Apply Calcium Alginate and cover with border gauze as needed for skin impairment and every evening shift for skin impairment. (9/3/24) Review of the Wound Care Evaluation & Management Summary, dated 9/5/24, indicated the following: -Site: 1 Coccyx wound was at goal. -Site: 2 Right Buttock was at goal. No changes were made to either treatment and the recommendations remained the same as the orders implemented on 8/27/24. -Site: 3 Sacrum was resolved. Review of the Wound Care Evaluation & Management Summary, dated 9/12/24, indicated the following: -Site: 1 Coccyx wound was at goal. -Site: 2 Right Buttock was at goal. Dressing Treatment Plan for both areas was for Collagen Sheet and cover with border gauze. Review of the Physician's Orders failed to indicate the Wound Care Physician's recommendations were ordered as recommended. Review of the physician and nursing notes failed to indicate the recommendations for the dressings were reviewed with the Attending Physician and declined. Review of the Wound Care Evaluation & Management Summary, dated 9/19/24, indicated the following: -Site: 1 Coccyx wound was not at goal. Consider patient behavior as factor that is complicating wound healing and discussed it further with staff and/or family. -Site: 2 Right Buttock was not at goal. Dressing Treatment Plan for both areas was for Collagen Sheet and cover with border gauze. Review of the Physician's Orders indicated the following: (7 days after initially recommended by the Wound Doctor) -Coccyx: Cleanse area with normal saline or wound cleanser. Apply skin barrier wipe to peri wound area. Apply Collagen Sheet (cut collagen sheet size of wound) and cover with border gauze as needed for skin impairment and every evening shift for skin impairment. (9/19/24) -Right Buttock: Cleanse area with normal saline or wound cleanser. Apply skin barrier wipe to peri wound area. Apply Collagen Sheet (cut collagen sheet size of wound) and cover with border gauze as needed for skin impairment and every evening shift for skin impairment. (9/19/24) During an interview on 10/9/24 at 2:55 P.M., the Director of Nurses (DON) said Resident #37 declines to get out of bed and is non-complaint with repositioning as he/she likes to lay on their back. She said Resident #37 has a very long history of large pressure areas to his/her sacrum/buttocks/coccyx. She said she does rounds with the Wound Doctor and the Assistant Director of Nurse (ADON) writes the orders after the notes come over. During a wound care observation on 10/10/24 at 2:00 P.M., the Wound Doctor confirmed both areas were present on admission, have improved at this time, and said Resident #37 is non-compliant with offloading the wounds. He said there is a long history of pressure ulcers to this area making him/her more susceptible for future breakdown. During an interview on 10/11/24 at 8:55 A.M., the DON said the Medication Nurse and/or ADON review the recommendations when they come in. She said the Attending Physician doesn't always agree but if they disagree there should be a note in the medical record. During an interview on 10/11/24 at 9:49 A.M, the ADON said the DON does the actual wound rounds and she writes the orders after the notes are done. She said she usually has the recommendations and writes the orders the next day. She said typically the Attending Physician goes along with wound care recommendations and if they decline, then there should be a note in the record. The ADON did not recall why Resident #37 had an order for Silver Sulfadiazine Cream on admission and not a dressing. Regarding the Wound Care recommendations not ordered timely from visits on 8/15, 8/22, and 9/12, the ADON said they had some issues getting the notes to upload into the electronic medical record but could not recall the exact dates. She said if the notes are not uploaded the next day, she usually emails the Wound Doctor. She said she has never called him looking for missing recommendations. The ADON was unable to provide any email correspondence from August 2024 between her and the Wound Doctor regarding missing recommendations. The ADON provided the surveyor with one email correspondence dated 9/17/24 that indicated they were unable to use recommendation, today is Wednesday that is a delay in treatment. PCP came into the facility with new order to continue same treatment. The ADON said a week is unreasonable to wait for a recommendation to come over and it should be received and addressed by the next day. She said she did not have the Wound Doctor's phone number, so she just sends an email and waits for them to come in. She said sometimes the notes are emailed to us and other times they are directly uploaded to the medical record. During an interview on 10/11/24 at 11:38 A.M., the DON said she does rounds with the Wound Doctor, but he does not give verbal recommendations. She said he usually reviews the chart, finishes the notes, and then uploads them into the medical record. She said usually they have the notes within 24 hours, not days/weeks later. She said there were some integration issues, so he was emailing the recommendations, but she was not aware they were having issues getting the recommendations timely. She said if they did not get the recommendation then they should be contacting the Wound Doctor for them, she said she has his phone number and email and then they should be writing a progress note. During an interview on 10/11/24 at 2:20 P.M., the Wound Doctor said he rounds weekly with the DON and the notes are supposed to sync/integrate but they don't always, so he emails them and/or manually uploads them himself. He said IT was investigating because there was no rhyme or reason to what was and was not uploading. He said he recalls some communication with the ADON about notes and said when he was notified they did not receive a note he would send it right over. He said he did not recall specifically how many times there was a delay in receiving the recommendations, but it was few, with different residents and even in different buildings. He said it was a system problem that they need to get fixed and in the meantime, he had just been manually uploading the notes himself. The Wound Doctor failed to provide any correspondence regarding missing notes or integration issues with Resident #37.

Based on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Quarterly MDS assessment within the required time frame for three Residents (#30, #21, #41), out of a total of 28 comprehensive assessments reviewed from September 2024 through October 9, 2024. Findings include: The MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment. A Quarterly MDS assessment is considered timely if the Assessment Reference Date (ARD) of the Quarterly MDS is completed within 92 days of the most recent OBRA Assessment reference date (Admission, Annual, Quarterly, or a Significant Change in Status Assessment), and submitted no later than 14 days after the assessment reference date. 1. Resident #30 was admitted to the facility in November 2017. Review of the quarterly MDS assessment, dated 9/17/24, indicated it was not completed until 10/3/24, a total of three days late. 2. Resident #21 was admitted to the facility in July 2017. Review of the quarterly MDS assessment, dated 9/17/24, indicated it was not completed until 10/3/24, a total of three days late. 3. Resident #41 was admitted to the facility in January 2020. Review of the quarterly MDS assessment, dated 9/17/24, indicated it was not completed until 10/3/24, a total of three days late. During an interview on 10/10/24 at 11:03 A.M., the MDS Coordinator said she was responsible for the completion of the MDS assessments and was aware that they were not being completed timely. She said she was recently out of work and there was nobody to assist her with the completion of the assessments while she was out of the building. During an interview on 10/10/24 at 1:57 P.M., the MDS timeliness was discussed with the Administrator. He said there should be someone to support the MDS Coordinator when she is out so the assessments are not completed late.

Based on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Comprehensive MDS assessment within the required time frame for five Residents (#59, #20, #23, #42, #22), out of a total of 28 comprehensive assessments reviewed from September 2024 through October 9, 2024. Findings include: The MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment. An Admission MDS assessment is considered timely when it is completed within 14 calendar days after admission to the facility. 1. Resident #59 was admitted to the facility in September 2024. Review of the admission MDS assessment, dated 9/16/24, indicated it was not completed until 9/27/24, a total of four days late. 2. Resident #20 was admitted to the facility in September 2024. Review of the admission MDS assessment, dated 9/16/24, indicated it was not completed until 10/2/24, a total of eight days late. 3. Resident #23 was admitted to the facility in September 2024. Review of the admission MDS assessment, dated 9/16/24, indicated it was not completed until 9/26/24, a total of three days late. 4. Resident #42 was admitted to the facility in August 2024. Review of the admission MDS assessment, dated 9/3/24, indicated it was not completed until 9/12/24, a total of two days late. 5. Resident #22 was admitted to the facility in August 2024. Review of the admission MDS assessment, dated 8/26/24, indicated it was not completed until 9/4/24, a total of two days late. During an interview on 10/10/24 at 11:03 A.M., the MDS Coordinator said she was responsible for the completion of the MDS assessments and was aware that they were not being completed timely. She said she was recently out of work and there was nobody to assist her with the completion of the assessments while she was out of the building During an interview on 10/10/24 at 1:57 P.M., the MDS timeliness was discussed with the Administrator. He said there should be someone to support the MDS Coordinator when she is out so the assessments are not completed late.

Based on observation, record review, policy review and interview, the facility failed to assess the use of a restraint for 5 Residents (#17, #43, #6, #47, #51) out of a total sample of 33 residents. Review of the facility's policy titled Physical Restraints, revision date 8/21, included the following: - Physical restraint is defined as any manual method, physical or mechanical device, equipment or material that meets the following criteria: -Is attached to adjacent to the patient's body. -Cannot be removed easily by the patient -Restricts the patient's freedom of movement or normal access to his/her body. -Bedrails, position change alarms and positioning devices may be considered restraints. Positioning devises include pillows and barrier or scoop mattresses. All potentially restraining devices require assessment to determine if the device constitutes a restraint. 1. Device evaluation- Any resident who is utilizing a device that could constitute a restraint will be evaluated to determine if the device is a restraint. a. The device evaluation will be completed and reviewed. b. If the evaluation determines that the device does not meet the guidelines for physical restraint, the device will be addressed on the plan of care. A restraint evaluation will NOT be completed on a device that has been assessed as NOT meeting the definition of a restraint. c. If the evaluation determines that the device meets the definition of a restraint, a restraint evaluation will be completed. 2. Restraint evaluation - All residents who are utilizing a device that meets the definition of a restraint will be evaluated: a. At the time the device is implemented b. Quarterly c. Annually d. At the time of any condition change e. Admission or readmission 4. Consent - All restraints require consent from the resident or his/her representative. Findings include: 1. Resident #17 was admitted to the facility in December 2018 with diagnoses that include Alzheimer's disease, unspecified dementia, unsteadiness on feet, anxiety disorder, history of falling and insomnia. Review of Resident #17's most recent Minimum Data Set (MDS) indicated that the Resident was unable to complete the Brief Interview for Mental Status exam indicating that he/she has severe cognitive impairment. Further review of the Resident's MDS indicates that he/she requires total dependance for all activities of daily living. Review of Resident #17's medical record indicates that his/her Health Care Proxy is activated. The surveyor made the following observations: On 7/19/23 at 8:22 A.M., Resident #17 was observed lying in bed with an extra-long body pillow secured under the fitted sheet on the left side of the resident. On the right side of the resident, blankets were secured under the fitted sheet nearly going the length of the bed. *On 7/20/23 at 6:40 A.M., Resident #17 was observed lying in bed with an extra-long body pillow secured under the fitted sheet on the left side of the resident. On the right side of the resident, blankets were secured under the fitted sheet nearly going the length of the bed. *On 7/21/23 at 6:49 A.M., Resident #17 was observed lying in bed with an extra-long body pillow secured under the fitted sheet on the left side of the resident. On the right side of the resident, blankets were secured under the fitted sheet nearly going the length of the bed. Review of Resident #17's Physician's orders dated 10/5/21 indicated the following: *Apply body pillows while in bed for positioning. May remove for care and reapply. Review of Resident #17's document titled Device Assessment, dated 3/6/23 indicated that the Resident uses body pillows as an enabler and/or positioning device. The Assessment further indicates that Resident #17 cannot remove and/or exit the device when asked. The Assessment further says that the facility does not have informed consent from the Resident and/or the responsible person for the device, with the state reason section left blank. Review of Resident #17's most recent Restraint assessment dated [DATE], indicates the use of body pillows as a restraint related to frequent falls. The restraint assessment was last completed 15 months ago. During an interview on 7/24/23 at 11:01 A.M., Certified Nursing Assistant (CNA) #2 said Resident #17 is fully dependent on care and he/she is a fall risk. We use the body pillows for safety so he/she does not fall out of bed, it is put under the fitted sheet so he/she cannot pull them out. She continued to say the Resident #17 should not have blankets under his/her fitted sheet and it should be another body pillow. During an interview on 7/24/23 at 12:55 P.M., Nurse #1 said Resident #17 uses body pillows so he/she does not fall out of bed and fall. She further said if the body pillows go the full length of the bed then a restraint assessment should be completed, for this Resident, a restraint assessment should have been completed for the body pillows at least quarterly. During an interview on 7/24/23, at 1:04 P.M. the Director of Nursing (DON) said device assessments should be completed quarterly and her expectations are that body pillows under fitted sheets should be assessed. The DON further said she was not sure why Resident #17's Health Care Proxy was not notified about the device assessment. The DON said she was not aware of what the facility considered a restraint and was not aware of a restraint assessment needing to be completed. 2. Resident #43 was admitted to the facility in May 2022 with diagnoses including Parkinson's disease, unspecified dementia, neurocognitive disorder with Lewy bodies and psychotic disorder with delusions. Review of Resident #43's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident scored a 0 out of 15 on the Brief Interview for Mental Status exam indicating that he/she has severe cognitive impairment. Further review of the MDS revealed that Resident #43 requires total dependence with all activities of daily living. The surveyor made the following observations: *On 7/19/23 at 8:30 A.M., Resident #43 was sleeping in bed, blankets were stuffed and built up under the fitted sheet going the length of the mattress on both sides of the Resident. On 7/20/23 at 6:41 A.M., Resident #43 was sleeping in bed, blankets were stuffed and built up under the fitted sheet going the length of the mattress on both sides of the Resident. *On 7/21/23 at 6:50 A.M., Resident #43 was lying in bed, blankets were stuffed and built up under the fitted sheet going the length of the bed on the right side of the Resident. On the left side of the Resident, a head pillow was built up and stuffed under the fitted sheet. Review of Resident #43's medical record did not indicate the use of a restraint, a device assessment or a restraint assessment. During an interview on 7/24/23 at 11:01 A.M., Certified Nursing Assistant (CNA) #2 said the blankets and pillows are stuffed under Resident #43's sheets so they do not fall out of bed and are there for safety. Sometimes the Resident gets agitated, so the night shift staff do that, so he/she does not fall out of bed. CNA #2 said he/she is a fall risk for rolling out of bed. During an interview on 7/24/23 at 12:55 P.M., Nurse #1 said she was not sure why Resident #43 had blankets and pillows stuffed under his/her fitted sheet. She said if the blankets go the full length of the bed then a restraint assessment should be completed, for this Resident, a restraint assessment should have been completed for the blankets and pillow. During an interview on 7/24/23 at 1:04 P.M., The Director of Nursing (DON) said her expectation is that blankets and pillows should not be under fitted sheets without an assessment completed and that all staff will be educated. 36797 3. Resident #6 was admitted to the facility in February 2019 wish diagnoses including psychotic disorder, history of hip fracture, Alzheimer's dementia, anxiety and depression. Review of the Minimum Data Set, dated dated dated [DATE], indicated that Resident #6 is severely cognitively impaired. Further review indicated that Resident #6 is totally dependent of staff for activities of daily living. On 7/19/23, at 8:03 A.M., the surveyor observed Resident #6 in bed on her/his back, with bolsters under the fitted sheet on both sides of the bed. On 7/20/23, at 7:05 A.M., the surveyor observed Resident #6 in bed on her/his back, with bolsters under the fitted sheet on both sides of the bed. Review of the care plan failed to indicate the use of bolsters under the fitted sheet. Further review failed to indicate the use of a restraint. Review of the doctor's orders indicated may use body pillows for positioning and comfort while in bed. Further review failed to indicate an order for the use of a restraint. Review of a facility document titled UDA packet section 5 Device Assessment and dated 6/22/23, indicated the device under consideration are roll guards (bed bolsters) that do not assist the resident in enhancing/maintaining body movement nor can the resident remove and/or exit device when asked. Further review indicated that the implication for the use of the device was impaired balance and or gait disturbance and not positioning, as the document also indicated that Resident #6 does not require upper extremity support. Review of the medical record failed to indicate that Resident #6 was accurately assessed for bolsters placed under the fitted sheet along both sides of the resident. 4. Resident #47 was admitted to the facility in May 2020 with diagnoses including Alzheimer's dementia, stroke and psychotic disorder. On 7/19/23, at 8:27 A.M., the surveyor observed Resident #47 lying on her/his back in bed with bolsters under the fitted sheet. On 7/20/23, at 7:08 A.M. the surveyor observed Resident #47 lying on her/his back in bed with a bolster under the fitted sheet on one side of the bed and a wheelchair positioned lengthwise along the other side of the bed. Review of a facility document titled UDA packet section 5 Device Assessment and dated 6/1/23, indicated the device under consideration is a wheelchair. Further review of the medical record failed to indicate the use of bolsters under the fitted sheet was to be evaluated for the potential use of a restraint. Review of the progress note dated 6/15/23, indicated that Resident #47 is at risk for falls relate to psychotropic medication use, poor safety awareness, as well as reduced strength and endurance. Review of the care plan failed to indicate the use of a restraint or the need for bolster pillows when in bed for positioning. Review of the doctor's orders dated July 2023 failed to indicate an order for the use of a restraint. Review of the medical record failed to indicate that Resident #47 was accurately assessed for body pillows placed under the fitted sheet along both sides of the resident bed or on one side with a wheelchair blocking exit from the bed on the other side. 43882 5. For Resident #51 the facility failed to identify and assess the use of a restraint. Resident #51 was admitted to the facility in January 2021 with diagnoses including dementia, hypertension, and failure to thrive. Review of the most recent Minimum Data Set assessment dated , 6/11/23, indicated Resident #51 was rarely or never understood. On 7/19/23 at 8:44 A.M., the surveyor observed Resident #51 lying in bed with extra-long pillows secured underneath the fitted sheet along both sides of the Resident. On 7/20/23 at 7:18 A.M., 7:54 A.M., and 11:03 A.M., the surveyor observed Resident #51 lying in bed with an extra-long pillow secured underneath the fitted sheet along the right side of the Resident. On 7/21/23 at 7:01 A.M., the surveyor observed Resident #51 lying in bed with extra-long pillows secured underneath the fitted sheet along both sides of the Resident. On 7/24/23 at 7:59 A.M., the surveyor observed Resident #51 lying in bed with extra-long pillows secured underneath the fitted sheet along both sides of the Resident. Review of Resident #51's medical record indicated the following: -Physician Orders dated 10/5/21, indicated to Apply body pillows while in bed for positioning. May remove for care. - Review of Device assessment dated [DATE], indicated Resident #51 used body pillows intermittently for poor head/trunk control. The assessment further indicated Resident #51 was unable to remove and/or exit device when asked. During an interview on 7/24/23, at 8:16 A.M., Certified Nursing Assistant #1 (CNA) accompanied the surveyor to Resident #51's room. CNA #1 said the pillows were placed under the sheet to prevent the Resident from falling or getting out of bed. During an interview on 7/24/23, at 1:04 P.M. the Director of Nursing (DON) was unsure why Resident #51 had body pillows underneath the fitted sheets on both sides of the bed. The DON said she was not aware of what the facility considered a restraint and was not aware of a restraint assessment needing to be completed. Review of the medical record failed to indicate that Resident #51 was accurately assessed for the use of body pillows, placed under the fitted sheet along both sides of the Resident, as a restraint.

Based on observation, record review and interview, the facility failed to implement the plan of care for 1) feeding assistance for 5 Residents (#1, #6, #15, #44 and #45), 2) elevating heels when in bed for 2 Residents (#43, #56) and 3) wandering behaviors for 1 Resident (#41) out of a total sample of 33 Residents. Findings Include: 1a. Resident #1 was admitted to the facility in December 2021 with diagnoses including Alzheimer's dementia, psychotic disorder and anxiety. On 7/19/23, at 8:27 A.M., the surveyor observed Resident #1 sitting in bed eating alone in the room. On 7/20/23, at 8:35 A.M., the surveyor observed Resident #1 sitting in bed eating alone in the room. Review of the medical record indicated a diagnosis of Dysphagia, Oropharyngeal Phase. Further review indicated a Modified Barium Swallow Study (MBSS) dated 4/14/23, with a discharge diagnosis of severe oropharyngeal dysphagia affecting the safety and efficiency of the swallow. Review of the care plan dated as last revised 8/16/22, indicated the following intervention for eating: Must be continually supervised for entirety of meal. Sitting upright at 90 degrees. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #1 scored an 8 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Further review indicated that Resident #1 requires an extensive assist of one staff member for eating. Review of the facility document titled Maintenance ADL (activities of daily living) & Safety Care Plan & Communication Tool dated as reviewed 9/27/22, indicated Resident #1 requires an assist of one with fluids. Review of the facility document titled ADL Flow Sheet dated July 2023 indicated that Resident #1 requires an extensive assist with eating. 1b. Resident #6 as admitted to the facility in February 2019 with diagnoses including psychotic disorder, history of hip fracture, Alzheimer's dementia, anxiety and depression. On 7/19/23, at 8:35 A.M. the surveyor observed Resident #6 eating alone in bed. On 7/19/23, at 12:04 P.M. the surveyor observed Resident #6 eating in her/his room without staff present. The surveyor also observed Resident #6 eating with his/her fingers. On 7/20/23, at 8:17 A.M. the surveyor observed Resident #6 eating in his/her room without staff present. Review of the Minimum Data Set, dated dated dated [DATE], indicated that Resident #6 is severely cognitively impaired. Further review indicated that Resident #6 is totally dependent on staff for activities of daily living and an extensive assist for eating. Review of the care plan intervention dated as last revised 1/26/22, indicated, EATING: Resident #6 requires physical assist of 1 staff with eating. Review of the facility document titled ADL Flow Sheet dated July 2023 indicated that Resident #6 requires an extensive assist with eating. 1c. Resident #15 was admitted to the facility in February 2017 with diagnoses including Parkinson's, multiple sclerosis, stroke and dementia. On 7/19/23, at 8:35 A.M., the surveyor observed Resident #15 in bed eating without a staff member present. On 7/19/23, at 12:07 P.M. the surveyor observed Resident #15 in bed eating without a staff member present. On 7/20/23, at 8:31 A.M. the surveyor observed Resident #15 in bed without a staff member present. Review of the care plan dated as last revised 8/1/2019, indicated that Resident #15 is to be continuously supervised with eating. Review of the facility document titled ADL Flow Sheet dated July 2023 indicated that Resident #15 requires continual supervision with eating. Review of the Minimum Data Set, dated dated dated [DATE], indicated that Resident #15 is moderately cognitively impaired. Further review indicated that Resident #15 requires supervision while eating. During an interview on 7/20/23, at 8:32 A.M. Certified Nurse's aide (CNA) #3 said that they give the residents the trays and if they can not eat then they help them. During an interview on 7/20/23, at 8:32 A.M. CNA #2 said that the CNA's can find how to care for a resident in the assignment books that have the Kardex's which are located behind the nurse's stations. Review of the facility document titled Maintenance ADL (activities of daily living) & Safety Care Plan & Communication Tool dated as reviewed 5/19/22, indicated Resident #15 requires supervision with eating. 1d. Resident #44 was admitted to the facility in October 2019 with diagnoses including Alzheimer's dementia, stroke and psychotic disorder. On 7/19/23, at 8:39 A.M. the surveyor observed Resident #44 eating in his/her room alone. On 7/20/23, at 8:37 A.M. the surveyor observed Resident #44 eating in his/her room alone. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #44 scored a 0 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicted that Resident #44 requires an extensive assist with eating. Review of the care plan intervention dated as last revised 1/11/23, indicated EATING: assisted by staff. Review of the facility document titled Maintenance ADL (activities of daily living) & Safety Care Plan & Communication Tool dated as reviewed 5/19/22, indicated Resident #44 requires assist of one with eating. Review of the facility document titled ADL Flow Sheet dated July 2023 indicated that Resident #44 requires extensive assistance with eating. 1e. Resident #45 was admitted to the facility in January 2020 with diagnoses including dementia and depression. On 7/19/23, at 8:25 A.M. the surveyor observed Resident #45 wandering up and down the hallway, going in his/her room and picking food off of the tray without staff present. On 7/20/23, at 8:20 A.M. the surveyor observed Resident #45 wandering up and down the hallway, going in his/her room and picking food of of the tray without staff present. Review of the care plan intervention dated as last revised 1/11/23, indicated EATING: I require continual supervision to physical assist from staff with eating at all meals. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #45 requires continual supervision/cueing with meals. During an interview on 7/20/23, at 8:32 A.M. Certified Nurse's Aid (CNA) #2 said that Resident #45 wanders during meals. CNA #2 then said that Resident #45's meal is placed in the room and he/she will wander in and out picking at the meal. 45984 2a. For Resident #43, the facility failed to implement the plan of care to elevate his/her heels when in bed. Resident #43 was admitted to the facility in May 2022 with diagnoses including Parkinson's disease, unspecified dementia, neurocognitive disorder with Lewy Body and psychotic disorder with delusions. Review of Resident #43's most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #43 scored a 0 out of 15 on the Brief Interview for Mental Status exam indicating that he/she has severe cognitive impairment. Further review of the MDS revealed that Resident #43 requires total dependence with all activities of daily living. The surveyor made the following observations: *On 7/19/23 at 10:27 A.M., 7/20/23 at 8:04 A.M. and 7/21/23 at 6:53 A.M., Resident #43 was observed sleeping in bed with his/her heels directly on the mattress. There was no pillow near his/her feet. Review of Resident #43's physician's orders dated 2/20/23, indicated the following: *Elevate feet on pillows when in bed to prevent pressure to heels, every shift Review of Resident #43's care plan for skin breakdown dated 5/23/22, indicated the following: *Intervention: Please follow all MD/NP (Medical Director/Nurse Practitioner) orders for skin care During an interview on 7/21/23, at 9:59 A.M., Certified Nursing Assistant (CNA) #2 and Nurse #1 said pillows are used to elevate the Resident's heels as a prevention for skin breakdown. CNA #2 and Nurse #1 said Resident #43's physician's orders should be followed, and his/her heels should have been elevated. They continued to say the night shift should have been elevating his/her heels. During an interview on 7/21/23, at 12:33 P.M., Administrator #1 said Resident #43's physician's orders should be followed, and his/her heels should be elevated on a pillow when in bed. 2b. For Resident #56, the facility failed to implement the plan of care to elevate his/her heels when in bed. Resident #56 was admitted to the facility in June 2022 with diagnoses including unspecified dementia, muscle weakness and heart failure. Review of Resident #56's most recent Minimum Data Set (MDS) indicated that Resident #56 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating that he/she has intact cognition. Further review indicated that he/she requires extensive assistance with all activities of daily living. The surveyor made the following observations: On 7/19/23, at 11:46 A.M., 7/20/23, at 6:50 A.M., 10:46 A.M., and 1:10 P.M., and 7/21/23, at 6:58 A.M., Resident #56 was observed sleeping in his/her bed with his/her heels directly on the mattress. There was no pillow near his/her heels. Review of Resident #56's physician's orders dated 6/27/22, indicated the following: *Elevate feet on pillows when in bed to prevent pressure to heels. During an interview on 7/21/23, at 9:59 A.M., Certified Nursing Assistant (CNA) #2 and Nurse #1 said pillows are used to elevate the Resident's heels as prevention for skin breakdown. CNA #2 and Nurse #1 said Resident #56's physician's orders should be followed, and his/her heels should have been elevated. They continued to say the night shift should have been elevating his/her heels. During an interview on 7/21/23, at 12:33 P.M., Administrator #1 said Resident #56's physician's orders should be followed, and his/her heels should be elevated on a pillow when in bed. 3. For Resident #41, the facility failed to develop a care plan for wandering behavior. Resident #41 was admitted to the facility in June 2021 with diagnoses including unspecified dementia, psychotic disorder with delusions and insomnia. Review of Resident #41's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident scored a 6 out of 15 on the Brief Interview for Mental Status score indicating that he/she has severe cognitive impairment. Further review of the MDS indicates that Resident #41 has behaviors of wandering daily and his/her wandering significantly intrudes on the privacy or activities of others. Review of Resident #41's most recently completed document titled Wandering Risk Scale, dated 6/21/22, indicated that the Resident scored a 14 which indicates that the Resident is a High Risk to Wander. Review of Resident #41's clinical Nursing Notes dated 2/22/23, indicated the following: *Resident alert and responsive wandering around unit. Review of Resident #41's Behavior Notes indicated the following: *Dated 2/22/23: Risk Meeting Note: Resident #43 wanders daily and presents with physical aggression 4-6 days a week. Safety maintained. *Dated 2/15/23: Wandering exhibited on this day. Review of Resident #41's medical record failed to indicate a care plan for wandering behavior was developed. During an interview on 7/20/23, at 1:24 P.M., Nurse #1 said Residents who have a high risk for wandering should have a care plan in place. Nurse #1 said she does not think Resident #41 needed a care plan despite his/her most recent wandering risk assessment indicating that the Resident is a high risk for wandering. During an interview on 7/21/23, at 12:33 P.M., Administrator #1 said residents who exhibit wandering behavior and are high risks for wandering should have a care plan in place. She was not sure why Resident #41 did not have a care plan for wandering.

Based on interview and observation, the facility failed to ensure window screens, sinks, bedroom doors, tiles and painted areas were in good condition. Findings include: 1. During observations of the facility's North Wing on 7/19/23, throughout the morning and afternoon, the surveyor noted the following: * Shared bathroom room [ROOM NUMBER], no window screen and window was open approximately 3 inches. Floor was wet and slippery, drain pipe from the sink is wet and leaking. * Bedroom [ROOM NUMBER], bedroom window screen has a 1 x 1 inch tear, window was open approximately 4 inches. Bedroom entry door unable to close, door hinges were misaligned. * Bedroom [ROOM NUMBER], window screen torn approximately 1 x 2 inches and window was open approximately 3 inches. * Shared bathroom room [ROOM NUMBER], no window screen and window was open approximately 3 inches. Leaky bathroom sink faucet, surveyor heard water running from the hallway. Surveyor was unable to shut off the water flow from the faucet. * Shared bathroom room [ROOM NUMBER], no window screen, window was open approximately 2 inches. Leaky sink faucet, surveyor was unable to shut off the water flow. During a tour of the North Wing bedrooms and bathroom with the Maintenance Director on 7/21/23 at approximately 1:30 P.M., the surveyor told the Maintenance Director of these environmental concerns. 36876 During environmental rounds on 7/24/23 at 8:01 A.M., the surveyor observed the following on the South Wing: room [ROOM NUMBER]: There were cracked tiles on window sill and the drawer handle for B bed was broken on the nightstand. There were scuffs on the wall and the rubber baseboard molding was peeling away from wall. Shared bathroom: 144: There was plaster on the wall and the light fixture had visible debris. Shared bathroom [ROOM NUMBER] and 137: The sink had a continuous drip and the hot water tap was broken. room [ROOM NUMBER]: The rubber baseboard molding was peeling away from walls. There was a ceiling stain above closet. Shared bathroom: 139 & 140: There was chipped and peeling paint on the door frame and no window treatment for privacy in the bathroom. Shared bathroom [ROOM NUMBER] & 142: One of the overhead light bulbs was out. 45984 During environmental rounds on 7/24/23 at 8:20 A.M. the surveyor observed the following on the East Wing: *room [ROOM NUMBER]: There was chipped paint and scuffed walls next to both beds. *room [ROOM NUMBER]: The door panel on the outside of the room door was peeling off. *room [ROOM NUMBER]: There was chipped paint on the wall behind the B bed. *room [ROOM NUMBER]: There was chipped paint on the wall between the two beds and the door panel on the outside of the room door was peeling off. *Blue Hills Dining Room: There was chipped paint and scuff marks on the walls, ceiling plaster was chipped off around the ceiling lights.

Based on interview, policy review and observation, the facility failed to 1) speak respectfully to 2 Residents (#24 and #39) and 2) serve meals to residents in a dignified manner, from a total sample of 33 residents. Findings include: Review of the facility policy Dignity/Quality of Life dated 12/6/21, indicated: * Residents shall always be treated with dignity and respect. * Staff shall always speak respectfully to residents, including addressing the resident by his or her name of choice and not labeling or referring to the residents by his or her room number, diagnosis, or care needs. 1a. Resident #24 was admitted to the facility in September 2016, and had diagnoses which included non-traumatic brain dysfunction and hemiplegia. Resident #24's Minimum Data Set assessment dated [DATE], indicated total dependence on staff for eating. On 7/19/23, at 8:40 A.M., the surveyor observed Resident #24 lying in bed, awake. Certified Nurse Aide (CNA) #4 entered the room and told the surveyor that Resident #24 needed to have breakfast, but that he/she would remain in bed because he/she was a feeder. 1b. Resident #39 was admitted to the facility in October 2018, and had diagnoses which included dementia and cerebral vascular accident. Resident #39's Minimum Data Set assessment dated [DATE], indicated severely impaired cognitive skills for daily decision making, and required extensive staff assistance for eating. During an observation on 7/19/23, at 9:31 A.M., located in the activity room, the surveyor asked Nurse #2 to identify Resident #39. Nurse #2 identified Resident #39, who was sitting at a table. Nurse #2 said to the surveyor, in the presence of Resident #39, This is one of our feeders. But [Resident #39] was very good. During an interview with the Staff Development Coordinator (SDC) on 7/21/23, at 9:07 A.M., the surveyor informed her that a staff person referred to Resident #24 and Resident #39 as feeders, while in the presence of these Residents. The SDC said it was disrespectful to refer to any resident as a feeder. 45984 2) During the lunch meal on 7/19/23 at 12:26 P.M., two staff members were observed standing over two residents, not at eye level while feeding the residents as they were sitting in wheelchairs. During the breakfast meal on 7/20/23, the following observations were made: *At 8:33 A.M., a Certified Nursing Assistant was observed standing over a resident, not at eye level while feeding the resident while he/she was sitting up in bed. *At 8:41 A.M., a staff member in the Blue Hills dining room was observed standing over a resident, not at eye level while feeding one resident oatmeal as he/she was in his/her wheelchair. During the lunch meal on 7/20/23, at 12:19 P.M., the surveyor observed a Certified Nursing Assistant, in the East unit dining room, standing over a resident as she assisted him/her with drinking from a cup. During an interview on 7/21/23, at 12:33 P.M., Administrator #1 said staff should be sitting at eye level with residents as they assist them with feeding.

Based on observation and interview, the facility failed to follow proper infection control practices during dining for the residents on the East and North units. Findings include: During an observation on 7/19/23, at 12:26 P.M. in the North unit dining room, a staff member was observed alternating feeding two residents at the same time without performing hand hygiene between assisting each resident. During an observation on 7/20/23, at 8:05 A.M. in the East unit dining room, a staff member was observed assisting a resident with feeding and then wiped her hands on the tablecloth of the table next to the resident and then left the dining room to pass out trays without performing hand hygiene. During an observation on 7/20/23, at 12:10 P.M. in the East unit dining room, a staff member was observed holding one resident's utensils assisting him/her with meals and then assisted a second resident with cutting up his/her food and then assisted a third resident with feeding. No hand hygiene was performed between assisting each resident. During an observation on 7/24/23, at 8:07 A.M. on the East unit, a Resident was observed eating his/her breakfast on top of a clean meal delivery cart with clean meals still inside the cart. There was cereal and milk spilled on top of the cart. During an interview on 7/21/23, at 12:33 P.M., Administrator #1 said staff should be performing hand hygiene in between assisting other residents with feeding otherwise it is an infection control risk. She continued to say staff should not be wiping their hands on the tablecloths.

Based on record review and interview, the facility failed to follow professional standards of nursing practice by not following physician orders regarding the timing of medication administration for 1 Resident (#5) out of a total sample of 33 Residents. Findings include: Resident #5 was admitted to the facility in April 2023 with diagnoses including vascular dementia, anxiety disorder and major depressive disorder. Review of Resident #5's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating that the Resident has moderate cognitive impairment. Review of Resident #5's physician orders indicate the following: *Dated 4/14/23: diazepam (a benzodiazepine) Oral Tablet 5 MG (milligrams) Give 1 tablet by mouth two times a day for anxiety do not give diazepam and oxycodone together. *discharge date [DATE]: Oxycodone HCl (Opiate) Oral Tablet 5 MG Give 2.5 mg by mouth two times a day do not give with with diazepam. Review of Resident #5's Medication Administration Audit Report indicated the following medication administration times: *4/14/23: diazepam administered at 10:02 A.M., oxycodone administered at 10:36 A.M. - 34 minutes apart *4/15/23: diazepam administered at 12:46 P.M., oxycodone administered at 12:51 P.M. - 5 minutes apart *4/16/23: diazepam administered at 10:20 A.M., oxycodone administered at 10:20 A.M. - administered at the same time *4/17/23: diazepam administered at 10:09 A.M., oxycodone administered at 10:08 A.M. - 1 minute apart *4/19/23: diazepam administered at 10:03 A.M., oxycodone administered at 9:37 A.M. - 26 minutes apart *4/21/23: diazepam administered at 11:35 A.M., oxycodone administered at 10:54 A.M. - 41 minutes apart *4/30/23: diazepam administered at 10:03 A.M., oxycodone administered at 9:21 A.M. - 42 minutes apart *5/3/23: diazepam administered at 10:38 A.M, oxycodone administered at 10:38 A.M. - administered at the same time *5/4/23: diazepam administered at 10:15 A.M, oxycodone administered at 10:04 A.M. - 1 minute apart *5/6/23: diazepam administered at 10:02 A.M., oxycodone administered at 9:27 A.M. - 35 minutes apart *5/9/23: diazepam administered at 10:12 A.M., oxycodone administered at 9:52 A.M. - 20 minutes apart *5/11/23: diazepam administered at 10:01 A.M., oxycodone administered at 9:41 A.M. - 20 minutes apart *5/27/23: diazepam administered at 10:03 A.M., oxycodone administered at 9:53 A.M. - 10 minutes apart *5/29/23: diazepam administered at 10:39 A.M., oxycodone administered at 10:38 A.M. - 1 minute apart *5/30/23: diazepam administered at 3:22 P.M., oxycodone administered at 3:22 P.M. - administered at the same time *5/31/23: diazepam administered at 11:32 A.M., oxycodone administered at 11:48 A.M. - 16 minutes apart *6/2/23: diazepam administered at 11:34 A.M., oxycodone administered at 11:34 A.M. - administered at the same time *6/13/23: diazepam administered at 1:07 P.M., oxycodone administered at 1:07 P.M. - administered at the same time *6/16/23: diazepam administered at 1:07 P.M., oxycodone administered at 12:28 P.M. - 39 minutes apart *6/17/23: diazepam administered at 3:29 P.M., oxycodone administered at 3:27 P.M - 2 minutes apart *6/22/23: diazepam administered at 1:45 P.M., oxycodone administered at 1:45 P.M - administered at the same time *6/28/23: diazepam administered at 1:13 P.M, oxycodone administered at 12:52 P.M. - 21 minutes apart *6/29/23: diazepam administered at 1:44 P.M., oxycodone administered at 1:43 P.M - 1 minute apart During a phone interview on 7/20/23 at 10:05 A.M., the Physician said taking these two medications at the same time could result in sedation for the Resident, he/she should be taking them at least one hour apart to avoid this. During an interview on 7/20/23 at 10:55 A.M., Nurse #1 said taking a benzodiazepine and an opiate at the same time could result in dizziness and sedation and we try and wait one hour minimum between administering them to residents. During an interview on 7/20/23 at 11:11 A.M., the Director of Nursing and Corporate Nurse #1 said both benzodiazepines and opiates are central nervous system depressants and could cause sedation if taken together. Corporate Nuse #1 said these should be taken separately if the physician's order indicates it. She said the order will need to be updated so staff can administer the medications at the correct time.

Based on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for 3 Resident's (#3, #54, #49), from a total sample of 33 residents. Specifically, the facility failed to ensure specific Resident names were not included in care plans. Findings include: Review of the facility policy titled, Confidentiality of Information, revision date 2010 included the following: - The facility will safeguard all resident records, whether medical, financial, or social in nature to protect the confidentiality of the information. 1. For Resident #3 the facility failed ensure the residents name was protected from another residents care plan. Resident #3 was admitted to the facility in January 2018 with diagnoses including, traumatic brain injury, and cognitive communication deficit. Review of the most recent Minimum Data Set assessment dated [DATE] included a Brief Interview for Mental Status score of 5 out of a possible 15 indicating severe cognitive impairment. During a review of another Resident's medical record, Resident #3's name was identified in an intervention in the care plan. During an interview on 7/21/23, at 1:40 P.M., Corporate Nurse #1 said Residents identifiers should not be in the Care Plans unless it is that specific resident's medical record. 2. For Resident #54 the facility failed ensure the residents name was protected from another residents care plan. Resident #54 was admitted to the facility in November 2021 with diagnoses including dementia and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 6/28/23, indicated a Brief Interview for Mental Status score of 9 out of possible 15 indicating moderate cognitive impairment. During a review of another Residents medical record, Resident #54's name was identified within another residents care plan. During an interview on 7/21/23, at 1:40 P.M., Corporate Nurse #1 said Residents identifiers should not be in the Care Plans unless it is that specific resident's medical record. 3. For Resident #49 the facility failed ensure the residents name was protected from another residents care plan. Resident #49 was admitted to the facility in October 2021 with diagnoses including hypertension and dementia. Review of the most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 6 out of a possible 15 indicating severe cognitive impairment. During a review of another Residents medical record, Resident #54's name was identified within another residents care plan. During an interview on 7/21/23, at 1:40 P.M., Corporate Nurse #1 said Residents identifiers should not be in the Care Plans unless it is that specific resident's medical record.

Based on observation, interview and record review, the facility failed to provide assistance with eating for 1 Resident (#43) out of a total sample of 33 residents. Findings include: Review of the facility policy titled Activities of Daily Living, dated and revised December 2022 indicated the following: *A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. *Procedure: The facility will provide care and services for the following activities of daily living - Dining: eating, including meals and snacks. Resident #43 was admitted to the facility in May 2022 with diagnoses including Parkinson's disease, unspecified dementia, neurocognitive disorder with Lewy bodies and psychotic disorder with delusions. Review of Resident #43's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident scored a 0 out of 15 on the Brief Interview for Mental Status exam indicating that he/she has severe cognitive impairment. Further review indicated that Resident #43 requires total dependence with all activities of daily living and extensive assistance, one-person physical assistance with eating. On 7/19/23, at 10:28 A.M., Resident #43 was observed eating his/her breakfast in his/her bed with oatmeal on his/her chest. The Resident was observed having shaky hands when trying to bring food from his/her plate to his/her mouth. The Resident's curtain was drawn, and he/she was not visible from the hallway. On 7/20/23, at 8:27 A.M., Resident #43 was observed eating in bed with no supervision or assistance. At 8:38 A.M., the Resident was still eating unassisted and without supervision, he/she was observed having shaky hands trying to bring food from his/her plate to his/her mouth. The Resident had chunks of banana on his/her chest. On 7/21/23, at 8:13 A.M., Resident #43 was observed eating in bed with no assistance or supervision, the Resident had visible muffin crumbs on his/her chest. Review of Resident #43's nursing care card indicated that the Meals section was left blank and did not indicate the level assistance required for meals. Review of Resident #43's care plan, dated and revised 5/24/22, indicated the following: *Focus: Resident #43 is dependent on staff to provide my ADL's. *Intervention: I am dependent on 1 staff to provide and feed me all my meals and snacks - dated 6/26/23. Review of Resident #43's Comprehensive Nutrition Assessments dated 4/26/23, and 7/21/23, indicated that the Resident is dependent for dining assistance for eating and drinking. Review of Resident #43's Certified Nursing Assistant's (CNA) ADL Flow Sheets for the months of May, June and July 2023 indicated that the Resident required either extensive assistance or total dependence with eating. During an interview on 7/21/23, at 9:59 A.M., CNA #2 said she knows what level of care residents require based on their care card and that she knows the residents too. We help them with feeding if they need it. CNA #2 continued to say when a resident requires extensive assistance with meals then they need help with feeding. CNA #2 and Nurse #1 said Resident #43 is a limited assist with meals and most of the time, feeds him/herself. CNA #2 and Nurse #1 were unaware that Resident #43 was care planned for total dependence for meals. During an interview on 7/21/23, at 12:33 P.M., Administrator #1 said Resident #43 should be getting assistance with meals from the staff.

Based on record review and interviews, the facility failed to ensure staff initiated Cardiopulmonary Resuscitation (CPR) appropriately for one Resident (#212) out of two closed Records. Specifically, after Resident #212 was found unresponsive and without a pulse, despite his/her code status of Do Not Resuscitate (DNR), staff initiated life saving measures in an attempt to resuscitate him/her, including administering CPR and calling 911. When staff determined that Resident #212 was a DNR, staff terminated CPR before Emergency Medical Staff (EMS) arrived. Findings include: Review of the facility's Cardiopulmonary Resuscitation policy, undated, indicated: *If an individual (Resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless: it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual. *Upon determining there is no pulse or breathing, call for help. *Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victims pulse. *CPR should continue, repeating steps as above for compressions and rescue breaths until EMS arrives. Resident #212 was admitted to the facility in [DATE] with diagnoses including afib and traumatic brain injury. Review of Resident #212's Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE], indicated he/she was a DNR. Review of the facility's internal investigation dated [DATE], indicated that on [DATE], Resident #212 was found by Physical Therapy Assistant (PTA) #1 unresponsive and not breathing. PTA #1's written witness statement indicated that he/she observed Resident #212 in bed with poor color and was unresponsive. PTA #1 then called for help and initiated CPR. During an interview on [DATE], at 11:09 A.M. Occupational Therapist (OT) #1 said on [DATE], PTA #1 called for help and she went to Resident #212's room and observed Resident #212 was blue and unresponsive. OT #1 said that PTA #1 told her to go get a nurse and PTA #1 lowered Resident #212's bed so he/she was in a laying position and started chest compressions. During an interview on [DATE], at 11:23 A.M., PTA #1 said on [DATE], she saw Resident #212 from the hallway and he/she looked a little pale. PTA #1 said she entered Resident #212's room and he/she was unresponsive. PTA #1 said she adjusted the bed so Resident #212 was laying flat, called for OT #1 to get help and then began chest compressions. PT #1 said that a Code Blue was called and when nursing staff arrived and said Resident #212 was a DNR, she stopped performing chest compressions. Review of PTA #1's CPR Certification indicated her certification expired in [DATE]. During an interview on [DATE], at 12:18 P.M. Director of Nursing (DON) said that when CPR is initiated, it shouldn't be stopped until EMS arrives. The DON said that she called 911 on [DATE], when she heard the code blue and that Resident #212 was unresponsive. The DON said staff are expected to follow a Resident's plan of care and that Resident #212 was a DNR.

Based on observations, record reviews and interviews, the facility failed to ensure 1 Resident (#5) was wearing a wanderguard to prevent possible elopement, out of a total sample of 33 residents. Findings include: Review of the facility policy titled Resident Elopement/Prevention, dated and revised 10/19/21, indicated the following: *The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision. Procedures Post-Elopement: *Any new physician orders will be implemented and communicated to the resident/family/authorized representative. Resident #5 was admitted to the facility in April 2023 with diagnoses including vascular dementia, anxiety disorder and major depressive disorder. Review of Resident #5's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating that the Resident has moderate cognitive impairment. Review of the Healthcare Facility Reporting System indicated that Resident #5 eloped out of the facility on May 7, 2023. Review of Resident #5's physician's orders dated 4/13/23 indicated the following: *Check Wanderguard (a bracelet around the wrist or ankle that locks or alarms facility doors when resident is near them) placement Q (every) shift for safety *Check Wanderguard Function every night shift for safety On 7/20/23 at 8:15 A.M., the surveyor observed Resident #5 in his/her room, he/she was not wearing a Wanderguard on his/her right ankle. Review of Resident #5's care plan dated 4/13/23 indicates the following: *Focus: It is unsafe for me to leave this facility, however I may attempt to do so r/t (related to) attempt to elope *Goal: I will remain safe within the facility through next review *Interventions: Please keep all exits secured with a locking system or code and change the code monthly to prevent me from wandering out Review of Resident #5's document titled Elopement Risk Screen dated 5/7/23 determined that the Resident is a serious actual risk of eloping. During an interview on 7/20/23 at 8:15 A.M., Resident #5 said he/she sometimes takes the Wanderguard off because it irritates his/her skin. He/she continued to say he/she does not know where it is right now. During an interview on 7/20/23 at 8:18 A.M., Certified Nursing Assistant (CNA) #2 said Resident #5 should be wearing a Wanderguard so he/she does not leave the building. The CNA confirmed the Resident was not wearing a Wanderguard. During an interview on 7/20/23 at 8:18 A.M., Nurse #1 said Resident #5 should be wearing a Wanderguard so the front door will lock if he/she tries to leave. The nurse continued to say she does not know where the Resident's Wanderguard is. During an interview on 7/20/23 at 8:20 A.M., Administrator #1 said her expectations would be for Resident #5 to be wearing his/her Wanderguard. She continued to say he/she could elope again without wearing it which would be a safety concern.

Based on interview and record review the facility failed to develop a dementia care plan with measurable goals and interventions to address the care and treatment for a resident with dementia for two Residents (#57 and #262) out of a total sample of 33 residents. 1. Resident #57 was admitted to the facility in May 2022 with diagnoses including, dementia with behavioral disturbances, mood disorder with depressive features, congestive heart failure, and muscle weakness. Review of Resident #57's Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 0 out of a possible 15 indicating severe cognitive impairment. Further review indicated Resident #57 had daily physical behaviors towards others, and daily verbal behaviors towards others. The MDS further indicated Resident #57 received daily antipsychotic medications and daily antidepressants. Review of Resident #57's medical record failed to indicate an active care plan with individualized interventions for the diagnosis of dementia. During an interview on 7/21/23 at 1:34 P.M., the Corporate Nurse #1 said the interdisciplinary team is responsible for care plans and the expectation would be to have an active plan of care for dementia. 2. Resident #262 was admitted to the facility in October 2021 with diagnoses including dementia, hypertension, bipolar depression, and post-traumatic stress disorder. Review of the Resident #262's Minimum Data Set Assessment (MDS) dated , 4/21/23, indicated a Brief Interview for Mental Status score of 3 out of a possible 15 indicating severe cognitive impairment. Further review indicated Resident #262 had frequent physical behavior symptoms every 1 to 3 days and verbal behavioral symptoms every 4 to 6 days. The MDS further indicated Resident #262 received daily antipsychotic medications. Review of Resident #262's medical record failed to indicate an active care plan with individualized interventions for the diagnosis of dementia. During an interview on 7/21/23 at 1:34 P.M., the Corporate Nurse #1 said the interdisciplinary team is responsible for care plans and the expectation would be to have an active plan of care for dementia.

Based on record review and interview, the facility failed to follow the pharmacist's recommendations in a timely manner and have the physician review recommendations for 1 Resident (#41) out of a total same of 33 residents. Findings include: Review of the facility policy titled Medication Regimen Review, undated, indicated the following: *The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the administrator. *Recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. *At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and director of nursing, at a minimum. Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendations, undated, indicated the following: *Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. *Recommendations are acted upon and documented by the facility and staff and/or prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. Resident #41 was admitted to the facility in June 2021 with diagnoses including unspecified dementia, psychotic disorder with delusions and insomnia. Review of Resident #41's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident scored a 6 out of 15 on the Brief Interview for Mental Status score indicating that he/she has severe cognitive impairment. Review of Resident #41's monthly pharmacy notes dated 2/28/23 indicated the following: Medications reviewed. See Consultant Pharmacist Report for Recommendations. Review of Resident #41's Consultant Pharmacist Report for February 2023 indicated the following: *This resident has been receiving the anti-psychotic agent Risperdal 0.25 milligrams (mg) BID (twice daily) since 8/17/22. Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs benefit of continued therapy with current regimen. Review of Resident #41's Medication Administration Records for March, April, May, June, and July 2023 indicated that he/she received Risperdal 0.25 mg BID. The Physician's response to the Consultant Pharmacist Report was left blank indicating it was not addressed. Corporate Nurse #1 reviewed Resident #41's Pharmacist Recommendation on 7/20/23, nearly five months after the recommendation was made. During an interview on 7/20/23 at 2:16 P.M., Corporate Nurse #1 said Resident #41's pharmacy recommendation was not addressed in a timely manner, and it should have been. She continued to say the physician should have acknowledged it and she could not find any documentation that the physician acknowledged it.

Based on observation, record review, policy review, and interview, the facility failed to ensure adequate supervision and safety interventions were developed and consistently implemented to maintain each Residents' safety. Specifically, the facility failed to 1) For Resident #61, provide adequate supervision, monitor the effectiveness of fall interventions, and revise the plan of care as per the facility policy, in an attempt to prevent four falls, two of which resulted in major injury; and 2) Ensure a treatment cart was locked and not accessible to residents on one unit (East Unit) out of three units in the facility. Findings include: 1) Review of the facility's policy titled Fall Reduction, last revised 7/26/21, indicated the goal was to identify residents at risk for falls and to decrease the incidence of resident falls. The policy included, but was not limited to: - The facility will identify residents at risk for falls. - The facility will implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk. - In the event that a fall occurs, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls. - Upon admission, re-admission, quarterly, annually and with a change in condition and /or after a fall has occurred, residents will be evaluated for risk of potential falls by completing a Fall Risk Assessment. - Residents identified at risk for fall will be identified as low, moderate, or high risk for falling. - The facility will implement Universal Safety Standards, and will review for specific intervention, and document the fall risk prevention measures that have been instituted. - After a fall occurs, the facility will conduct a physical assessment to determine if there is any injuries, notify the facility administration staff, physician, and family, and monitor for neurological signs if a head injury is suspected from the fall. - The facility will evaluate why the resident had fallen, implement interventions to prevent recurrence and complete an Incident Report. Resident #61 was admitted to the facility in August 2020 with diagnoses which included dementia. Review of the Minimum Data Set (MDS) assessments, dated 7/15/21 and 10/7/21, indicated Resident #61 would need an interpreter to communicate, had short and long term memory problems, had no falls since last assessment, and ambulated at a supervised level with cueing and oversight from staff. Review of the most recent MDS assessment, dated 12/30/21, indicated Resident #61 would need an interpreter to communicate, had short and long term memory problems, had a fall with a major injury since the last assessment, and required the physical assistance of staff to ambulate. Review of the Falls Care Plan, initiated on 8/11/20 and last revised on 8/17/20, indicated Resident #61 was at risk for falling related to reduced strength, endurance, and use of psychoactive medications. - The goal was Resident #61 would not fall or have an injury. - The interventions to achieve this goal were as follows: - anticipate and meet any needs. - be sure his/her call light is within reach and encourage use of assistance. - ensure Resident #61 has non-skid socks, slippers, or shoes on when out of bed and ambulating. - if resident falls, follow the facility policy for assessments, reporting to physician, family, and treatment. - keep frequently used items within reach. - maintain a safe environment. Review of the clinical record indicated Resident #61 sustained one injury of unknown origin and three falls between January 2021 and December 2021. All four incidents (falls and injury) were unwitnessed on 1/26/21, 10/16/21, 12/4/21, and 12/27/21. Review of the clinical record and the Fall Risk Assessment reports indicated the facility failed to follow their policy and procedures for falls and injuries. The facility failed to thoroughly investigate why the Resident may have fallen and failed to implement and revise interventions to prevent reoccurrence. Specifically, the facility failed as follows: - The Clinical Nurse's note, dated 1/26/21, indicated Resident #61 sustained a possible nose fracture and was transferred to the hospital. The readmission nurse's note, dated 1/26/21, indicated the Resident sustained a maxillary sinus fracture (nasal fracture). - The Risk Management Fall Assessment report, dated 1/26/21, indicated Resident #61 was found on the floor with a nosebleed. The assessment indicated there were no predisposing environmental factors and the physiological factors and situational factors included incontinence, confusion, memory impairment, and ambulating without assistance. The assessment indicated there were no post incident injuries and the Resident had not been transferred to the hospital. -The Risk Management Fall report, dated 1/26/21, identified the Resident was at high risk for falls and indicated a fall prevention plan should be implemented. - Further review of the medical record failed to indicate that following the fall, the factors contributing to the fall were thoroughly investigated and a plan of action was developed to minimize further falls and or injuries. - On 2/10/21, the facility completed an Event Report/Investigation and reported the 1/26/21 injury to the Department of Public Health. No new recommendations were added to the care plan to help reduce the risk of future falls. - The Clinical Nurse's note, dated 10/16/21, indicated Resident #61 had an unwitnessed fall and sustained a laceration to the bridge of the nose and forehead. The Resident was transferred to the hospital and diagnosed with a nasal fracture. - The Risk Management Fall Assessment, dated 10/16/21, indicated the Resident had an unwitnessed fall and sustained injuries which included a laceration to the bridge of the nose and forehead. The report indicated Resident #61 was unable to explain the cause of the fall due to a language barrier. The report indicated there were no predisposing environmental or situational factors contributing to the fall, and the physiological factors included gait imbalance, impaired eyesight, confusion, and memory impairment. The Risk Management Fall Assessment further identified the Resident was at high risk for falls and indicated a fall prevention plan should be implemented. - The Fall Assessment report was not signed or dated. - On 10/19/21, two days after the fall, the Clinical Nurse's note indicated Resident #61 was diagnosed with a fractured right knee cap. No additional assessments were completed, and no preventative plan was implemented to prevent future injuries. - The Clinical Nurse's note, dated 12/4/21, indicated Resident #61 was found with bruising to the right side of his/her face. The note indicated due to a language barrier, the Resident required an interpreter and said he/she walked into a door frame. Further review indicated the facility failed to complete an incident/accident report and/or a Fall Management Risk assessment. - A statement, dated 12/4/21, was completed by the Certified Nursing Assistant (CNA) who identified the injury. The CNA completed her statement on a Risk Management Statement form. She indicated Resident #61 was in the hallway and approached the CNA. The CNA identified the injury, and the Resident was unable to tell the CNA what happened to cause the bruise. - No new recommendations were added to the care plan to help reduce the risk of future injuries. - The Clinical Nurse's note, dated 12/27/21, indicated Resident #61 fell and did not sustain an injury. - The Risk Management Fall Report, dated 12/27/21, indicated the Resident was found on the floor with no apparent injury. The report indicated there were no predisposing environmental factors that contributed to the fall and the predisposing physiological and situation factors included gait imbalance, confusion, weakness, ambulating without assist, and memory impairment. - Further review of the clinical record indicated there were no new recommendations added to the care plan to help reduce the risk of further falls and failed to indicate the facility followed their policy for fall preventions. On 2/8/22 at 8:11 A.M., the surveyor observed Resident #61 in bed. The Resident had a scooped/concaved mattress (the features of this type of mattress is to minimize the possibilities of falling and or preventing the resident from getting out of bed, as both sides of the mattress have raised sides). The mattress was not part of Resident #61's plan of care. During an interview on 2/8/22 at 10:17 A.M., Unit Manager #1 said Resident #61 was confused, and required assistance from staff. She said the Resident was able to walk with assistance from staff, but that he/she currently required a wheelchair for out of room transportation. Unit Manager #1 said she was unsure when the mattress was placed on the Resident's bed. Unit Manager #1 said the scooped/concaved mattress should have been included in the plan of care. During an interview on 2/9/22 at 2:28 P.M., the Director of Nurses said following each event, a Fall Risk Assessment should be done and the factors contributing to the fall should be identified, the staff should implement interventions to prevent reoccurrence, and monitor through documentation. The Director of Nurses said she did not know why the plan of care had not been revised following any of the incidents and injuries. 2) The surveyor made the following observations on the East Unit of the facility Dementia Special Care Unit where 15 residents with Alzheimer's dementia/dementia resided: On 2/3/22 at 1:48 P.M., the surveyor observed a treatment cart in an alcove area unlocked, unattended, and easily accessible to all residents residing on the East Unit. The five-drawer treatment cart contained the following items: The first drawer included: Multiple bottles of [MEDICATION(S)] (antifungal medication) Disposable razors The second drawer contained: Multiple bottles of [MEDICATION(S)] Preparation H Cream/suppositories Triamcinolone Acetate 0.1% (steroid medication) [MEDICATION(S)] Sodium Topical Gel 1% (nonsteroidal anti-[CONDITION(S)]) Hydrocortisone suppositories (corticosteroid) Hydrocortisone 1% Cream Muscle and Joint gel (analgesic) Silver Sulfa Creme 1% (topical antibiotic) [MEDICATION(S)] (antibiotic) Silver Antimicrobial Wound Dressing DermaGinate/Ag Calcium Alginate Wound Dressing with Antibacterial Silver The third drawer included: Hydrocortisone 1% Cream DermaGinate/Ag Calcium Alginate Wound Dressing with Antibacterial Silver Xeroform Gauze Dressing Impregnated with Xeroform and Petroleum Enema Saline [MEDICATION(S)] The fourth drawer contained: [MEDICATION(S)] ointment The fifth drawer contained: 1 bottle of hand sanitizer H-Chlor 12 0.125% (used to treat wounds) Skin staple removers 5 boxes of DermaGinate/Ag Calcium Alginate Wound Dressing with Antibacterial Silver On 2/3/22 at 1:50 P.M., the surveyor observed a wandering resident approach the unlocked treatment cart and reach into the drawers. The surveyor immediately notified Certified Nursing Assistant #2 who was in the vicinity of the unlocked cart. On 2/8/22 at 9:37 A.M., the surveyor observed a treatment cart in the alcove area unlocked, unattended, and easily accessible to all residents residing on the East Unit. The surveyor observed two residents standing within close proximity to the cart.

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of a left heel pressure ulcer for one Resident (#40), out of 18 sampled residents. Findings include: Resident #40 was admitted to the facility in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 12/9/21, indicated the Resident was totally dependent on staff for bed mobility and transfers. The MDS also indicated the Resident was at risk for the development of pressure ulcers. Review of the Nurse's Progress Note, dated 1/12/22, indicated the Resident had a new open area to the left heel. The physician was notified and a treatment to apply skin prep (protective skin barrier) to the left heel daily was ordered. The progress note failed to indicate the size, appearance, and type of wound. Review of the Weekly Skin Assessment, dated 1/12/22, indicated an open area to the left heel with a treatment in progress. The assessment had no documentation on the appearance of the wound, size of the wound, or stage of the wound. Review of the Weekly Skin Check, dated 1/19/22, had no documentation on the left heel wound except that a treatment was in progress. There was no documentation of the progress of the wound, the appearance of the wound, stage of the wound, or the size of the wound. Review of the facility form titled Wound Documentation Form, dated 1/24/22, 12 days after the initial observation of the wound, indicated Resident #40's left heel wound was a stage IV pressure area (deep wound that reaches muscle, ligaments, and sometimes bone) and measured 3.5 centimeters (cm) x 3 cm x 0.1 cm. Documentation indicated the VA Hospital was made aware of the wound. Review of the Physician's Assistant (PA)'s Progress Note, dated 2/3/22, a total of 22 days since the wound was first documented, indicated the Resident had an ulcer to the left heel for several weeks and the ulcer was non-healing. The PA documented that nursing would consult with the wound clinic at the VA. The PA initiated [MEDICATION(S)] (antibiotic) 100 mg twice a day for 10 days for concern of infection. The PA failed to document that the wound was assessed and failed to document the appearance of the wound, size of the wound, or stage of the wound. Review of the Weekly Skin Check, dated 2/4/22, indicated the left heel was a facility acquired pressure ulcer. Documentation indicated the PA was notified and examined the wound. The skin check failed to document size, appearance, and stage of the wound. Review of the Nurse's Progress Note, dated 2/5/22, indicated that nursing placed a called to the VA hospital to set up an appointment at the wound clinic. The note indicated that the VA hospital would call the facility back. Review of the PA's Progress Note, dated 2/7/22, indicated the Resident had a left heel ulcer for several weeks which was non-healing. The PA documented that an appointment with the Wound MD at the VA was pending. This was four days since the PA last documented on the wound and 26 days since the wound was found. The PA documented that there was concern for [CONDITION(S)] (inflammation/infection of the bone) and that an MRI (Magnetic Resonance Imaging) would be obtained. On 2/9/22 at 10:41 A.M., the surveyor observed the left heel pressure ulcer with Nurse #1. The base of the wound was bright red with a large amount of bleeding. The left foot had notable [CONDITION(S)] (swelling). The wound bed was fragile and had an area of yellow slough (compromised skin tissue) and black eschar (dead tissue). During an interview on 2/9/22 at 10:55 A.M., Nurse #1 said the heel wound bleeds a lot during dressing changes. She said she did not do measurements of the wound, but only changed the dressing. Nurse #1 said the Assistant Director of Nurse (ADON) assessed the wound weekly. During an interview on 2/9/22 at 11:52 A.M., the ADON said she was responsible for the weekly assessment of wounds. She said she completed a weekly skin form on Fridays which included measurements and change of condition to the wounds. The ADON said she did not document her findings in the medical record, but said she relied on the nursing staff to communicate any changes in the wound between each skin assessment. She said the nurses do not document on wounds in the medical record. Review of the form titled Skin Grid of Pressure Ulcers, which the ADON used for wound documentation, indicated the wound had increased in size between 1/22/22 and 1/28/22 and that the wound treatment was changed. Review of the grid indicated that on 1/14/22 the wound measured 3cm x 2cm x 0.1cm. On 1/21/22, the wound measured 3cm x 2cm x 0.1cm. On 1/28/22 the wound measured 3.5cm x 3cm x 0.1cm, indicating that the wound had increased in size. On 2/4/22 the wound measured 3.5cm x 3cm x 0.1cm and now was identified as a Stage IV wound. Review of the Nurse's Progress Notes failed to include any documentation on wound care between 1/12/22 and 2/8/22. Review of the Treatment Administration Record (TAR), dated 1/12/22 through 2/8/22, indicated that nursing signed off on the TAR that they were monitoring the wound, but failed to document the size, appearance, or stage of the wound. During an interview on 2/9/22 at 12:05 P.M., the ADON said she had discussed the wound with the PA and about scheduling an appointment with the Wound MD at the VA. She said the appointment for the MRI and the Wound MD had not been scheduled, 16 days after recommendations were made.

Based on record review, interviews and observations, for 9 of 17 sampled residents (Resident #1, #2, #4, #5, #6, #8, #13, #14 and #15), who had the [DIAGNOSES REDACTED]. The Facility failed to provide documentation that thorough investigations were conducted for resident falls and injuries of unknown origin. The Facility failed to ensure fall prevention care plans were re-evaluated and alternative interventions implemented in response to residents who fell . Findings include: 1. The Facility's Marketing Brochure, dated as reviewed in May 2105, indicated: the Facility was a licensed Long Term Care Facility with services focusing on the special needs of individuals who suffer from Alzheimer's disease and other forms of dementia; and during care delivery each plan of care is re-evaluated by all members of the care team to ensure the level of care is adjusted according to patient/resident needs. 2. The Facility Policy titled Fall & Injury Management indicated staff were to evaluate and review factors for falls and injuries. The Facility Policy titled Event Reporting - Resident/Patient indicated an event report will be completed for any occurrence outside the routine operational expectation of the Facility, including but not limited to: bruises, falls (witnessed or unwitnessed), resident noted on the floor and interrupted falls. 3. The Surveyor interviewed the Director of Nurses (DON) at 1:15 P.M. on 8/11/15 and throughout the day on 8/12/15, 8/13/14 and 8/17/15. During an interviewed at 8:05 A.M. on 8/12/15, the DON said the Facility did not have a formal protocol in place to assess residents' fall risk and Staff did not perform a Fall Risk Assessment because, residents have the right to fall or words to that effect. The Surveyor interviewed the Medical Director at 1:00 P.M. on 8/13/15. The Medical Director said that a [DIAGNOSES REDACTED]. The Surveyor interviewed the Staff Development Coordinator (SDC)/Risk Manager (RM) at 12:55 P.M. on 8/11/15 and throughout the day on 8/12/15, 8/13/15, 8/17/15 and 8/18/15. During an interview at 2:15 P.M. on 8/18/15, the SDC/RM said the DON would not permit her the time to complete a thorough investigation of residents' falls and/or injuries of unknown origin, and instructed her to close an event report before completion of her investigation. 4. Resident #1's Admission Minimum Data Set (MDS) assessment, dated 12/11/14, indicated Resident #1 was cognitively impaired, required 1 person physical assistance with transfers and ambulation, and had a history of [REDACTED]. The plan of care, dated as reviewed on 3/15/15, indicated Resident #1 required personal alarms, on bed and chair, at all times. A Nurse Progress note and an Event Report record, both dated 5/25/15, indicated Resident #1 was observed by staff lying on the floor in the dining room at 3:00 P.M., and no injuries were noted. The Facility's Event Report record and the Physicians Order, dated 5/25/15, indicated Resident #1 was placed on 15 minute checks for 72 hours. The Plan of Care, dated as reviewed on 5/25/15, indicated Resident #1 was placed on 1 to 1 supervision, and personal alarms, on bed and chair, at all times. Resident #1's Treatment Record, dated May 2015, indicated Resident #1's bed and chair alarms were discontinued. This was not reflected on Resident #1's care plan and there was no physician order in place to discontinue Resident #1's bed and chair alarms. The Maintenance Activity of Daily Living (ADL) Safety Care Plan and Communication Tool, dated 6/8/15, utilized by the Certified Nurse Aides (CNA), indicated Resident #1 required 1 person physical assistance with transfers and ambulation, and had bed and chair alarms. Resident #1's Treatment Record, dated 6/1/15 through 6/14/15, indicated Resident #1's bed and chair alarm were not documented as checked in place and functioning correctly at all times. A Nurse Progress note and an Event Report, both dated 6/14/15, indicated Resident #1 was observed walking around the Unit and staff noted that Resident #1 had a bruise on his/her forehead. The Note and Event Report indicated approximately 2 hours and 45 minutes later, Resident #1 had a huge bump on his/her forehead, and scrapes on his/her right elbow and knee. Resident #1 was transferred to the Hospital where he/she was diagnosed with [REDACTED]. The Surveyor interviewed CNA # 6 at 3:15 PM., and Nurse #1 at 4:25 P.M. on 8/11/15. CNA #6 and Nurse #1 said Resident #1 would often get out off bed during the night, he/she would wander around the unit and on redirection would go back to bed. CNA #6 and Nurse #1 said Resident #1 did not have an alarm on his/her bed to alert them in the event Resident #1 tried to get out of bed without assistance. CNA #6 said that on 6/14/15, at approximately 4:00 A.M., she heard a noise in Resident #1's room. CNA #6 said when she entered the room she found Resident #1 sitting up in bed and when she approached Resident #1, she saw a small bruise on Resident #1's forehead. CNA #6 said she called out to Nurse #1 for help and Nurse #1 assisted her to settle Resident #1 in bed. Nurse #1 said he did not notify the Physician about Resident #1's injury of unknown origin because it was the middle of the night or words to that effect. Nurse #1 said he performed neurological assessments on Resident #1 throughout the remainder of his shift, however, he did not turn on the overbed light or perform a full skin assessment on Resident #1 to identify if he/she had further injuries. CNA #6 said she found Resident #1 wandering around the Unit on 2 more occasions prior to change of shift at 7:00 A.M. and redirect Resident #1 back to his/her room and assisted him/her into bed. The Surveyor interviewed Nurse #3 at 12:30 P.M. on 8/12/15. Nurse #3 said 6/14/15, at approximately 6:45 A.M., he saw a huge bump on Resident #1's forehead the size of a circumference of a soda can or words to that effect. Nurse #3 said he pulled back the bed sheets and saw scrapes on Resident #1's right elbow and right hip. Nurse #3 said he notified the Physician and Resident #1 was transferred to the Hospital for further evaluation. The Hospital Diagnostic Imaging CT (computed tomography) Scan Report, dated 6/14/15, indicated Resident #1 had an acute hemorrhage in the subarachnoid space in his/her brain. The Facility's Internal Investigation File and Event Report record, dated 6/14/15, indicated a thorough investigation into surrounding events as to how Resident #1's injury occurred was not completed. The DON said that it was his assumption that Resident #1 rolled out of bed and somehow was able to pull him/herself up from the floor and back into bed, or words to that effect. The Plan of Care, dated as reviewed on 6/14/15, indicated Resident #1 was placed on 15 minute safety checks and personal alarms in place at all times. On 8/11/15 at 11:15 A.M., the Surveyor observed Resident #1 sitting in a wheelchair, which he/she was unable to self propel. The chair alarm was attached but turned off. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #1. 5. Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 5/7/15, indicated Resident #2 was severely cognitively impaired, he/she required 1 person physical assistance with ambulation, and he/she had a history of [REDACTED]. The Plan of Care, dated 5/21/15, indicated staff were to: redirect Resident #2 and reinforce his/her safety awareness; keep his/her call light within reach; allow Resident #2 to ambulate until fatigued; and a handwritten note to ensure personal alarms were in place at all times, was crossed out. There was no documentation to indicate how staff were to identify if Resident #2 was fatigued from ambulating. The Maintenance ADL Safety Care Plan and Communication Tool, dated 6/4/15, indicated Resident #2 was ambulatory, however, there was no documentation indicating the level of assistance Resident #2 required from staff with ambulation. A Nurse Progress Notes and Event Report, both dated 6/10/12, indicated Resident #2 had 2 unwitnessed fall, The Note indicated at 12:15 P.M. a visitor informed staff that Resident #2 was lying on the floor in the dining room; and 45 minutes later, at 1:00 P.M., staff found Resident #2 lying on the floor in the dining room. There was no documentation to indicate Resident #2's care plan was re-evaluated, and alternative interventions implemented in an effort to prevent falls after the two falls on 6/10/15. A Nurse Progress Note, dated 7/19/15, indicated staff observed Resident #2 walking in the hallway with a bump on his/her forehead. The Facility's Internal Investigation File and Event Report record, dated 7/19/15, indicated a thorough investigation into surrounding events related to Resident # 2's injury was not completed, and indicated Resident #2 ambulated at will and frequently ambulated with his/her arms clasped behind him/her and with his/her head tilted down looking towards his/her feet. There was no documentation to indicate Resident #2's care plan was re-evaluated, and alternative interventions implemented in an effort to prevent further injury after he/she was noted with a bump on his/her forehead on 7/19/15. A Nurse progress note, dated 7/28/15, indicated that at 7:45 P.M. Resident #2 was found lying on the floor in another resident's room, and he/she was bleeding from his/her nose. Resident #2 was transferred to the ER for further evaluation. The Surveyor interviewed CNA #5 at 4:10 P.M. on 8/12/15. CNA #5 said that on the evening of 7/28/15 said she left Resident #2 alone in his/her room. CNA #5 said when she returned, Resident #2 was not in his/her room. When CNA #5 went back into the hallway she saw Resident #2 entering another resident's room at the opposite end of the hallway. CNA #5 said she walked into the room and she saw Resident #2 lying face down on the floor covered in blood. The ER report, dated 7/29/15, indicated Resident #2 had a head injury with a nasal fracture following an unwitnessed fall. The Facility's Internal Investigation File and Event Report record, dated 6/10/15 and 7/19/15, indicated a thorough investigation into surrounding events as to how Resident #2's injury occurred was not completed. Resident #2's Plan of Care, dated 8/2/15, indicated Resident #2 was to have personal alarms on his/her bed and chair at all times. On 8/12/15, at 1:38 P.M., the Surveyor observed Resident #2 lying horizontally across the bed with his/her feet hanging over the edge of the bed. The bed alarm was attached but turned off. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #2. 6. Resident #4's Annual MDS assessment, dated 4/16/15, indicated Resident #4 was severely cognitively impaired, was unsteady when ambulating, required 1 person physical assist with transfers, ambulation and bed mobility, and had a history of [REDACTED]. The Plan of Care, dated 4/29/15, indicated staff were to ensure Resident #4 wore appropriate footwear, call light was within reach, and ensure the bedside table was next to the side of the bed when Resident #4 was not eating. The Maintenance ADL Safety Care Plan and Communication Tool, dated 6/4/15, indicated Resident #1 required the assist of 1 person for transfers and ambulation, was dependent on staff for bathing and dressing, and had a bed alarm. A Nurse Progress Note, dated 7/26/15, indicated that at 7:30 A.M. staff discovered a 4 centimeter (cm) x 4 cm laceration on Resident #4's scalp with discoloration around his/her right eye, and on assessment Resident #4 appeared to be in pain displaying facial grimacing and moaning during active range of motion. Resident #4 was transferred to the ER and returned later that afternoon with no new orders. The Facility's Incident Report submitted to the Department of Public Health, dated 8/6/15, indicated Resident #4's injury was noted at 6:45 A.M. on 7/26/15. The Report indicated that on 7/30/15, staff came forward and reported to the Director of Nurses (DON) that Resident #4 had fallen on 7/26/15 and was put back to bed, but on further investigation staff had no recollection of Resident #4's fall and denied any knowledge that Resident #4 had fallen. The Report indicated Resident #4 ambulated at will independently throughout the Facility, and indicated, due to Resident #4's unsteadiness, it was assumed that Resident #4 hit his/her head on the bedside rail while self transferring out of bed sometime during the night. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #4. 7. Resident #5's Quarterly MDS assessment, dated 5/21/15, indicated Resident #5 was severely cognitively impaired, and required 1 person physical assist with transfers, ambulation, dressing and toileting. The Plan of Care, dated 6/4/15, indicated staff were to assist Resident #5 with care as needed. The Maintenance ADL Safety Care Plan and Communication Tool, dated 6/4/15, indicated Resident #5 transferred and ambulated with the assist of 1 person, was dependent on staff for bathing and dressing, and had a bed alarm. A Nurse Progress Note, dated 8/10/15, indicated during routine care at 11:30 P.M. Resident #5 was noted to have swollen right hip, which was yellowish in color, of unknown etiology, Resident #5 was transferred to the ER for evaluation, and at 3:15 A.M. the Facility received a call from the ER and were informed Resident #5's did not have a fracture and his/her bruise was old. The Facility's Internal Investigation File and Event Report record, dated 8/10/15, indicated Resident #5 ambulated independently and a thorough investigation into surrounding events related to Resident #5's injury of unknown origin was not completed. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #5. 8. An Admission Data Collection and Initial Plan of Care, dated as completed on 6/14/15, indicated Resident #6 was admitted on [DATE], he/she ambulated independently and a fall risk assessment was not completed. The Maintenance ADL Safety Care Plan and Communication Tool, dated 6/12/15, indicated Resident #6 required 1 person assistance and use of a gait belt for transfers and 1 person hand held assistance with ambulation. Resident #6's admission Plan of Care, dated 6/14/15, indicated staff were to redirect Resident #6, reinforce safety awareness, keep call light within reach, encourage Resident #6 not to lie on tables and redirect to a safe destination. A Nurse Progress Note, dated 6/18/15, indicated Resident #6 was observed standing on a wheelchair, staff assisted him/her off the chair and then Resident #6 lay down on the floor. The Admission MDS assessment, dated 6/19/15, indicated Resident #5 was severely cognitively impaired, and he/she required 1 person physical assistance with transfers, ambulation, dressing and toileting. The Plan of Care, revised on 6/19/15, indicated Resident #6 attempts to lie on floor, however, no revisions or updates were documented. A Nurse Progress Note, dated 6/23/15, indicated staff discovered Resident #6 kneeling on the floor in the main lobby area. There was no documentation to indicate Resident #2's care plan was re-evaluated after staff discovered Resident #6 kneeling on the floor on 6/23/15. The Facility was unable to provide supporting documentation indicating that a thorough investigation was completed into the events surrounding how Resident #6 was able to reach the main lobby area and how he/she knelt/fell on his/her knees unwitnessed on 6/23/15. A Nurse Progress Note, dated 7/1/15, indicated Resident #6 had a laceration above his her left eyebrow. The Facility's Internal Investigation File and Event Report, dated 7/1/15, indicated Resident #6 was transferred to the ER where he/she received dermabond (a topical skin closure product) to his/her laceration and a Tetanus injection. The Investigation File and Event Report record, indicated an investigation into surrounding events related to Resident #6's injury of unknown origin was not completed, and the Event Analysis Report indicated that because Resident #6 ambulated freely around the Facility with his/her head down and his/her eyes closed, it was possible he/she may have ambulated into an object causing the laceration. However, a late entry note, for 7/1/15, indicated Resident #6 fell from a wheelchair belonging to another resident, and sustained a 4 centimeter (cm) x 6 cm skin tear on his/her left arm. A Nurse Progress Note, dated 7/2/15, indicated Resident #6 was transferred on a Section 12 (involuntary transfer and admission to a locked psychiatric facility) for evaluation of changes in his/her behaviors. Nurses' Progress Notes indicated Resident #6 was readmitted to the facility on [DATE], and the note, dated 7/22/15, indicated he/she was placed on 1 to 1 supervision. A Nurse Progress Note, dated 7/29/15, indicated Resident #6 was found sitting on the floor beside/his/her bed, he/she was noted to have 2 skin tears on his/her left arm, and at that time his/her bed alarm was in place, but was not turned on. The Facility's Internal Investigation File and Event Report record, dated 7/29/15, indicated a thorough investigation into the events related to Resident #6's fall was not completed. On 8/13/15, at 12:35 P.M., the Surveyor observed Resident #6 attempting to climb out of his/her recliner chair which was situated beside the nurses' station. Two staff members were standing at the nurses' station, with their backs to Resident #6, one of the nurses was using an electronic tablet. The Surveyor intervened by calling out for help and on closer observation saw that Resident #6's chair alarm was attached, but turned off. At 4:20 P.M. the Surveyor observed Resident #6 lying in bed. The bed alarm was attached, but turned off. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #6. 9. Resident #8 was admitted to the Facility at 3:00 P.M., in August 2015, with [DIAGNOSES REDACTED].#8 had a recent Geriatric-psychiatric admission. The Admission Physician's orders, dated 8/13/15, indicated Resident #8 was to have 15 minute checks each shift for three days, and a pressure alarm when in bed and/or the wheelchair. The Individualized Care Plan for Safety and Fall Risk for Resident #8, dated 8/2015, indicated he/she was at risk for a fall or fall related injury because of a previous fall in the Facility; interventions included bed and chair personal alarms, low platform bed, and call light within reach. The Maintenance ADL and Safety Care Plan Communication Tool, for Resident #8, dated 8/13/15, indicated he/she required pressure alarms in bed and in the chair, assistance of two to turn and reposition, but the Communication Tool was blank regarding Resident #8's need for assistance with toileting, transfers and ambulation. The ADL Flow Sheet, dated 8/13/15 through 8/16/15, indicated resident #8 was totally dependent for transfers, and required the assistance of two for ambulation and toileting needs. The Nurse's Progress Note, dated 8/14/15 at 7:00 A.M., indicated Resident #8 in bed, toileted, clean, refused to sleep, as needed Ativan (antianxiety) 0.5 milligrams (mg) administered at 12:10 A.M., with some effect, bed alarm on and functioning, staff responded to alarm sounding at 2:15 A.M., and found Resident #8, lying on the floor beside his/her bed. The Resident Monitoring Tool, dated 8/14/15, indicated 15 minute checks were conducted on Resident #8 starting at 12:00 A.M., through 2:15 A.M., and signed off by nursing as completed. The Neurological Assessment Flow Sheet, dated 8/14/15, indicated 15 minute neurological checks were conducted on Resident #8 at 1:30 A.M., 1:45 A.M., and 2:00 A.M., by nursing staff. The Event Report, dated 8/14/15, indicated Resident #8 was last seen by nursing staff at 1:30 A.M., for toileting rounds, however that information conflicts with documentation on the Resident Monitoring Tool, and the Neurological Assessment Flow Sheet. On 8/17/15, Resident #8, who remained on 15 minute checks, had an unwitnessed fall out of bed, was found with his/her head on the floor, and both feet were still in the bed when staff responded to his/her bed alarm. The Event Report, dated 8/17/15, indicated Resident #8's skin was intact, no injury noted, however the nurse's statement indicated Resident #8 had a bruise on the front of his/her head, and Physician's order was obtained to transfer Resident #8 to the Hospital for evaluation. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #8. 10. The Quarterly MDS, dated [DATE], indicated Resident #13 was severely cognitively impaired, required extensive assistance of two staff to reposition in bed, was dependent for transfers, and was unable to ambulate. The ADL and Safety Care Plan Communication Tool, dated 6/8/15, indicated Resident #13 required a pressure chair pad alarm while in the wheelchair, was non ambulatory, and was dependent for mobility and transfers. On 8/17/15, at approximately 8:50 A.M., Resident #13 was observed in the dining room seated at a table. Resident #13's chair alarm was attached, but turned off. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #13. 11. Resident #14's Annual MDS, dated [DATE], indicated Resident #14 was severely cognitively impaired and required 1 person physical assistance with transfers and ambulation. Review of Resident #14's medical record indicated Resident #14 did not have a completed Maintenance ADL Safety Care Plan and Communication Tool. The Plan of Care, dated 5/22/15, indicated Resident #14 was to have a bed alarm in place, and staff were to guide Resident #1 away from high traffic areas and take him/her to his/her room to lie down when tired. A Nurse Progress Note, dated 5/22/15, indicated Resident #14 was found lying on the floor next to his/her bed and on assessment had 3 bruises on his/her right elbow measuring 2 cm x 2 cm, 1.5 cm x 1.75 cm and 2 cm x 1 cm, and 2 reddened areas on his/her right hip measuring 9 cm x 5 cm and 7 cm x 4 cm. The Facility's Internal Investigation File and Event Report record, dated 5/22/15, indicated a thorough investigation into the events related to Resident #14's fall was incomplete. The Event Analysis Report indicated it was assumed Resident #14 most likely had an hypoxic event (the body is deprived of oxygen) upon trying to rise from bed and fell . There was no documentation available indicating Resident #14's bed alarm was in place and/or functioning correctly at the time of his/her unwitnessed fall. The Plan of Care revised on 5/22/15, following Resident #14's fall, indicated additional interventions included Resident #14 required the assistance of 2 people to transfer and 1 person to assist with ambulation. A Nurse Progress Note, dated 6/18/15, indicated Resident #14 was found lying on the floor. The Facility's Internal Investigation File and Event Report record, dated 6/18/15, indicated Resident #14 was found by staff at 5:40 P.M., during routine care rounds, lying on the floor under a chair. A thorough investigation into surrounding events as to how Resident #14 fell was not completed. There was no documentation available indicating Resident #14's bed alarm was in place and/or functioning correctly at the time of his/her unwitnessed fall. There was no documentation to indicate Resident #14's care plan was re-evaluated after staff discovered Resident #14 was found lying on the floor on 6/18/15. A Nurse Progress Note, dated 8/14/15, indicated Resident #14 was found to have a skin tear measuring 2 cm x 1 cm on his/her right arm. The Facility was unable to provide supporting documentation indicating that a thorough investigation was completed into surrounding events as to how Resident # 14 sustained a skin tear. On 8/17/15, the Surveyor observed Resident #14 on numerous occasions, ambulating independently throughout the Facility, and observed him/her knocking on doors and entering staff offices. The Surveyor asked staff to intervene and redirect Resident #14. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #14. 12. Resident #15's Annual MDS, dated [DATE], indicated Resident #15 was severely cognitively impaired and required 1 person physical assist with transfers and ambulation. The Maintenance ADL Safety Care Plan and Communication Tool, dated 6/8/15, indicated Resident #15 required 1 person physical assist with transfers and ambulation. The Plan of Care for Fall/Fall Risk, dated 6/11/15, indicated staff were to invite, encourage, remind and escort Resident #15 to activity programs consistent with his/her interest. A Nurse Progress Note, dated 7/3/15, indicated that, at approximately 7:45 A.M., Resident #15 was found in bed, with a swollen, bleeding lip and dried blood was noted on the floor next to Resident #15's bed. The note indicated that Resident #15 ambulated and transferred independently. The Situation Background Assessment Request (SBAR) dated 7/3/15, indicated Resident #15 was found in his/her bed with a swollen, bleeding lip, sensitive to touch, and scrapes to his/her knee., The SBAR indicated that the cause of Resident #15's injury was unable to be determined. Resident #15 was transferred to the ER for evaluation and treatment. A Nurses' progress Note, dated 7/3/15, indicated Resident #15 returned to the Facility with no new orders. Review of the Facility's Internal Investigation File and Event Report, dated 7/3/15, indicated a thorough investigation into the events related to Resident #15's injury of unknown origin was not completed, and the Event Analysis Report indicated Resident #15 ambulated independently and wandered at will during the night, fell and got himself/herself off the floor. The Facility failed to ensure that fall risk assessments were performed and failed to implement effective interventions with adequate monitoring and supervision to prevent injuries for Resident #15.

Based on record review and interviews, for 4 of 17 sampled residents (Resident #2, #3, #6 and #15) who had the [DIAGNOSES REDACTED]. In addition, - Resident #2 fell twice on 6/10/15; on 7/19/15 was observed to have a bump on the forehead, the care was plan was not re-evaluated following these incidents; on 7/28/15, Resident #2 fell in another resident's room and sustained facial injuries, which included a head injury and a nasal fracture. -On 6/23/15, Resident #6, who required assistance with ambulation, was found on the floor; the care plan was not updated; and on 7/1/15, was found with a laceration above the eyebrow, which required dermabond to close. Findings include: 1. Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 5/7/15, indicated Resident #2 was severely cognitively impaired, required 1 person physical assistance with ambulation, and had a history of [REDACTED]. The Plan of Care, dated 5/21/15, indicated staff were to redirect Resident #2, reinforce safety awareness, keep call light within reach, allow Resident #2 to ambulate until fatigued, and a handwritten note, which indicated personal alarms were to be in place at all times, was crossed out. The date the entry was crossed out was not documented. A Nurse Progress Note and Event Report Records, both dated 6/10/15, indicated Resident #2 had two unwitnessed falls; at 12:15 P.M., a visitor informed staff that Resident #2 was lying on the floor; and 45 minutes later, at 1:00 P.M., staff found Resident #2 lying on the floor in the dining room. There was no documentation to indicate Resident #2's care plan was re-evaluated, and alternative interventions implemented in an effort to prevent falls after the two falls on 6/10/15. A Nurse Progress Note, dated 7/19/15, indicated staff observed Resident #2 walking in the hallway with a bump on his/her forehead. There was no documentation to indicate Resident #2's care plan was re-evaluated, and alternative interventions implemented in an effort to prevent injuries of unknown origin, after Resident #2 was noted to have a bump on his/her forehead. A Nurse Progress Note, dated 7/28/15, indicated that on 7:45 P.M., Resident #2 was found lying on the floor in another resident's room, and was bleeding from his/her nose. Resident #2 was transferred to the emergency room (ER) for further evaluation. The ER report, dated 7/29/15, indicated Resident #2 had a head injury with a nasal fracture following an unwitnessed fall. 2. Resident #3's Annual MDS assessment, dated 4/23/15, indicated Resident #3 was severely cognitively impaired, required 1 person physical assist with transfers, ambulation, personal hygiene, dressing and toileting. The Plan of Care, dated 5/6/15, indicated staff were to redirect Resident #3, reinforce safety awareness, and keep call light within reach. These care plan interventions were not individualized based on Resident #3's severe cognitive impairment. 3. Resident #6's Admission Plan of Care, dated 6/14/15, indicated staff were to redirect Resident #6, reinforce safety awareness, keep call light within reach, encourage Resident #6 not to lie on tables and redirect to a safe destination. The Admission MDS assessment, dated 6/19/15, indicated Resident #6 was severely cognitively impaired, required 1 person physical assistance with transfers, ambulation, dressing and toileting. A Nurse Progress Note, dated 6/18/15, indicated Resident #6 was observed standing on a wheelchair, staff assisted him/her off the chair and Resident #6 lay down on the floor. The Plan of Care, revised on 6/19/15, indicated Resident #6 attempts to lie on floor, however, no updates and/or alternative, preventive interventions were documented. A Nurse Progress Note, dated 6/23/15, indicated staff discovered Resident #6 kneeling on the floor in the main lobby area. No updates and/or individualized interventions for the prevention of falls were documented following staff discovering Resident #6 kneeling on the floor on 6/23/15. A Nurse Progress Note, dated 7/1/15, indicated Resident #6 had a laceration above his/her left eyebrow. A late entry Nurse Progress Note for 7/1/15, indicated Resident #6 fell from a wheelchair belonging to another resident, and sustained a 4 centimeter (cm) x 6 cm skin tear on his/her left arm. The Facility's Internal Investigation File and Event Report record, dated 7/1/15, indicated Resident #6 was transferred to the ER where he/she received dermabond (a topical skin closure product) to his/her laceration and a Tetanus injection. 4. Resident #15's Annual MDS, dated [DATE], indicated Resident #15 was severely cognitively impaired, and required 1 person physical assistance with transfers and ambulation. The Plan of Care for Falls/Fall Risk, dated 6/11/15, indicated staff were to invite, encourage, remind and escort Resident #15 to activity programs consistent with his/her interest. A Nurse Progress Note, dated 7/3/15, indicated at approximately 7:45 A.M., Resident #15 was found in bed, with a swollen, bleeding lip and dried blood was noted on the floor next to Resident #15's bed. The note indicated that Resident #15 ambulated and transferred independently. Resident #15 was transferred to the ER and returned later that afternoon with no new orders.

Based on record review, observation and staff interview, the facility failed to ensure for 1 (Resident #2) of 6 residents who sustained falls, out of a total sample of 17 residents, that adequate supervision was provided, and that appropriate safety measures were developed and monitored for effectiveness to maintain the safety of the residents. Findings include: For Resident #2, who sustained 10 falls in 6 months, the facility failed to provide adequate supervision and effective interventions to prevent falls that resulted in progressive injury to the resident. Resident #2 was admitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. Review of the Falls Prevention policy provided by the Administrator on the last day of survey, indicated the following: "Our Drop-In program has one purpose...to prevent falls. The assigned CNA's (Certified Nurse Assistant's) are expected to have all their attention focused on the resident's. If help is needed, or a problem occurs yell for help. Don't leave the room. Please don't sit down and consider that time as break. It is a 30-minute period of being extra alert for trouble. It is expected that the staff monitoring residents will be walking around or standing near where trouble is occurring." Review of the Drop-In Center staff schedule indicated that CNA and Activity staff assigned to provide care on the units or in the Activities programs are also assigned by rotation, to provide supervision in the Drop In Center for 30 minute increments between the hours of 9:30 A.M. and 11:30 A.M., 1:00 P.M. and 4:30 P.M. and 6:30 P.M. through 8:00 P.M. Review of Resident #2's Fall Care Plan, initiated on 1/29/14, indicated that the resident was assessed at high risk for fall related injury due to dementia, declined cognitive function,antipsychotic medication and a history of falls. Interventions listed included: - Institute the falling star program - Pressure alarm at all times - Low / platform bed - Appropriate footwear - Side body pillows while in bed (initiated 1/31/14) - Escort to activity programs consistent with resident's interests to enhance physical strength needs The initial Minimum Data Set (MDS) assessment completed 2/4/14, indicated that the resident was cognitively impaired and was dependent on facility staff for all activities of daily living and required a 2 person assist for all transfers. The resident was coded with unsteady balance, was receiving antipsychotic and anxiety medications and had a history of [REDACTED]. A review of the clinical record on 8/7/14 indicated that the resident had 10 falls including 5 unwitnessed falls, that occurred on 2/10/14, 3/11/14, 5/7/14, 5/14/14, 5/28/14, 6/7/14, 6/20/14, 7/23/14, 7/25/14 and 7/30/14. Nurse #1 was interviewed on 8/13/14 at approximately 10:20 A.M. and reviewed the facility incident reports and nursing documentation with the surveyor. Review of the incident reports and nursing notes documentation indicated the following: Review of the 2/10/14 nurse's note indicated that staff responded to an alarm sounding at 7:35 A.M. and found the resident on the floor next to the bed. The nurse indicated that no injury was reported. No new interventions were implemented. Review of the nurse progress notes from 3/5/14 - 3/9/14 indicated that the resident made numerous attempts on multiple shifts to get out of the wheelchair unassisted. On 3/11/14 at 2:00 P.M. the activity staff member who was assigned to provide supervision in the facility "Drop In Center" yelled for help. Nurse #1 documented she responded and found the resident on the floor with the alarm sounding and observed the activity staff member assisting another resident who was attempting to ambulate unassisted. No injury was identified. Review of the activity staff member's statement indicated that "during Drop In three of the residents are trying to get up. I went to help the first resident by the time I got to the next one he/she already sat on the floor." Nurse #1 said during interview on 8/13/14 at 10:20 that the activity staff member was providing supervision to multiple residents at high risk for falls. Nurse #1 said the level of supervision at the time of the resident's fall was "not safe." On 5/7/14 at 11:00 A.M. the nurse's note indicated he/she responded to the alarm sounding and found the resident on the floor next to the bed. No injury was identified. Bilateral floor mats added for safety. Nurse #1 said on 8/13/14 at 10:20 A.M. that she could not explain why the resident was still in bed at 11:00 A.M. or if the resident was incontinent of bladder and bowel at the time of the fall. There was no documentation on the indicent report to address these questions. On 5/14/14 at 2:35 P.M. the nurse responded to the occupational therapist's call for help and found the resident on the floor mat on the left side of the bed with the alarm sounding. The resident was incontinent of bowel and bladder. No injury was reported. Interventions listed in the incident report on 5/15/14 indicated to put the resident back to bed after lunch for one half hour. On 5/28/14 at 11:30 A.M. a nurse working on the adjacent unit documented that he witnessed the resident ambulating in the corridor without assistance. The nurse indicated that the resident fell before he/she could reach him/her. No injury was reported. Review of the investigation documented on the incident report failed to identify and include if staff were on the unit, but did indicate that no unit staff responded to the resident alarm sounding until after the resident had fallen. A Velcro seat belt with alarm was added to prevent further falls. On 6/17/14 at 12:55 P.M. the nurse responding to a CNA yelling for help in the Drop-In Center observed the resident on the floor with the alarm sounding. No injury was reported. Review of the CNA statement in the incident report investigation indicated that the resident fell when the CNA was attempting to assist another resident who was agitated and ambulating unassisted. The new intervention indicated that the resident would not be put in the Drop-In Center and would be encouraged to go to activities. Nurse #1 said on 8/13/14 at 10:20 A.M. that activities programs are in the front dining room but the resident was unable to attend these programs because there was "not enough staff" to watch the resident due to his/her fall risk. On 6/20/14 at 8:45 P.M. the nurse's note indicated that the resident removed his/her alarmed safety belt, ambulated unassisted in the corridor and fell before staff could reach him/her. The resident sustained [REDACTED]. The intervention listed on the incident report was to change the Velcro seat belt to a clip alarm seatbelt, initiated 6/23/14. Nurse #1 said on 8/13/14 at 10:20 A.M.,that she could not explain the rationale for this intervention as the resident was repeatedly observed by staff removing both the Velcro and clip alarm seat belt while in the wheelchair. On 7/23/14 at 6:30 P.M. the nurse responding to the alarm sounding observed the resident lying face down on the floor with the left arm underneath his/her body. The nurse and a physical therapist, who was on the unit at the time, assisted the resident back to the wheelchair. The incident report did not indicate that any CNA staff were present on the unit at the time of the fall. Nurse #1 said that the 7/24/14 intervention listed was to continue the Velcro alarm seat belt until anti-roll back brakes were available. Nurse #1 said that the anti-roll back brakes were already in place at the time of the fall. Nurse #1 said she could not explain why no CNA staff were on the unit, according to the incident report documentation. On 7/25/14 at 6:15 P.M. the CNA assigned to provide supervision to residents in the Drop-In Center wrote in his/her witness statement that Resident #2 released the Velcro safety belt and stood up. The CNA who was assisting another resident at the time, ran to Resident #2 and caught him/her falling forward. The resident's head struck the CNA's knee and the resident's knees hit the floor. The resident was assisted back to the wheelchair by the CNA who then called for the nurse. The nurse observed a 2 centimeter (cm) long laceration to the resident's left upper eyebrow with moderate bloody drainage and purple bruising to the cheekbone. The nurse documented that the resident was incontinent. The resident was transported to the hospital where a CT scan of the head was negative for fracture and the resident returned to the facility with 6 sutures in place. The intervention noted on the incident report investigation to prevent further falls indicated for the resident to be "placed by the door (of the Drop -In Center) with grouping of other residents who are at increased risk of falls to allow for easier access to the resident." Nurse #1 said on 8/13/14 at 10:20 A.M. said that she could not explain why the resident was placed in the Drop-In Center since that intervention was discontinued following the 6/17/14 fall. Nurse #1 said she was concerned about a single staff member being assigned to provide supervision in the Drop-In Center with multiple residents at high risk for falls. Nurse #1 described the current staffing as "not safe" and said she had repeatedly conveyed her concern with facility management. On 7/30/14 at 9:00 P.M. the resident was found on the floor next to the bed with the alarm sounding and incontinent of urine. Redness to the right wrist and shoulder were noted. The physician was contacted and ordered scheduled pain medication and a urine culture that was reported as negative. Nurse #1 said during interview on 8/13/14 at 10:20 A.M. that the resident had resided in the same room since admission and said he/she was concerned that the resident's room was not in close proximity to the nurse's station. The facility failed to provide adequate supervision and effective interventions to prevent falls resulting in injury. For example: - On 8/12/14 at 11:15 A.M. on the East wing near the nurses' station, 6 residents including Resident #2, were observed to be lined up in chairs along the hallway wall. The "Serenity" room was empty except for one resident and a visitor. During interview at that time, Nurse #5 said that the "Serenity" room was not used in the morning, only from lunch time through the afternoon and there was no staff available for close supervision for residents. The Drop-In Center on the North Unit was open with close supervision scheduled through 11:30 A.M. Nurse #5 could not explain why these residents, including Resident #2, were seated in the hallway, and not receiving supervision to prevent falls. During observation on 8/12/14 at 3:50 P.M., Residents #2 was observed in the small "Serenity" room on the East unit. A group of eight residents were in the room with one CNA who was standing in the doorway. During observation starting at 3:50 P.M. from the area of the nurses' station for 10 minutes, the CNA remained standing in the doorway of the room, and did not interact with any of the residents in the room. At 4:40 P.M., the residents were observed in the "Serenity" room, still sitting in the same places. Resident #13 was asleep in the chair, Residents #2 and #4 were sitting idly in their chairs. At that time, there was a different CNA in the room, who was sitting in a chair, not interacting and apart from the residents, and watching the movie that was on the television. Observation on 8/13/14 at 10:10 A.M. of the Drop-in Center room on the North unit revealed three residents (sampled residents #4 and #5 and one non-sampled resident (NS#2) seated in the room. Upon entering the room, it was observed a CNA was sitting in a chair to the side of the room and was not interacting with the residents.

Based on record review, interview with staff and observation of residents, the facility failed to implement adequate interventions and individualized nutrition and meal plans for three residents (#3, #4 and #8) with nutritional risk or demonstrated weight loss in a total sample of 17 residents. Findings include: 1. For Resident #4, the facility failed to provide an individualized meal plan, including food preferences, for significant weight loss and failed to monitor the resident's response to and intake of on-going supplements. Resident #4 was admitted to the nursing facility in 1/2010, and had a primary [DIAGNOSES REDACTED]. Review of the dietitian's documentation indicated that the resident had been on the same supplements since at least September 2013. The Dietitian's note, dated 9/17/13, indicated that the resident weighed 136.2 pounds, which represented about a five pound weight loss (3.8% of body weight) over three months (from 141.6 pounds in 6/2013). The dietitian wrote that at that time, the resident ate independently with supervision, and the plan was to monitor for any further weight loss trends. Review of the Dietitian's notes and nutrition care plan revealed that no changes were made to the resident's nutrition plan and no new interventions were implemented to attempt to avoid any further weight loss. Review of the Dietitian's documentation indicated that the resident continued to lose weight, and a note written on 3/4/14 said the resident had "inadequate energy intake related to dementia as evidenced by weight loss." The Dietitian noted that the resident weighed 128.2 pounds, a 5.8% loss over 6 months, which was not significant, and the Dietitian noted the weight was stabilizing and within ideal body weight range. The Dietitian's note said the resident remained on the same diet and the same supplements and laboratory results were within normal range. The dietitian wrote that the nutritional [DIAGNOSES REDACTED]. Review of the Dietitian's notes and nutrition care plan revealed that no changes were made to the resident's nutrition plan and no new interventions were implemented at the time of this weight loss. Review of the nutrition note on 4/29/14 revealed the Dietitian wrote that the resident continued with weight loss trends and the current weight was 121.8 pounds, a significant weight loss of 5.7% in one month. The supplements remained the same with super cereal, super mashed potatoes and Boost Glucose Control. The Dietitian wrote that the resident was a risk for further weight loss if intake did not improve, and recommended to add Health Shakes with all meals. The written plan was to continue to encourage intake and monitor weight trends. Review of the most recent Minimum Data Set (MDS) assessment for significant change, with a reference date of 5/15/14, revealed the resident was 64 inches tall and weighed 122 pounds. This was noted on the MDS to be a significant unplanned weight loss, and the MDS noted the resident was on a therapeutic diet. During interview on 8/12/14 at 2:00 P.M., the Dietitian could not provide any specific information related to the resident's food preferences and said that because the residents in the facility were primarily dementia, an assessment of food preferences was not routinely completed. The Dietitian said the resident was always provided with a tray of the planned menu for each meal, with the addition of the fortified foods and supplement drinks. The Dietitian could provide no information related to how well the resident accepted the fortified foods and supplements. The Dietitian said there had been no assessment of the resident's preferences, or specific food acceptance, and no attempt had been made to develop and implement an individualized meal plan to optimize the resident's meal plan. During review of all the Dietitian's notes, it was noted that there was no documentation of the resident's food preferences at any point during the stay at the facility. There was also no documentation of how the resident accepted each of the several fortified foods and supplements, and how much of the fortified foods supplements the resident consumed. There was no documentation in the record that any attempt had been made to alter the planned menu or develop an individualized meal plan to include foods the resident might prefer to eat or accept. During interviews, no additional information was provided. 2. Resident #3 was admitted to the nursing facility in 10/2013, had primary listed [DIAGNOSES REDACTED]. Review of the resident's history in the record revealed that the resident was born in another country and came to the United States approximately [AGE] years ago. The resident spoke only his/her native language. Review of the guardianship petition in the record revealed that the resident had no known family or friends. Review of the most recent Minimum Data Set (MDS) assessment, the annual review with a reference date of 6/5/14, revealed the resident required limited assistance of one person for eating. The resident was noted to be 65 inches tall and weigh 124 pounds, with no significant weight loss or gain. Review of the Nutrition Risk care plan revealed that the resident was at risk for weight loss. The care plan indicated the resident was to have a regular diet of mechanical soft texture and supplemental foods of peanut butter and jelly sandwiches at lunch and dinner, super mashed potatoes at lunch and super cereal at breakfast. A liquid protein supplement was to be provided, 120 ml twice daily. Review of the most recent Dietitian's note, dated 6/5/14, indicated the resident did not have a significant weight loss, but had lost 5.2 pounds (4% of body weight) over the previous 6 months. The Dietitian wrote that the resident weighed 129.3 pounds in November 2013 and weighed 124.1 pounds in May 2014. During observation of the lunch meal on 8/6/14 at 12:15 P.M. in the main dining room, the resident was observed seated at a table with 3 other residents. The resident was quiet and calm, and ate very little of the meal, including the super mashed potatoes, approximately less than 25%. The resident was not observed to eat a peanut butter and jelly sandwich. During observation of the lunch meal on 8/8/14 at 12:20 P.M. in the main dining room, the resident was observed seated at a table with 3 other residents. The resident was not eating the meal provided and Nurse #4 brought him two Twinkies. On interview, Nurse #4 said that the resident loved sweets, so if he did not want to eat the meal they give Twinkies or some other sweet to the resident, which the resident accepted and ate. The resident was observed to eat the Twinkies, but was not observed to eat any super mashed potatoes or peanut butter and jelly sandwich. Staff was not observed to offer the resident a peanut butter and jelly sandwich or to encourage the resident to eat the planned meal or super mashed potatoes. During interview on 8/12/14 at 2:00 P.M., the Dietitian said that the resident often refused meals, but that supplements were offered to try to maintain weight. The Dietitian said he/she did not speak the resident's native language, and there had been no attempt made to identify foods that the resident liked or that were culturally appropriate, and, therefore, had not attempted to develop an individualized meal plan for the resident. The Dietitian said that for a while the facility was ordering out for Chinese food for the resident once a week, but he wouldn't eat it. When asked, the Dietitian said he/she did not know that Chinese food and the resident's native cuisine were different, and thought that it would be all right because it was all Asian. 3. For Resident #8, the facility failed to provide adequate meal assistance to maintain the Resident's weight. The facility failed to determine the Resident's food preferences and provide food of the Resident's liking. Resident #8 was admitted to the nursing facility in 8/2013, with a primary [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment, with a reference date of 9/3/13, revealed that the resident was 66 inches tall and weighed 179 pounds. On the most current quarterly MDS review, with a reference date of 5/8/14, the resident was noted to have significant weight loss, with a noted weight of 160 pounds. The MDS also noted the resident required extensive assistance for meals. Review of the Dietitian's note, dated 9/27/13, revealed that the resident was showing a downward trend in weight since admission, and recorded the resident's weight as 172 pounds. The Dietitian wrote that food preferences were offered but it was hit or miss as to whether the resident would accept or not. The Dietitian wrote that the resident reported liking ice cream, so the plan was to add ice cream with dinner and also adding a supplement drink twice daily. Review of the Dietitian's note of 11/22/13 indicated the resident was hospitalized from [DATE] to 10/17/13, and the resident's weight on return was 169 pounds. As a result, fortified food of supercereal at breakfast was added, along with ice cream, a peanut butter and jelly sandwich at lunch and supplement drink 120 ml three times daily. Review of the Dietitian's note of 2/11/14 revealed continued weight loss to 167 pounds. The Dietitian wrote that the resident required extensive assistance to eat. The plan was to continue the supplements and fortified foods already in place and to add an additional peanut butter and jelly sandwich at dinner, add super mashed potato and super pudding at lunch as the resident liked sweets. The Dietitian noted a nutritional [DIAGNOSES REDACTED]." Review of the Dietitian's note of 4/29/14 revealed that the resident presented with a significant weight loss of 10 pounds (5.7% body weight) in one month, from 170 pounds in 3/2014 to 160 pounds in 4/2014. The Dietitian wrote that the resident intake had declined. The Dietitian recommended to continue all the previous fortified foods and supplements, to increase ice cream to two meals, and increase the amount of supplement drink from 180 ml to 240 ml as nursing reported the resident accepted it very well. Review of the physician's orders [REDACTED]. There were also orders for the following dietary supplements: Boost Plus supplement 240 ml three times daily, super cereal at breakfast, ice cream all meals, peanut butter and jelly sandwich at lunch and dinner, super pudding at dinner. Review of the Dietitian's note, dated 7/29/14, and the resident's weekly weight record revealed that on 5/23/14 the resident's weight was recorded as 165 pounds and the resident had remained at that weight through 7/3/14, with the last recorded weight available on 7/11/14 at 166 pounds. During interview on 8/6/14 at 2:30 P.M., the resident's family said that the resident did not receive enough assistance with meals in that setting. The family member said that now the resident ate lunch and dinner in the small "Serenity" room on the unit, which was better but still not enough assistance to ensure the resident received enough time and attention. The family member said that there were generally 8 to 10 residents in the Serenity room at meal time, with one CNA assigned to provide assistance to all those residents. Observation of the Serenity room on 8/12/14 at 4:40 P.M. revealed that there were 9 residents in the room, set up and awaiting delivery of the supper meal. During observation of the breakfast meal on 8/7/14 at 8:50 A.M., the resident was observed lying in bed with the head up and the breakfast tray on an overbed table in front of the resident. There were cut up pieces of French toast on the plate, and only a couple of pieces were missing. The resident was chewing and licking syrup off the fingers, then playing with a glass of juice. A glass of milk was observed half empty and a large puddle of milk was on the floor next to the resident's bed. A large mound of pureed supercereal was observed on the paper tray liner. Certified Nurse Aide (CNA) #1 was in the room feeding the resident's roommate, and she got up, left the room, returned with a towel and proceeded to wipe up the spill of milk on the floor. The resident continued to play with the food on the tray, but did not eat anything else. CNA #1 went back to feeding the roommate. At 9:02 A.M., CNA #1 went over to Resident #8 to provide assistance with the meal. By that time, per observation, the resident was not interested in eating any of the food on the tray. During interview at that time, CNA #1 said the resident only wanted to play with the food and did not want CNA #1 to help. CNA #1 said the resident sometimes refuses to eat like that. Review of the meal intake record, CNA #1 recorded that the resident ate 50% of the breakfast meal. The resident did not eat the supplemental supercereal which had been dumped out on the tray, and did not receive the supplemental ice cream as planned. During interview on 8/12/14 at 2:00 P.M., the Dietitian said that the resident often refused to eat the planned meals, even with staff assistance. The Dietitian could not provide any specific information related to the resident's food preferences and said that because the resident had a primary [DIAGNOSES REDACTED]. The Dietitian said the resident was always provided with a tray of the planned menu for each meal, with the addition of the fortified foods and supplement drinks. The Dietitian could provide no information related to how well the resident accepted the fortified foods and supplements.

Based on record review and staff interview, the facility failed to provide adequate supervision and assistive devices to keep the resident safe and prevent falls with injuries for 1 (#2) of 21 sampled residents. Findings include: Resident #2 had [DIAGNOSES REDACTED]. On 6/22/12 the facility identified that Resident #2 was at risk for fall related injuries due to the disease process (dementia) and medication use (antipsychotic and antihypertensive) and documented a care plan for falls. The identified care plan goal was that the resident would not sustain fall-related injuries by utilizing fall precautions through next review. The generic approaches included: 1. Use fall risk screen to identify fall factors. 2. Report falls to physician and responsible party. 3. Observe for side effects of any drugs that could cause gait disturbances, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness and change in mental status. 4. Report to the physician any side effects associated with the resident's medication. 5. Provide environmental adaptations including adequate glare free lighting and area free from clutter. 6. Remind and reinforce safety awareness with resident: sit on side of bed for a few minutes before rising, wear appropriate footwear and 15 minute checks. 7. Invite, encourage, remind, escort to activity programs consistent with resident's interests to enhance physical strengthening needs. 8. Referral to screen and treat as needed (OT, PT, Mental Health). 9. Provide resident/family teaching. The Initial (admission) Minimum Data Set (MDS) signed as completed on 7/5/12, indicated that the resident had short and long term memory deficit and was severely impaired for decision making. The MDS also identified that the resident was inattentive, wandered, required supervision while ambulating with a walker, and required extensive assist of one for toileting, bathing and hygiene. The MDS identified that the resident had no falls and received medications including an antipsychotic, an antidepressant, an antianxiety and an antibiotic. Review of the Resident Care Card, utilized by all staff including Certified Nursing Assistants (CNA), revealed that the resident required assist of one for toileting. Review of the medical record on 6/3/13 indicated that the resident had 5 unwitnessed falls (some with injuries) from 7/28/12-5/26/13. These include: 1. On 7/28/12 at 6:15 P.M. the staff was alerted by another resident that Resident #2 was on the floor, in room 140, on the South Unit. The resident was found flat on his/her back on the floor, at the foot of bed 140 C, and rubbing the back of his/her head. Skin assessment noted a mild abrasion to the right shoulder and it was documented that the right clavicle bone was protruding. The physician was notified and ordered X-rays which identified an old clavicle separation. New documented interventions included 15 minute checks (which were already in effect), redirect the resident to East Unit and toilet the resident after supper. On 7/30/12 and 8/3/12 the care plan was updated to identify the new interventions. 2. On 8/30/12 at 12:25 P.M. a CNA notified a nurse that the resident was on the floor in the main dining room. The nurse interviewed all staff members present and they identified that the resident was sitting in the stationary chair then on the floor. The staff did not witness the actual fall. Review of the facility incident report, dated 8/30/12, indicated that the resident "slipped out of the stationary chair, when attempting to stand, lost his/her balance and fell to the floor." There were no documented injuries to the resident during the fall. The care plan was updated on 8/31/12 and 9/14/12 to include the interventions to toilet the resident before lunch and a PT evaluation was ordered. 3. On 2/26/12 at 4:10 A.M. the resident was found lying on the floor parallel to the bed. Upon skin exam the resident was found to have a left elbow skin tear. Review of the Facility Incident Report identified the cause of the Incident to be "behavior" but did not elaborate on the specific behavior exhibited by the resident. The immediate intervention documented on 2/26/13 was to use a bed alarm during the 11-7 shift. 4. On 3/3/13 at 2:30 P.M. the resident was found lying on the bathroom floor with his/her head against the door, in room 127. It was further documented that the resident had no pants on and there was a large amount of feces on the floor (formed but soft). The were no documented injuries to the resident during this fall. The care plan was updated to reflect the new intervention of bed alarm on at all times when the resident was in bed and conduct a Bowel and Bladder pattern for Resident #2. 5. On 5/26/13 at 4:30 P.M. a CNA called a nurse into the bathroom in room 127 and observed that resident #2 was sitting on the floor with his/her upper back and head against the bathroom door. The resident stated that he/she hit their head. Skin assessment completed on the resident noted eight (8) skin tears on the left arm, located between the wrist and elbow, ranging in different sizes. At 9:30 P.M. an addendum was documented in the nurse's progress notes identifying all the sizes of the 8 skin tears as follows: 1 - 1.0 cm (centimeters) X 0.5 cm 2 - 1.0 cm X 0.5 cm 3 - 0.5 cm X 0.5 cm 4 - 1.5 cm X 1.0 cm 5 - 3.0 cm X 0.5 cm 6 - 2.0 cm X 1.0 cm 7 - 1.0 cm X 1.0 cm 8 - 1.0 cm X 0.5 cm Unit Manager #2 was interviewed on 6/3/13 at 10:30 A.M. and stated that Resident #2 required an assist of 1 to toilet the resident and the CNA left the resident unattended in the bathroom to obtain a towel, just prior to the fall. Review of the facility's post fall evaluation and confirmed by interview with the DON on 6/5/13 at 8:30 A.M. stated that "the plan of care remains appropriate" and the problem was caused by the staff member leaving the resident unattended in the bathroom resulting in the resident falling. For Resident #2, the facility failed to provide adequate supervision to prevent falls with injuries.