Every finding on record at The Grove at Carvalho

Based on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program.Findings include:Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance.- Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.- The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.- Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of the facility's policy titled Antibiotic Stewardship Program, dated as revised September 25, 2023, indicated but was not limited to the following:Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program.-The purpose of our Antibiotic Stewardship Program is to improve the use of antibiotics in our facility to protect residents and reduce the threat of antibiotic resistance to monitor the use of antibiotics in our residents.-When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the provider as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.Review of the facility's policy titled Infection Surveillance, dated as reviewed/revised December 2025, indicated but was not limited to the following: -The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility.-Updated McGeer criteria (surveillance-based definitions used to track confirmed infections) or other nationally recognized surveillance criteria will be used to define infections.-The facility will communicate via written reports to staff and/or prescribing practitioners information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical interventions as indicated.-All resident infections will be tracked. Review of the facility's policy titled Infection Prevention and Control Program (IPCP), undated, indicated but was not limited to the following:Antibiotic Stewardship-Antibiotic usage is evaluated and practitioners are provided with feedback on reviews. During an interview on 4/2/26 at 1:26 P.M., the Infection Preventionist (IP) said the facility utilizes McGeer criteria to determine if an illness meets the criteria for an infection requiring use of antibiotics. The IP said she completes the McGeer criteria on paper and keeps the completed documents in her office. Review of the Revised McGeer Criteria for Infection Surveillance Checklist, indicated but was not limited to the following: Urinary Tract Infection (UTI) Surveillance Definitions UTI without indwelling catheter: Must fulfill both 1 and 2 1. At least one of the following signs or symptoms:-Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate-Fever or leukocytosis, and 1 or more of the following: -Acute costovertebral angle pain or tenderness-Suprapubic pain-Gross hematuria-New or marked increase in incontinence, urgency, frequency-If no fever or leukocytosis, then one or more of the following:-Suprapubic pain-Gross hematuria-New or marked increase incontinence, urgency 2. At least one of the following microbiologic criteria:- greater than or equal to 102 colony forming units (cfu)/milliliters (mL of no more than 2 species of organisms in a voided urine sample)- greater than or equal to 102 cfu/mL of any organism(s) in a specimen collected by an in-and-out-catheter UTI with indwelling catheter: Must fulfill both 1 and 2 1. At least one of the following signs or symptoms:-Fever, rigors, or new-onset hypotension, with no alternate site of infection.-Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis-New-onset suprapubic pain or costovertebral angle pain or tenderness-Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate2. Urinary catheter specimen culture with greater than or equal to 105 cfu/mL of any organism(s) Review of the facility's Surveillance Sheets for February 2026 indicated but were not limited to the following: Resident #11 had a urinary catheter in place with a concern for a UTI with an onset date of 2/23/26 and was placed on Ceftriaxone (antibiotic). The surveillance stated it was for empiric treatment due to signs/symptoms, no lab services were completed due to weather, and a 48-hour time out (review of therapy 48-72 hours after initiation to ensure proper use) was completed and did meet criteria for infection (although it did not meet criteria per documentation). Review of Resident# 11's McGeer criteria, dated 2/25/26, indicated the concern fulfilled only one criteria (new-onset suprapubic pain or costovertebral angle pain or tenderness), no urine specimen completed, and the concern met criteria for infection (although it did not meet criteria due to no urine specimen completed).Review of the medical record failed to indicate a 48-hour time out had been completed even though the symptoms did not meet criteria for infection.Resident #59 did not have a urinary catheter and a concern for a UTI with an onset date of 2/22/26 and was placed on Bactrim (antibiotic). The surveillance stated it was for empiric treatment due to signs/symptoms, no lab services were completed due to weather, and a 48-hour time out was completed and did meet criteria for infection. Review of Resident# 59's McGeer criteria, dated 2/25/26, indicated the concern fulfilled both 1 and 2 criteria and did meet criteria for infection (although it did not meet criteria due to no urine specimen completed). Review of the medical record failed to indicate a 48-hour time out had been completed even though the symptoms did not meet criteria for infection. During an interview on 4/7/26 at 1:38 P.M., the IP said when a resident is prescribed an antibiotic, she uses the McGeer criteria to collect data, and she files them in her office. The IP said she gathers information about illnesses from resident records and in morning report. The IP said the facility began conducting 48-hour timeouts in January 2026, and it consists of her reviewing the medication with the provider within 48 to 72 hours, but she does not document the information in the resident record. She said she only makes a notation on her surveillance sheet. The IP said she has not been reviewing all antibiotic use with the providers. The surveyor and IP reviewed the completed McGeer criteria for Resident #11 and Resident #59 together and the IP said both McGeer criteria documents were completed inaccurately and the concern did not meet the criteria for infection. She said her surveillance was incorrect.During an interview on 4/7/26 at 2:44 P.M., the Director of Nursing (DON) said the IP should be communicating with the physician regarding any antibiotics that do not meet criteria, and document the communication in the medical record. She said the McGeer criteria should be completed accurately to ensure proper tracking of infections and antibiotic usage.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections within the facility; and 2. Ensure appropriate personal protective equipment (PPE) was utilized when providing care to two Residents (#11, #5) on Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves while performing direct care activities to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) including one Resident (#23) on Transmission-Based Precautions (TBP: additional infection control measures beyond standard precautions to prevent the spread of highly transmissible pathogens); and3. Ensure Resident #15's nebulizer treatment equipment, including mask and tubing, were stored in a sanitary manner. Findings include:1. Review of the facility's policy titled Infection Surveillance, dated as reviewed/revised December 2025, indicated but was not limited to the following: -A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. -The Infection Preventionist (IP) serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility. -The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread. -Updated McGeer criteria (surveillance-based definitions used to track confirmed infections) or other nationally recognized surveillance criteria will be used to define infections. -All infections will be tracked Review of the facility's policy titled Infection Prevention and Control Program (IPCP), undated, indicated but was not limited to the following: -The program is based on accepted national infection prevention and control standards. -An IPCP is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemic. During an interview on 4/2/26 at 1:26 P.M., the IP said the facility utilizes McGeer Criteria to determine if an illness meets the criteria for an infection requiring use of antibiotics. The IP said she completes the McGeer criteria on paper and keeps the completed documents in her office. Review of the facility's surveillance sheets titled [Facility Name] Line Listing for the months of December 2025, January 2026, February 2026, and March 2026 indicated the following: -The December 2025 line listing 20 out of 20 residents met McGeer criteria for infection and 20 out of 20 residents were started on antibiotics. -The January 2026 line listing 31 out of 31 residents met McGeer criteria for infection and 31 out of 31 residents were started on antibiotics. -The February 2026 line listing 27 out of 27 residents met McGeer criteria for infection and 27 out of 27 residents were started on antibiotics. -The March 2026 line listing 26 out of 26 residents met McGeer criteria for infection and 26 out of 26 were started on antibiotics. Review of Resident #59's progress notes indicated on 3/23/26, he/she had complaints of dysuria (pain on urination), recently completed course of antibiotics for Urinary Tract Infection (UTI), and to obtain a follow up urine. Urinalysis resulted on 3/27/26 with less than 10,000 units of bacteria, and the Resident was not started on antibiotics. Further review of the March 2026 line listing failed to include Resident #59's concern for illness. Further review of the line listing sheets failed to indicate any tracking or trending of illnesses, not prescribed antibiotics, for surveillance of the potential spread of illnesses. During an interview on 4/7/26 at 1:38 P.M., the IP said she gathers information about illnesses from resident records and in morning report. She completes surveillance sheets for COVID-19 and Influenza outbreaks but does not keep track of illnesses on a day-to-day basis that do not require the use of antibiotics. 2. Review of the facility's policy titled [Corporate Name], undated, indicated but was not limited to the following: -Standard precautions are used for all patient care when exposure to blood, body fluids, non-intact skin or mucous membranes is possible. -Infection Control Measures for Standard precautions include: -Enhanced Barrier Precautions was implemented by Centers for Disease Control and Prevention (CDC) in 2019 to prevent the risk of targeted MDROs. Enhanced precautions to be used for infection of colonization of MDROs when contact precautions do not apply -Enhanced Barrier Precautions include: Standard precautions for infection control measures and PPE, gowns and gloves for high-contact care activity which includes dressing, transferring, wound care or device care. -Transmission Based Precautions are the second tier of basic infection control and are used in addition to standard-based precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed. -They may include Extended-Spectrum B-lactamase (ESBL: enzymes produced by bacteria making them resistant to many common antibiotics and spread through contaminated surfaces, food, or person-to-person contact). Review of the CDC Enhanced Barrier Precautions sign indicated the following: -Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Transferring Wound Care: any skin opening requiring a dressing Review of the CDC Contact Precautions sign indicated the following: -Everyone must: Clean their hands, including before entering and when leaving the room. -Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A. Resident #11 was admitted to the facility in November 2025 with diagnoses including history of vancomycin resistant enterococci (VRE – bacteria that have developed resistance to vancomycin, a powerful antibiotic), pressure ulcer of left buttocks and heel, gastrostomy tube (G-tube: a device surgically inserted through the abdomen directly into the stomach to provide nutrition, fluids, and medications) and urinary retention with an indwelling urinary catheter in place. Review of Resident #11's active Physician's Orders indicated, but was not limited to, the following: -Maintain Enhanced Barrier Precautions related to history of VRE, G-Tube, Foley (urinary catheter), wounds every shift – start date 12/4/25 On 4/02/26 at 10:19 A.M., the surveyor observed an orange CDC Enhanced Barrier Precautions sign posted on the wall over the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. The surveyor observed Certified Nursing Assistant (CNA) #2 and CNA #3 rolling the Resident side to side on his/her bed, placing a cloth pad underneath the Resident. The CNAs then hooked the cloth pad to the Hoyer lift (a medical device designed to safely transfer patients) and transferred the Resident to his/her chair. CNA #2 and CNA #3 were not wearing gowns or gloves during the transfer. During an interview on 4/2/26 at 10:31 A.M., CNA #3 said Resident #11 is on EBP because he/she has a catheter. She said she only needs to use PPE for direct care, not for putting the Resident in his/her chair. B. Resident #23 was admitted to the facility in March 2025 with diagnoses including ESBL in urine. Review of Resident #23's active Physician's Orders indicated, but was not limited to, the following: -Maintain Contact Precautions related to ESBL in the urine every shift – start date 3/30/25 On 4/7/26 at 8:21A.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall over the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. The surveyor observed Nurse #1 seated on Resident #23's bed and the Resident was seated beside her in a chair, with his/her bedside table placed in from of them with their breakfast tray placed on top of the table. Nurse #1 was feeding the Resident breakfast. Nurse #1 was not wearing a gown or gloves. During an interview on 4/7/26 at 8:24 A.M., Nurse #1 said she was not required to wear a gown or gloves when feeding the Resident. She said PPE is needed only when providing direct care. Surveyor and Nurse #1 reviewed the contact precaution sign together and she said she should have had a gown and gloves on and did not. Nurse #1 said she made a mistake. During an interview with an observation on 4/7/26 at 8:35 A.M., the surveyor observed Nurse #3 enter Resident #23's room, without donning (putting on) PPE. Nurse #3 removed the Resident's breakfast tray and exited the room. Nurse #3 and the surveyor reviewed the contact precaution sign together and she said she should have put on PPE prior to entering the Resident's room, but she usually does not work on this unit and was unaware. C. Resident #5 was admitted to the facility in August 2025 with diagnoses including pressure ulcers of the right heel, sacral region (base of the spine) and neuropathic bladder with indwelling urinary catheter. Review of Resident #5's active Physician's Orders indicated, but was not limited to, the following: -Maintain Enhanced Barrier Precautions related to wounds and Foley every shift – start date 2/5/26 On 4/2/26 at 12:27 P.M., the surveyor observed an orange CDC Enhanced Barrier Precautions sign posted on the wall over the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. Nurse #6 was assisted by a CNA completing a dressing change to Resident #5's right heel. Nurse #6 and the CNA were not wearing a gown. During an interview on 4/7/26 at 9:51 A.M., Nurse #6 said she should have had a gown on to do the dressing change because the Resident is on EBP for their wounds. During an interview on 04/07/26 at 2:44 P.M., the surveyor reviewed observations of PPE breaches with the IP and Director of Nursing (DON). The IP said her expectations were for the staff to follow the guidelines that were posted outside of the Residents' room. She said transferring a resident and completing a dressing change is considered high contact care and the staff should have been wearing gowns and gloves; it is the standard of practice. The IP said residents on contact precautions require PPE to be donned prior to entering the room. The DON said the line listings should include all illnesses in the facility, even without antibiotic use for accurate tracking and trending of infections. 3. Review of the facility's policy titled Nebulizer Therapy, dated last revised 12/2025, indicated but was not limited to the following: - It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Review of the facility's policy titled Oxygen Administration, dated last revised January 2025, indicated but was not limited to the following: - If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated. - Keep delivery devices covered in plastic bag when not in use. Resident #15 was admitted to the facility in September 2022 with diagnoses including Parkinson's disease and chronic obstructive pulmonary disease (COPD). Review of Resident #15's Minimum Data Set (MDS) assessment, dated 2/10/26, indicated he/she had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15. Review of Resident #15's Physician's Orders indicated but were not limited to the following: - 9/10/25: change nebulizer/tubing every week; every night shift every Tuesday and as needed; label and date tubing when changed. - 1/29/26: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/ 3 ML (milliliters); 3 ML inhale orally two times a day for COPD; 9 A.M. and 9 P.M. - 2/10/26: Formoterol Fumarate Inhalation Nebulization Solution 20 MCG (micrograms)/2 ML; 2 ML inhale orally two times a day related to COPD; 8 A.M. and 8 P.M. Review of Resident #15's April Medication Administration Record (MAR) indicated his/her nebulizer medications/treatments were administered as ordered. On the following dates/times, the surveyor observed Resident #15's nebulizer mask and tubing left open to air on top of the nebulizer machine on his/her bedside nightstand: - 4/2/26 at 9:06 A.M. and 9:28 A.M. - 4/2/26 at 12:26 P.M. and 3:02 P.M. - 4/3/26 at 7:31 A.M. and 10:15 A.M. During an interview on 4/3/26 at 10:23 A.M., Nurse #1 said if a resident utilizes nebulizer treatment equipment, such as the mask and/or tubing, it should be placed in a bag when not in use. Nurse #1 said nebulizer masks and/or tubing should not be left open to air. During an interview on 4/3/26 at 10:25 A.M., Nurse #2 said Resident #15 utilizes nebulizer treatments. Nurse #2 said Resident #15's nebulizer equipment should be stored in a bag at his/her bedside when it is not in use. Nurse #2 and the surveyor entered Resident #15's room to observe the nebulizer mask and tubing. Nurse #2 took the nebulizer mask, which was resting on the nebulizer machine, and placed it into a bag she had brought into the room. During an interview on 4/3/26 at 10:42 A.M., the DON said nebulizer equipment, including masks and tubing, should be changed weekly. The DON said when nebulizer equipment is not in use it should be stored in a bag and not left open to air.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen floor tile was maintained in a sanitary and safe condition and was free of standing, pooled water. Findings include:Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following: 1-2 Definitions 1-201 Applicability and Terms Defined1-201.10 Statement of Application and Listing of Terms.Easily Cleanable.(1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or other contaminants into food based on the surface's approved placement, purpose, and use. Smooth means:(3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. 6-201.12 Floors, Walls, and Ceilings, Utility Lines. Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. 6-101.11 Surface Characteristics. Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned. Floor surfaces that are graded to drain and consist of effectively treated materials will prevent contamination of foods from dust and organisms from pooled moisture. Review of the facility's policy titled Environment from the Dining Services Policy and Procedure Manual, last revised 9/2017, indicated but was not limited to:-The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.-The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. On the following dates and times, the surveyor observed, in the dishwashing room and in front of the 3-bay sink of the main kitchen, several missing tiles and/or partial/cracked tiles, with pooled gray colored standing water:-4/2/26 at 8:20 A.M.-4/7/26 at 11:26 A.M.-4/8/26 at 9:05 A.M. During an interview on 4/8/26 at 9:02 A.M., the Food Service Director (FSD) said he is aware of the broken/missing tiles and has entered a work request with maintenance for them to be fixed. The FSD said staff do use a dry mop after the dishes are done to clean the areas of pooled water. The FSD said the kitchen is routinely cleaned according to a schedule that is kept in a binder that staff sign off daily. The FSD said he expected the main kitchen floor to be easily cleanable with no missing or broken tiles. During an interview on 4/8/26 at 9:10 A.M., the Maintenance Director said he did not have any current open work requests for the tile floor in the main kitchen, and the tiles in the kitchen were last updated about two years ago. The Maintenance Director said he has discussed with the FSD the difficulty of replacing the tiles in this area due to the area being consistently wet and he has tried some different solutions that have failed. During an interview on 4/8/26 at 9:15 A.M., the Administrator stated he expected the tile floor of the kitchen to be in good repair, easily cleanable, and free of pooled water.

Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of 5% or greater when two out of three nurses observed during a medication pass made two errors out of 39 opportunities, resulting in a medication error rate of 5%. Those errors impacted two Residents (#33 and #64), out of five residents observed.Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to, the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to:- Medications are administered in accordance with prescriber orders, including any required time frame.- The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.1. For Resident #33, Nurse #5 administered:-The incorrect formula of a probiotic (live microorganisms that provide health benefits when consumed, generally by improving or restoring the microbiota in the gut).On 4/6/26 at 8:45 A.M., the surveyor observed Nurse #5 prepare and administer medications to Resident #33 including:-Lactobacillus acidophilus (a bacteria-based probiotic that produces lactic acid, making the environment unfavorable to other bacteria by increasing the pH) 1 capsuleReview of Resident #33's Physician's Orders indicated but was not limited to: -Lactobacillus rhamnosus (a bacteria-based probiotic that does not produce lactic acid and does not make the environment unfavorable to other bacteria) 1 capsule by mouth in the morningDuring an interview on 4/6/26 at 9:55 A.M., Nurse #5 said the facility supplies Lactobacillus acidophilus, not Lactobacillus rhamnosus, and Resident #33's order should be changed. 2. For Resident #64, Nurse #6 administered:- An anti-nausea medication ordered to be given before meals and scheduled at 7:30 A.M., late and at least one hour after breakfast.On 4/6/26 at 9:11 A.M., the surveyor observed Nurse #6 prepare and administer medications to Resident #64, including:- Zofran (or Ondansetron, a medication used to prevent/treat nausea and vomiting) 4mg 1 tabletReview of Resident #64's Physician's Orders indicated, but was not limited to, the following:-Zofran 4 mg by mouth before meals for nauseaDuring an interview on 4/6/26 at 12:41 P.M., Nurse #6 said Resident #64 was taking anti-nausea medication because he/she had been hospitalized for nausea. Nurse #6 said Resident #64's Zofran should be scheduled earlier so it can be given before breakfast and not administered late.During an interview on 4/7/26 at 11:12 A.M., the Director of Nursing said it was her expectation that nurses in the facility follow physician's orders during medication administration.

Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in a safe and secure manner as required. Specifically, the facility failed to ensure:1. Licensed staff locked one of two treatment carts, which contained numerous topical treatments and biologicals, when it was not in use and left in the hallway where it could be accessed by residents or passersby on the Oak Grove unit; and2. Medications were dated once opened, and discarded according to manufacturer's guidelines, in one of three medication carts observed.Findings include:Review of the facility's policy titled Storage of Medications, undated, indicated, but was not limited to, the following:-Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 1. On 4/6/26 on the Oak Grove unit, the surveyor made the following observations of the Oak Grove treatment cart:-3:06 P.M. - The treatment cart was unlocked against the wall in the hallway beside the nurse's station. Residents and unlicensed staff were in the general area of the treatment cart but no nurse was visible in the area.-3:11 P.M. - The treatment cart remained unlocked against the wall in the hallway near, but not visible from, the nurse's station. Nurse #6, the nurse who was assigned to the cart, returned to the unit via the elevator. -3:22 P.M. - The treatment cart remained unlocked against the wall in the hallway near, but not visible from, the nurse's station. The surveyor approached the treatment cart and was able to open all drawers. The treatment cart was found to contain prescription creams and ointments and other treatment supplies. Residents remained in the hallway in the vicinity of the unlocked treatment cart.-3:32 P.M. - The treatment cart remained unlocked against the wall in the hallway near, but not visible from, the nurse's station. Residents from the [NAME] and Oak Grove units were congregated in the area by the nurse's station waiting to go downstairs. -3:40 P.M. - The treatment cart remained unlocked against the wall in the hallway near, but not visible from, the nurse's station. Nurse #6 walked from the Oak Grove unit to the [NAME] unit, then returned to the Oak Grove unit and went downstairs via the elevator.-3:53 P.M. - The treatment cart remained unlocked against the wall in the hallway near, but not visible from, the nurse's station. Five residents remained in the general vicinity of the treatment cart.On 4/7/26 at 11:19 A.M., the surveyor observed the Oak Grove unit Float Assignment medication cart unlocked in the hallway across from the nurse's station. Two residents were sitting in wheelchairs beside the medication cart. The nurse was observed in the unit dining room administering medication to a resident with her back to the dining room door and out of line of sight of the medication cart.During an interview on 4/7/26 at 11:45 A.M., Nurse #6 said the treatment cart should always be locked when not in use.During an interview on 4/8/26 at 10:32 A.M., the Director of Nursing said medication and treatment carts should be locked when the nurse is not at the cart.2. During observation of the Oak Grove medication cart with Nurse #6 on 4/7/26 at 11:34 A.M., the surveyor observed two opened bottles of Latanoprost eye drops for Resident #69 in the medication cart. Neither bottle was marked with the date opened. Per the manufacturer's instructions, Latanoprost eye drops should be discarded six weeks after opening.The surveyor also observed one bottle of ProStat (a liquid protein supplement) labeled with a date opened of 12/15/25. Per the manufacturer's instructions, ProStat should be discarded three months after opening.During an interview on 4/7/26 at 11:45 A.M., Nurse #6 said Latanoprost bottles should be labeled with the date opened and medications should be discarded per the manufacturer's instructions.During an interview on 4/8/26 at 10:32 A.M., the Director of Nursing said eye drops should be dated when opened and discarded per the manufacturer's instructions.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who per rehabilitation staff required the use of a mechanical lift for all transfers, and per facility policy two staff members were required to complete lift transfers, the facility failed to ensure that 1) Resident #1's individualized comprehensive plan of care, which included his/her care Kardex, clearly indicated the number of staff members required to provide assistance during the transfers, and as a result one staff member attempted to transfer him/her alone, he/she fell, and sustained a fracture to his/her left ankle, and 2) failed to ensure they developed and implemented a comprehensive plan of care related to Resident #1's ankle fracture, that accurately identified care and treatment needs associated with new placement of a fiberglass splint, that included appropriate interventions, goals and outcomes.Findings include:Review of the Facility Policy titled, Comprehensive Care Plans, dated as revised May 2025, indicated the following:-the interdisciplinary team (IDT) would develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality;-the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being and include an assessment of the resident's strengths and needs;Review of the Facility Policy titled, Safe Resident Handling/Transfers, dated as revised May 2025, indicated the following:-the facility will ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines;-while manual lifting techniques may be utilized if appropriate for the resident's condition and mobility, use of mechanical lifts are a safer alternative and should be used;-the IDT will evaluate and assess each resident's individual mobility needs;-the resident's mobility needs will be addressed based on direct care staff observations or recommendations;-mechanical lifts include equipment such as full body lifts or sit to stand lifts;-two staff members must be utilized when transferring residents with a mechanical lift;-staff members are expected to maintain compliance with safe handling/transfer practices;-resident lifting and transferring will be performed according to the resident's individual care plan;Resident #1 was admitted to the Facility in March 2024 diagnoses included cerebral palsy, embolism and thrombosis of deep veins (blood clot) of left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis (inflammation of bone tissue) and wedge compression fracture of fifth lumbar vertebra (lower back).Review of his/her Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was alert and oriented, with a Brief Interview for Mental Status (BIMS) of 15 (intact cognitive function) and was dependent on staff with transfers.1) Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 01/02/26, indicated that on 01/01/26 at 7:00 P.M., Resident #1 was assisted by staff via the Sit/Stand Lift when he/she let go of the hand supports and slid out of the lifts sling onto the floor. The Report indicated that Resident #1 complained of pain to his/her left ankle and was transferred to Emergency Department (ED) for evaluation. The Report further indicated that Resident #1 had a fracture of the distal end of the left tibia and left fibula (ankle fracture), was non-weight bearing to his/her left lower extremity and to follow-up with orthopedics. During an interview on 02/03/26 at 1:21 P.M., Resident #1 said that he/she fell out of the Sit/Stand Lift during a transfer and broke his/her left ankle. Resident #1 said that there were always two staff members present when he/she was transferred with the Sit/Stand Lift. Resident #1 said that the day he/she fell out of the Sit/Stand Lift, a male CNA transferred him/her without the assistance of another staff member. Resident #1 said that he/she did not know who the male CNA was who transferred him/her.Review of Resident #1's Care Plan related to Activities of Daily Living (ADL), dated as reviewed and renewed with his/her October 2025 MDS, indicated that he/she required physical assistance to dependence of staff with transfers.However, Resident #1's ADL Care Plan did not indicate the number of staff members that were required to participate in order to safely complete the transfers.Review of Resident #1's Resident Care Card, (used as a reference guide by CNA's, provides direct care staff with a brief overview of each resident's care needs), (reviewed and updated in conjunction with his/her plan of care), indicated that he/she required physical assistance to dependence of staff with transfers.However, Resident #1's Care Card also did not indicate the number of staff members that were required to participate to safely complete the transfers.Review of Resident #1's Occupational Therapy Recertification, Progress Report and Updated Therapy Plan, dated 12/29/25, indicated he/she was assessed as being dependent for transfers with use of Sit/Stand Lift and required moderate to maximum assistance of two staff members for all transfers.During an interview on 02/03/26 at 11:50 A.M., the Certified Occupational Therapy Assistant (COTA) said that Resident #1 was receiving skilled therapy prior to his/her fall on 01/01/26. The COTA said that Resident #1's lower extremities were weak, that he/she required a Sit/Stand Lift for all transfers and maximal assistance of two staff members with transfers.During an interview on 02/03/26 at 12:06 P.M., the Occupational Therapist (OT) said that Resident #1 had a functional decline prior to his/her fall on 01/01/26 and was on skilled therapy for upper and lower body strengthening. The OT said that Resident #1 required a Sit/Stand Lift for all transfers and maximal assistance of two staff members with transfers.During a telephone interview on 02/04/26 at 10:42 A.M., CNA #1 said that 01/01/26 on the 3:00 P.M. to 11:00 P.M. shift, that it was his first time working at the facility. CNA #1 said that when he received report at the beginning of the shift about the residents on his assignment, that the other staff members that worked with him on the unit that night, informed him that Resident #1 required the use of a Sit/Stand Lift for transfers. CNA #1 said he has been a CNA for 18 years, had been trained on the use of a Sit/Stand Lift, was familiar with the Sit/Stand Lift at the facility and knew how to work the Sit/Stand Lift device. CNA #1 also said that he was aware that transfers with the Sit/Stand Lift required the assistance of two staff members. CNA #1 said there was another CNA nearby in the hallway when he transferred Resident #1 with the Sit/Stand Lift, but she was not in the room during the transfer. CNA #1 said that on 01/01/26 at approximately 7:00 P.M. he transferred Resident #1 using a Sit/Stand Lift without the assistance of another person, that Resident # 1 let go of the bars on the lift and fell to the floor. CNA #1 could not explain why he transferred Resident #1 without the assistance of another staff member.During a telephone interview on 02/04/26 at 11:03 A.M., CNA #4 said that she worked on 01/01/26 during the 3:00 P.M. through 11:00 P.M. shift. CNA #4 said that she reviewed CNA #1's assignment with him at the start of the shift on 01/01/26 and said she told CNA #1 that Resident #1 required the assistance of two staff members for transfers with the Sit/Stand Lift. CNA #4 said that she offered to assist CNA #1 with Resident #1's transfer and was available to help with Resident #1's transfer when needed. CNA #4 said CNA #1 never came to get her during her shift to ask for help.Review of a Nurse Progress Note, dated 01/02/26, (written by Nurse #1) indicated that CNA #1 notified her that during a sit to stand transfer, Resident #1 let go of the sling and slid down to the floor. The Note indicated that Resident #1 complained of left ankle pain and was transferred to the Hospital ED for evaluation.During a telephone interview on 02/03/26 at 4:43 P.M., Nurse #1 said that on 01/01/26, at around 7:00 P.M., CNA #1 (who was an agency CNA) came to the nurse's station and informed her that during a sit to stand transfer, Resident #1 fell from the Sit/Stand Lift onto the floor. Nurse #1 said that Resident #1 required a Sit/Stand Lift for all transfers and said that Sit/Stand Lift transfers always required the assistance of two staff members. Nurse #1 said that when she assessed Resident #1, he/she was sitting on the floor complaining of left ankle pain. Nurse #1 said that Resident #1 was transferred to the Hospital ED for evaluation. Nurse #1 said that she could not recall if CNA #1 transferred Resident #1 with another staff member.During a telephone interview on 02/05/26 at 12:46 P.M., Nurse #4 said that she worked 01/01/26 during the 3:00 P.M. through 11:00 P.M. shift. Nurse #4 said that she was informed by Nurse #1 that Resident #1 fell during a transfer with a Sit/Stand Lift and needed to be transferred to the Hospital ED. Nurse #4 said that when Nurse #1 gave her report she said that CNA #1 transferred Resident #1 with the Sit/Stand Lift without the assistance of another staff member. Nurse #4 said that Resident #1 required the physical assistance of two staff members with transfers and that a Sit/Stand Lift transfer also requires the assistance of two staff members.During an interview on 02/03/26 at 2:30 P.M. and throughout the day of survey, the Director of Nurses (DON) said that she did not know why Resident #1's ADL Care Plan and Resident Care Card indicated that he/she required assistance to dependence with transfers and said there have been issues with consistency with the care plans. The DON said that Care Plans and Resident Care Cards should specifically indicate the number of staff assistance required. The DON said that if a resident requires a mechanical lift, it should be on their ADL Care Plan and Resident Care Card, and that both should indicate that two staff members are required during the transfer. The DON said that dependent level of care meant that the resident requires the physical assistance of two staff members. The DON said that it was her expectation that there would be two staff members present during any mechanical lift transfer. Refer to F6892) Review of Hospital Emergency Department (ED) Discharge summary, dated [DATE], indicated that Resident #1 presented to the ED after a fall at the facility. The Summary indicated that Resident #1 sustained a fracture of the distal end of left tibia and left fibula and that a short leg ortho fiberglass splint (pre-padded splinting solution used for immobilizing lower leg injuries) was applied to his/her left ankle.Review of a Resident #1's Orthopedic Consultations, dated 01/09/26 and 01/23/26 indicated to keep splint on his/her left lower extremity and maintain non-weight bearing status.Review of Resident #1's Resident Care Card, reviewed and updated in conjunction with his/her plan of care, indicated to encourage use of CAM boot to left lower extremity when out of bed and that his/her mobility status was non-weight bearing to the left lower extremity.Review of Resident #1's Care Plan related to ADL's, dated as revised 01/22/26, indicated Left Lower Extremity CAM boot while out of bed, check Circulation Sensation Motion (CSM) and skin integrity while on.Review of Resident #1's Care Plan related to Alteration in Musculoskeletal status due to recent fall with left distal tibia and fibula fracture, dated as initiated 01/08/26, indicated to encourage use of CAM boot to left lower extremity when out of bed and that his/her mobility status was non-weight bearing to the left lower extremity. During a telephone interview on 02/04/26 at 4:43 P.M., Nurse #1 said that Resident #1 sustained a fractured left ankle from a fall out of a Sit/Stand Lift during a transfer. Nurse #1 said that Resident #1 was transferred to the Hospital ED and returned with a fiberglass splint on his/her left lower extremity. Nurse #1 said that Resident #1 did not have a CAM boot on his left lower extremity, and that the Care Plan was not accurate.During an interview on 02/03/26 at 3:10 P.M., Nurse #3 said that Resident #1 had a fiberglass splint with an Ace (elastic compression bandage) wrap on his/her left lower extremity. Nurse #3 said that Resident #1 did not have a CAM boot on his left lower extremity.During a telephone interview on 02/05/26 at 12:46 P.M., Nurse #4 said that Resident #1 did not have a CAM boot on his/her left lower extremity.A CAM boot is an external removable orthopedic walking boot allowing you to bear weight, designed to immobilize and protect the foot or ankle during recovery from injuries or surgery. Unlike a traditional splint, it is removable which permits hygiene, wound care and rehabilitation exercises.A fiberglass splint is a device that supports and protects a broken bone, helps reduce pain and promote healing by keeping the injured part of your body still. It is held in place with an elastic bandage, is not a removable device and cannot support walking and weight bearing. Resident #1's Care Plans indicated for his/her to wear a CAM boot when out of bed, check CSM and skin integrity while on. A CAM boot cannot be worn over a fiberglass splint, and a fiberglass splint cannot be removed to check skin integrity. With a fiberglass splint, the nurse can check CSM, check that it is intact and held in place with an elastic bandage (ACE) but it cannot be removed and worn when out of bed only. A fiberglass splint must remain on at all times until an orthopedic physician orders otherwise.The Surveyor observed Resident #1 during the survey on 02/03/26. Resident #1 was observed with a left lower extremity splint covered with an Ace (elastic compression bandage) wrap. The Surveyor did not observe a CAM boot on Resident #1's left lower extremity and the staff were unable to locate a CAM boot that belonged to Resident #1. During an interview on 02/03/26 at 2:30 P.M. and throughout the day of the survey, the Director of Nurses (DON) said that Resident #1 had a fiberglass splint and an Ace wrap. The DON said that the Care Plans stated that Resident #1 had a CAM boot to his/her left lower extremity in error, that the Care Plans should have indicated he/she had a splint and said that the Care Plans were not accurate. The DON said that the Care Plans should have been updated after the Orthopedic Consults but were not, and should have included appropriate interventions, goals and outcomes.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a Sit/Stand Lift (mobility aid that helps people transition safely from sitting to standing), for all transfers, with two staff members present to assist and complete the transfer, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, in accordance with facility policy, to maintain his/her safety and prevent an incident/accident resulting in a significant injury. On 01/01/26, Certified Nurse Aide (CNA) #1 transferred Resident #1 with a Sit/Stand Lift, without another staff member present to assist him, Resident #1 slid out of the sling, fell onto the floor, complained of pain to his/her left lower extremity, was transferred to the Hospital Emergency Department (ED) and diagnosed with a left ankle fracture.Findings include:Review of the Facility Policy titled, Safe Resident Handling/Transfers, dated as revised May 2025, indicated the following:-the facility will ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines;-while manual lifting techniques may be utilized if appropriate for the resident's condition and mobility, use of mechanical lifts are a safer alternative and should be used;-mechanical lifts include equipment such as full body lifts or sit to stand lifts;-two staff members must be utilized when transferring residents with a mechanical lift;-staff members are expected to maintain compliance with safe handling/transfer practices;Resident #1 was admitted to the Facility in March 2024 diagnoses included cerebral palsy, embolism and thrombosis of deep veins (blood clot) of left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis (inflammation of bone tissue) and wedge compression fracture of fifth lumbar vertebra (lower back).Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was alert and oriented, with a Brief Interview for Mental Status (BIMS) of 15 (intact cognitive function) and was dependent on staff with transfers.Review of Resident #1's Care Plan related to Activities of Daily Living (ADL), dated as reviewed and renewed with his/her October 2025 MDS, indicated that he/she required physical assistance to dependence of staff with transfers.Review of Resident #1's Resident Care Card, (used as a reference guide by CNA's, provides direct care staff with a brief overview of each resident's care needs), (reviewed and updated in conjunction with his/her plan of care), indicated that he/she required physical assistance to dependence of staff with transfers.Review of Resident #1's Occupational Therapy Recertification, Progress Report and Updated Therapy Plan, dated 12/29/25, indicated he/she was assessed as being dependent with use of Sit/Stand Lift and required moderate/maximum assist of two staff members for transfers.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 01/02/26, indicated that on 01/01/26 at 7:00 P.M., Resident #1 was assisted by staff via the Sit/Stand Lift when he/she let go of the hand supports and slid out of the sling onto the floor. The Report indicated that Resident #1 complained of pain to his/her left ankle and was transferred to ED for evaluation. The Report further indicated that Resident #1 had a fracture of the distal end of the left tibia and left fibula (ankle), was non-weight bearing to his/her left lower extremity and to follow-up with orthopedics. Review of Hospital Emergency Department (ED) Discharge summary, dated [DATE], indicated that Resident #1 presented to the ED after a fall at the facility. The Summary indicated that Resident #1 sustained a fracture of the distal end of the left tibia and left fibula (ankle) and that a short leg ortho fiberglass splint (pre-padded splinting solution used for immobilizing lower leg injuries) was applied to his/her left ankle.During an interview on 02/03/26 at 11:50 A.M., the Certified Occupational Therapy Assistant (COTA) said that Resident #1 was receiving skilled therapy prior to his/her fall on 01/01/26. The COTA said that Resident #1's lower extremities were weak, and he/she required a Sit/Stand Lift for all transfers and maximal assistance of two staff members with transfers.During an interview on 02/03/26 at 12:06 P.M., the Occupational Therapist (OT) said that Resident #1 had a functional decline prior to his/her fall on 01/01/26 and was on skilled therapy for upper and lower body strengthening. The OT said that Resident #1 required a Sit/Stand Lift for all transfers and maximal assistance of two staff members with transfers.During an interview on 02/03/26 at 1:21 P.M., Resident #1 said that he/she fell out of the Sit/Stand Lift during a transfer and broke his/her left ankle. Resident #1 said on the day he/she fell out of the lift, that the male CNA transferred him/her without the assistance of another staff member. Resident #1 said that he/she did not know who the male CNA was who transferred him/her with the Sit/Stand Lift, that day. Resident #1 said before that day, that there were always two staff members present when he/she was transferred with the Sit/Stand Lift.During a telephone interview on 02/04/26 at 10:42 A.M., CNA #1 said on 0/01/26, at the beginning of his shift (3:00 P.M. to 11:00 P.M.) he got report on the residents on his assignment and said that the other staff members that worked with him that night on the unit, informed him that Resident #1 required a Sit/Stand Lift for transfers. CNA #1 said he has been a CNA for 18 years and knew how to work the Sit/Stand Lift device. CNA #1 said that he was aware that transfers a Sit/Stand Lift required the assistance of two staff members. CNA #1 said that on 01/01/26 around 7:00 P.M., he transferred Resident #1 using a Sit/Stand Lift without the assistance of another staff member and that Resident # 1 let go of the bars on the lift and fell to the floor. CNA #1 said that there was another CNA nearby in the hallway when he transferred Resident #1 with the Sit/Stand Lift, but she was not in the room during the transfer. CNA #1 could not explain why he transferred Resident #1 without the assistance of another staff member.During a telephone interview on 02/04/26 at 11:03 A.M., CNA #4 said that she worked on 01/01/26 during the 3:00 P.M. through 11:00 P.M. shift. CNA #4 said that she reviewed CNA #1's assignment with him at the start of the shift on 01/01/26 and said she told CNA #1 that Resident #1 required the assistance of two staff members for transfers with the Sit/Stand Lift. CNA #4 said that she offered to assist CNA #1 with Resident #1's transfers. CNA #4 said CNA #1 never came to get her during the shift to ask for assistance with Resident #1's transfer.Review of a Nurse Progress Note, dated 01/02/26, (written by Nurse #1) indicated that CNA #1 notified her that during a sit to stand transfer, Resident #1 let go of the sling and slid down to the floor. The Note indicated that Resident #1 complained of left ankle pain and was transferred to the Hospital ED for evaluation.During a telephone interview on 02/03/26 at 4:43 P.M., Nurse #1 said that Resident #1's fall occurred on 01/01/26 around 7:00 P.M. Nurse #1 said that CNA #1 (who was an agency CNA) came to the nurse's station and informed her that during a sit to stand transfer, Resident #1 fell from the sit to stand lift onto the floor. Nurse #1 said that Resident #1 required a Sit/Stand Lift for all transfers and said that Sit/Stand Lift transfers always require the assistance of two staff members. Nurse #1 said that when she assessed Resident #1, he/she was sitting on the floor complaining of left ankle pain. Nurse #1 said that Resident #1 was transferred to the Hospital ED for evaluation. Nurse #1 said that she could not recall if CNA #1 transferred Resident #1 with another staff member.During a telephone interview on 02/05/26 at 12:46 P.M., Nurse #4 said that she worked 01/01/26 during the 3:00 P.M. through 11:00 P.M. shift. Nurse #4 said that she was informed by Nurse #1 that Resident #1 fell during a transfer with a Sit/Stand Lift and needed to be transferred to the Hospital ED. Nurse #4 said that when Nurse #1 gave her report she (Nurse #1) said that CNA #1 had transferred Resident #1 with the Sit/Stand Lift without the assistance of another staff member. Nurse #4 said that Resident #1 required the physical assistance of two staff members with transfers and that a Sit/Stand Lift transfer also requires the assistance of two staff members.During an interview on 02/03/26 at 2:30 P.M. and throughout the day of the survey, the Director of Nurses (DON) said that she could not recall what the facility's policy was for a Sit/Stand Lift and said she assumed that it required two staff members with mechanical lifts. The DON said that she did not know if there were two staff members present during Resident #1's Sit/Stand transfer on 01/01/26. The DON said that CNA #1 was an agency CNA and said she did not interview him, about the transfer. The DON said that dependent level meant that the resident requires the physical assistance of two staff members. The DON said that it was her expectation that there would be two staff members present during any mechanical lift transfer and that staff members follow the facility's policies.Refer to F656

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had recently sustained a fracture of the distal end of the tibia and left fibula (fracture of the ankle), the Facility failed to ensure nursing staff provided care and services that met professional standards of quality, when nurses were unaware of what type of orthotic device he/she was wearing and were documenting they were providing care and treatment to his/her left ankle that they could not have completed, based on the type of orthotic device he/she had in place.Findings include:Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in March 2024 diagnoses included cerebral palsy, embolism and thrombosis of deep veins (blood clot) of left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis (inflammation of bone tissue) and wedge compression fracture of fifth lumbar vertebra (lower back).Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was alert and oriented, with a Brief Interview for Mental Status (BIMS) of 15 (intact cognitive function) and was dependent on staff with transfers.Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 01/02/26, indicated that on 01/01/26 at 7:00 P.M., Resident #1 was assisted by staff via the Sit/Stand Lift when he/she let go of the hand supports and slid out of the sling onto the floor. The Report indicated that Resident #1 complained of pain to his/her left ankle and was transferred to Emergency Department (ED) for evaluation. The Report further indicated that Resident #1 had a fracture of the distal end of the left tibia and left fibula (ankle) and was placed in a Controlled Ankle Motion (CAM) boot, was non-weight bearing to his/her left lower extremity and to follow-up with orthopedics. However, review of ED Discharge summary, dated [DATE], indicated that Resident #1 presented to the ED after a fall at the facility. The Summary indicated that Resident #1 sustained a fracture of the distal end of left tibia and left fibula and that a short leg ortho fiberglass splint (pre-padded splinting solution used for immobilizing lower leg injuries) was applied to his/her left ankle.Review of Resident #1's Care Plan related to ADL's, dated as revised 01/22/26, indicated he/she was to have Left Lower Extremity CAM boot while out of bed, check Circulation Sensation Motion (CSM) and skin integrity while on.Review of Resident #1's Care Plan related to Alteration in Musculoskeletal status due to recent fall with left distal tibia and fibula fracture, dated as initiated 01/08/26, indicated to encourage use of CAM boot to left lower extremity when out of bed.Review of Resident #1's Treatment Administration Record (TAR), dated January 1st, 2026 through February 3rd, 2026, indicated that the following treatments were signed off as being completed by the licensed nurses on all shifts:- Left lower extremity CAM boot on when out of bed every shift;- left heel apply skin prep for prevention every shift;- remove CAM boot as tolerated to assess skin for breakdown or signs/symptoms of swelling or infection.However, Resident #1 was not fitted with and never had a CAM boot on his/her left ankle.During an interview on 02/03/26 at 4:00 P.M., Resident #1 said that he/she fell out of the Sit/Stand Lift during a transfer and broke his/her left ankle. Resident #1 said that he/she went to the hospital after the fall and the hospital placed a splint on his/her left lower extremity. Resident #1 said that the nurses had not removed the splint.The Surveyor observed Resident #1 during the survey on 02/03/26. Resident #1 was observed with a left lower extremity splint covered with an Ace (elastic compression bandage) wrap. The Surveyor did not observe a CAM boot on Resident #1's left lower extremity and the staff were unable to locate a CAM boot that belonged to Resident #1. Review of Resident #1's Orthopedic Consultations, dated 01/09/26 and 01/23/26 indicated to keep splint on his/her left lower extremity and maintain non-weight bearing status.During an interview on 02/03/26 at 3:10 P.M., Nurse #3 said that she had completed and signed off on Resident #1's treatments as having been completed. Nurse #3 said that Resident #1 had a splint with an Ace (elastic compression bandage) wrap on his/her left lower extremity. Nurse #3 said that she did not know what a CAM boot was and that Resident #1 did not have a CAM boot on his left lower extremity. Nurse #3 said that she had not applied skin prep to Resident #1's left heel and that had not removed a CAM boot from his/her left foot, even though she signed off the TAR as having done so. Nurse #3 said she could not explain why she signed off the TAR as having completed those treatments earlier in her shift when she had not.During a telephone interview on 02/04/26 at 4:43 P.M., Nurse #1 said that Resident #1 sustained a fractured left ankle from a fall out of a Sit/Stand Lift during a transfer. Nurse #1 said that Resident #1 was transferred to the Hospital ED and returned from the Hospital ED with a splint on his/her left lower extremity. Nurse #1 said that Resident #1 did not have a CAM boot on his left lower extremity.During a telephone interview on 02/05/26 at 12:46 P.M., Nurse #4 said that Resident #1 sustained a fractured left ankle from a fall out of a Sit/Stand Lift during a transfer. Nurse #4 said that Resident #1 was transferred to the Hospital ED and returned with a splint on his/her left lower extremity. Nurse #4 said that Resident #1 did not have a CAM boot on his/her left lower extremity.During an interview on 02/03/26 at 2:30 P.M. and throughout the day of the survey, the Director of Nurses (DON) said that Resident #1 had a splint and an Ace wrap on his/her left lower extremity, and not a CAM boot. The DON said that Resident #1's treatments should have been updated after the Orthopedic Consultations. The DON said that the TAR should have indicated that Resident #1 had a splint and that his/her orders on the TAR should have been specific to nursing care, treatment and monitoring for the splint.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was dependent on the physical assistance of staff with Activities of Daily Living (ADL), the Facility failed to ensure they maintained a complete and accurate medical record, when Certified Nurse Aide (CNA) ADL Flow Sheets, daily documentation by CNA's (for all three shifts) were not consistently completed, with flow sheets left blank.Findings include:Review of the Facility's Policy tilted, Charting and Documentation, dated May 2023, indicated the following:-services provided to the resident to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record;-objective observations, treatments or services performed, are documented in the resident medical record;Resident #1 was admitted to the Facility in March 2024 diagnoses included cerebral palsy, embolism and thrombosis of deep veins (blood clot) of left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis (inflammation of bone tissue) and wedge compression fracture of fifth lumbar vertebra (lower back).Review of Resident #1's Care Plan related to Activities of Daily Living (ADL), dated as reviewed and renewed with his/her October 2025 MDS, indicated that he/she required partial to moderate assistance of staff with bed mobility, required substantial assistance to total dependence of staff with bathing, dressing and grooming and toileting and was dependent on the physical assistance of staff for transfers and showers.Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was alert and oriented and was dependent on the physical assistance of staff with transfers, dressing, personal hygiene, bathing and toileting.Review of Resident #1's CNA Documentation Record (ADL Flow Sheets), dated 12/01/25 through 12/31/25, indicated that for the following shifts, documentation on the flow sheets for all ADL care areas were incomplete:-7:00 A.M. to 3:00 P.M. - 6 days (out of 31) ADL care areas were left blank-3:00 P.M. to 11:00 P.M. - 17 days (out of 31) ADL care areas were left blank-11:00 P.M. to 7:00 A.M. - 20 days (out of 31) ADL care areas were left blankReview of Resident #1's CNA Documentation Record (ADL Flow Sheets), dated 01/01/26 through 01/31/26, indicated that for the following shifts, documentation on the flow sheets for all ADL care areas were incomplete:-7:00 A.M. to 3:00 P.M. - 7 days (out of 31) ADL care areas were left blank-3:00 P.M. to 11:00 P.M. - 18 days (out of 31) ADL care areas were left blank-11:00 P.M. to 7:00 A.M. - 24 days (out of 31) ADL care areas were left blankDuring an interview on 02/03/26 at 1:11 P.M., Certified Nurse Aide (CNA) #2 said that the documentation of ADL's is done in Point of Care (POC) in the Electronic Medical Record (EMR) and has to be completed by the end of the shift.During a telephone interview on 02/04/26 at 10:42 A.M., CNA #1 said that the documentation of ADL's is done in POC in the EMR and has to be completed by the end of the shift.During a telephone interview on 02/04/26 at 10:55 A.M., CNA #3 said that the documentation of ADL's is done in POC in the EMR and has to be completed by the end of the shift.During a telephone interview on 02/04/26 at 11:03 A.M., CNA #4 said that the documentation of ADL's is done in POC in the EMR and has to be completed by the end of the shift.During an interview on 02/03/26 at 4:15 P.M., the Director of Nurses (DON) said CNA documentation has been an issue at the facility. The DON said that CNA's document the ADL's they provided to the residents in POC in the EMR and that daily documentation should not be incomplete. The DON said it was her expectation that the CNA's should be documenting all care provided to residents by the end of every shift and should not be left blank.

Based on document review and interview, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day to day care of the population the facility currently serves. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memo titled Revised Guidance for Long-Term Care Facility Assessment Requirements, dated 6/18/24, indicated but was not limited to: -In conducting the facility assessment, the facility must ensure active involvement of the following participants in the process: - The facility's resident population, including, but not limited to: - The care required by the resident population; - The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and - Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. - The facility's resources, including but not limited to the following: - All buildings and/or other physical structures and vehicles; a. Equipment (medical and non-medical); b. Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. - A facility-based and community-based risk assessment, utilizing an all-hazards approach Review of the Facility Assessment, last updated 1/28/25, failed to indicate: - The facility's resident population including but not limited to: - Resident specific care needs - The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and - Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. - The facility's resources, including but not limited to the following: - All buildings and/or other physical structures and vehicles; - Equipment (medical and non-medical); - Contracts or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. - A facility-based and community-based risk assessment. During an interview on 2/19/25 at 8:31 A.M., the Administrator said the facility assessment provided to surveyors on 2/19/25 at 7:00 A.M. was the most updated facility assessment. The Administrator said the Facility Assessment was missing key elements and was not specific to the facility. The Administrator said the facility assessment should have included the facility's resident population including care, resources, and facility needs, list of contracts and other agreements, and a facility-based and community-based risk assessment but did not. The Administrator said the facility assessment should have been more specific to the facility's population and needs.

Based on record review and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and implemented an appropriate corrective action plan, to ensure satisfactory outcomes. Specifically, the facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI) plan and a Performance Improvement Project (PIP) that focused on a high risk or problem-prone area identified through data collection and analysis. Findings include: Review of the facility's policy titled QAPI Facility Plan, dated 3/4/2024, indicated but was not limited to: - The QAPI Plan is designed to establish and maintain an organized facility wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility. This is a living document that will continue to be refined and revised. - The QAA (Quality Assurance and Assessment) Committee's overall responsibility is to develop and modify the plan, analyze information, and set priorities for PIPs. Priority will be given to issues identified as high risk, high volume and those that fall within problem prone areas. - The facility uses a systemic approach to determine when an in-depth analysis is needed to fully understand the problem, its causes, and the complications of change. The facility uses a thorough and highly organized/structured approach to determine the root cause of the identified problems. The facility will utilize a variety of tools to describe the current process we use. - Each Performance Improvement Project (PIP) subcommittee will identify areas of improvement. Data will be collected during this process and then analyzed to determine the effectiveness of change. The PIP sub-committee will provide the QAA Committee with a summary report, analysis of activities, and recommendations. - The Committee shall maintain written meeting agendas, minutes, attendance records, and QAPI program progress reports. - The Committee will complete an annual review of the QAPI program. - The facility seeks to prioritize projects in high risk, high frequency and/or problem prone areas that impact quality of care and quality of life for our residents and conducts one improvement project annually based on these areas. - PIPs are reported by the project lead to the monthly QAA Committee meeting and documented in the meeting minutes. - The QAA Committee monitors progress to ensure that interventions or actions are implemented and effective in making and sustaining improvements. - The QAA Committee will review the key elements of the program to ensure they are occurring, that the program is efficient, and the results are being communicated to the appropriate audience. During an interview on 2/19/25 at 2:19 P.M., the Administrator said the QAPI committee meets and discusses concerns monthly and quarterly but there was not a tracking method, written goals, and quarterly or annual comparison on a project. The Administrator said there are QAPI projects that have been completed but they are not tracked month after month and are just done and completed within one month. The Administrator said there was not a way to track if QAPI projects were effective or needed to be re-evaluated because they are not monitored. The Administrator said up until January's QAPI meeting he did not keep meeting notes or keep track of past QAPI projects. The Administer said he did not have a current PIP, nor did he have one last year. The Administrator said he should have documented and tracked things better. At the end of the survey, the facility failed to provide the survey team with any additional documentation or evidence of QAPI minutes or PIPs.

Based on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for one Resident (#337), from a total sample of 21 residents, and unopened mail and other letters, packages and other materials delivered to the facility were promptly received by residents. Specifically, the facility failed to ensure: 1. Staff did not communicate Resident #337's private health information with his/her Nurse Practitioner (NP) via a text messaging application utilizing an unsecured mobile phone platform; and 2. United States Postal Service (USPS) mail and/or packages was promptly delivered to residents within 24 hours of delivery by the postal service. Findings include: Review of the facility's policy titled Security of Portable Electronic Devices, last revised January 2025, indicated but was not limited to: - To aid in the prevention of disclosure of confidential information, our company has adopted procedures for the safety and security of confidential business and protected health information. The purpose of this policy is to define requirements to safeguard sensitive data contained on portable devices and portable electronic storage media on or off company premises and procedures to follow. This policy applies to all company employees and business associates that create, store, and access sensitive data. Review of the facility's policy titled Personal Cell Phone Policy, last revised January 2025, indicated but was not limited to: - This facility prohibits employees from using personal cell phones for any reason on the nursing units or in working areas of the facility. - This includes calls, texts, social media or any other use of cell phones. Review of the facility's policy titled Confidentiality/HIPPA, undated, indicated but was not limited to: - All employees are responsible for protecting the privacy, both medical and personal, of all the residents of our facilities. - Residents' records whether medical or social in nature will be safeguarded to protect the confidentiality of the information. Review of the National Library of Medicine (NLM), dated 3/15/20, indicated but was not limited to: - The main problem of these commercial messaging apps is that they are owned by companies whose main aim is to collect data from their users. For this reason, it is difficult to imagine a future where these applications can satisfy the requests concerning the processing of personal health data both at European and US level. - What healthcare systems need are Secure Messaging Apps (SMA) specifically dedicated to keep confidentiality of patient data. Beyond encrypting data within a private communication network, SMA must prevent data being sent outside the healthcare organization's network. Saving of sensitive data to external hard-drives or outside the organization's network must be avoided and administrative control must be available, deleting messages if the smartphone is stolen or lost (remote wipe) or after a predetermined period of time. (https://pubmed.ncbi.nlm.nih.gov/32062746/) Resident #337 was admitted to the facility in February 2025 with diagnoses including dementia. During an interview on 2/13/25 at 1:17 P.M., Unit Manager (UM) #1 said she notified Resident #337's NP of his/her change in condition and transfer to hospital via text message. UM #1 showed the surveyor the text message to the NP. UM #1 said some Physicians and NPs used a secure messaging network but to contact Resident #337's NP she utilized his/her phone's text messaging platform. Review of the text message on UM #1's cell phone to Resident #337's NP included but was not limited to: - Resident #337's First and Last Name; - Resident #337's change in medical condition; and - Plan for Resident #337's treatment. During an interview on 2/18/25 at 2:09 P.M., UM #1 said she thought the text messaging platform she had utilized to contact Resident #337's NP was encrypted. During an interview on 2/19/25 at 12:35 P.M., the Director of Nursing (DON) said Resident #337's Physician and NP did not utilize a secure messaging platform and a text which included Resident #337's private health information should not have been sent to his/her NP. The DON said a phone call should have been placed to Resident #337's NP. The DON said personal cell phone messaging platforms are not secured unless a secure messaging platform was used or an encrypted company cell phone was used. The messaging platform and cell phone were not secure. 34145 2. During the Resident Group Meeting on 2/13/25 at 1:30 P.M., nine out of nine residents reported that USPS mail and packages are not delivered to them on Saturdays. The residents said that the receptionist sorts the mail and gives it to the activity staff to deliver to them during the week, but not on the weekends because the receptionist does not work on the weekends. During an interview on 2/13/25 at 2:12 P.M., the receptionist said she is responsible for sorting the residents' mail and packages when she works Monday through Friday and gives it to activity staff for distribution. She said mail is not distributed on Saturdays and she takes care of mail and packages delivered on Saturday when she returns to work on Monday.

Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for nine of nine residents who attended the resident group meeting, the facility failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s). Findings include: Review of the facility's policy titled Complaint/Grievance Policy Procedure, dated September 2023, indicated but was not limited to: - Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. - Grievance/Complaint forms will be available at the nurse's station or other designated area. - Residents and/or their responsible representative shall complete the form. - If a resident is unable to complete the form, a staff member shall assist them. - Staff shall complete a grievance form when residents or responsible representatives make verbal complaints, if not completed by the complainant. - Resident and/or responsible representative have the right to file a grievance anonymously. - Completed forms should be forwarded to the Grievance Official and notify the Executive Director. On 2/13/25 at 1:30 P.M., the surveyor held a resident group meeting with nine residents in attendance representing each of the facility's three units. Nine of nine residents said that they had not seen any postings about the grievance process and did not know how to file a grievance except for telling a staff member about a problem. The residents said they were not aware of the availability of grievance forms or that they could file a grievance anonymously. On 2/13/25 at 2:05 P.M., the surveyor toured the second-floor unit and was unable to locate any posting about the grievance process and no grievance forms. On 2/13/25 at 2:19 P.M., down a hallway across from the admissions office on the first-floor unit, the surveyor observed a wall mounted file holder with blank grievance forms. The forms were not easily visible as the file holder was black wire mesh. A sign was posted above the file holder and indicated the following: - Grievance Officer: Administrator - If you have any issues that you would like to file a grievance, please contact the following departments: Administrator, Director of Nursing, Social Services. The sign failed to indicate grievance forms were available in the wall mounted file holder and residents could file a complaint or grievance anonymously. During an interview on 2/13/25 at 2:20 P.M., the Administrator said he was the Grievance Officer and grievance forms were available on each of the units. He and the surveyor toured the second-floor unit and he found a black mesh file holder mounted to the wall in the hallway near a restroom. The file holder had papers in it, but it was not labeled and the papers were not easily visible through the black mesh. He said there should be a posting near the folder to inform residents how to file a grievance and that forms were available, but there were not. He said he was not aware that residents did not know they could file a grievance anonymously.

Based on observation, interviews, and record review, the facility failed to develop, implement and individualize comprehensive care plans for seven Residents (#1, #16, #78, #43, #14, #50 and #72), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #1, to implement the Resident's end stage renal disease (ESRD) care plan for fluid restriction; 2. For Resident #16 to ensure the Resident's urinary catheter care plan was Resident specific and included accurate information on the manner in which catheter care was provided and monitored; 3. For Residents #78, #43, and #14, to ensure a comprehensive care plan was developed to address the use of psychotropic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; 4. For Resident #50, to implement the Resident's nutritional care plan related to a fluid restriction; and 5. For Resident #72, to develop and implement a care plan for the resident's gastrostomy tube (G-tube-a surgically inserted tube that provides access to the stomach to deliver nutrition, medicine, and fluids). Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plan, dated May 2023, indicated but was not limited to the following: - The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident - the care plan interventions are derived from thorough analysis of the information gathered as part of the comprehensive assessment - the comprehensive care plan will include: measurable objectives and timeframes, describe services that are to be furnished, describe services that are not provided due to the resident exercising their rights, describe specialized services as a result of PASARR, include stated goals and desired outcomes, include preferences, incorporate identified problems and risk factors associated with those problems, build on resident strengths, reflect treatment goals, identify the professional services responsible for each element of care, aid in preventing decline, enhance optimal functioning, and reflect current recognized standards of practice for problem areas and conditions - areas of concern identified will be evaluated before interventions are added to the care plan - identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident - care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making 1. Resident #1 was admitted to the facility in October 2024 with diagnoses including: chronic kidney disease stage 5, ESRD, Bipolar disorder, and generalized anxiety. Review of the Brief Interview for Mental Status (BIMS), dated 2/9/25, indicated the Resident was cognitively intact with a score of 15 out of 15. Review of the [NAME] Concise Medical Dictionary, 8th Edition, 2010: one cubic centimeter (cc) is equal to one milliliter (ml) and one ounce is equal to 30 ml. During an interview on 2/13/25 at 8:29 A.M., the surveyor observed Resident #1 eating their breakfast. There was a 160 ml cup of coffee, a 5-ounce (150ml) plastic cup with water, an empty (used) plastic juice cup that the Resident said contained apple juice and a large 16-ounce (480 ml) styrofoam cup of a light orange-brown liquid in it that was 3/4 of the way empty and smelled like tea. The Resident said he/she did not have any food or fluid concerns and does not have any fluid restrictions that he/she recalled and could drink whatever he/she wanted. Resident #1 said after breakfast he/she usually headed downstairs for a cigarette and then got a snack or drink on the way up and requested it from the staff who provide him/her with anything he/she asks for. Review of the current Physician's Orders from 2/13/25 for Resident #1 indicated but were not limited to the following: - Diet: Regular textures, thin liquids, comment: Renal (10/31/24) - 1200 cc fluid restriction- Dietary to give 900cc; nursing to give up to 300cc in 24 hours. 7:00 A.M. - 3:00 P.M. shift 120cc; 3:00 P.M. - 11:00 P.M., shift 120cc; 11:00 P.M., to 7:00 A.M., shift 60cc. every shift fluids to be given with medications, no water to be left at bedside (2/5/25) - Resident to have dialysis on days: Monday, Wednesday, Friday. (11/27/24) Review of the current care plans for Resident #1 from 2/13/25, indicated but were not limited to the following: PROBLEM: I have acute on chronic Stage 5 renal failure related to end stage disease; I need hemodialysis three times per week; I am on a 1200 ml fluid restriction (revised: 2/5/25) INTERVENTIONS: 1200cc fluid restriction - dietary to give 900cc nursing to give 300cc in 24 hours. (2/6/25); Fluids as ordered - restrict or give as ordered (10/31/24) - (Nursing and Certified nurse assistant (CNA) were the responsible positions for both interventions) PROBLEM: I have a nutritional problem or potential nutritional problem related to obesity, therapeutic diet, weight gain Neither care plan indicated Resident #1 had a history of non-compliance with their fluid restriction. During an interview on 2/13/25 at 10:14 A.M., CNA #1 said she was not aware that Resident #1 was on a fluid restriction and that the Resident requests, receives, and keeps drinks on their bedside table frequently. During an interview on 2/13/25 at 1:05 P.M., CNA #2 said she was not aware that Resident #1 was on a fluid restriction. During an interview on 2/13/25 at 1:11 P.M., Nurse #2 said Resident #1 is on a prescribed fluid restriction, but is not very compliant with it and that she often finds the Resident with extra drinks. She said she doesn't think the Resident understands the fluid restriction and even though they try to limit the Resident it is hard to do. She said she previously wrote a note on the Resident not being compliant with the restriction and provided education to the Resident at that time. During an interview on 2/18/25 at 8:26 A.M., the Food Service Director (FSD) provided the surveyor with Resident #1's daily meal tickets. He said he does not have any knowledge of Resident #1 being on an ordered fluid restriction. He said the kitchen provides the Resident with a coffee at breakfast only that contains 160 ml and a cup of juice containing 240 ml. He said at the other two meals the Resident only receives 240 ml of juice from the kitchen, which is a large cup 3/4 of the way full. Throughout the survey the surveyor made the following observations on the following days and times: 2/13/25 at 8:29 A.M., the Resident had 1,030 ml of fluid available at the bedside including their medication water and dietary beverages (details above) 2/13/25 at 2:19 P.M., a 5-ounce (oz.) cup of water was at the bedside with approximately 1-2 sips remaining in it 2/13/25 at 3:38 P.M., a 480 ml cup of ginger ale and ice was at the bedside with approximately 1/2 inch of fluid remaining in the bottom 2/18/25 at 8:08 A.M., 160 ml of coffee and 240 ml of apple juice 2/18/25 at 9:22 A.M., Resident walking to his/her room drinking a 480 ml full cup of ginger ale 2/18/25 at 1:42 P.M., a 480 ml cup that has a few drops of fluid in the bottom and a 480 ml cup filled with ginger ale and ice During an interview on 2/18/25 at 8:17 A.M., Nurse #5 said Resident #1 has an ordered fluid restriction of 1200 ml a day and nursing was only allowed to provide 120 ml on the day and evening shift with meds and 60 ml on the night shift. She said the order also indicated no additional fluids should be left at the bedside. She said the Resident should not be having additional drinks throughout the day and the staff should not be providing them. She said the unit kitchenette is locked and not accessible to the residents without staff assistance. During an interview on 2/18/25 at 8:21 A.M., CNA #3 said Resident #1 pretty much drinks whatever they want and requests ginger ale all day every day. She said CNAs are supposed to complete I & O sheets and the Nurses total them daily. She said the I & O sheets for this Resident are incomplete and don't provide any information on a fluid restriction. She said the Resident does not have access to get their own drinks. During an interview on 2/18/25 at 9:22 A.M., the surveyor observed Resident #1 walking towards his/her room drinking from a 16-oz. cup. He/She said they requested a drink while downstairs and were given the large cup of ginger ale by the game playing people. The Resident said he/she does recall being told something about a fluid restriction in the past but doesn't think it's a problem anymore since the staff always give him/her the drinks when he/she asks for them. During an interview on 2/18/25 at 9:35 A.M., the Activity Director said she provided Resident #1 with a beverage as requested. She said she was not aware that Resident #1 was on a fluid restriction and follows a list of diets, fluids, and allergies from the kitchen daily. On review of the list, last printed 2/17/25 in the afternoon, the list did not indicate Resident #1 was on a fluid restriction. During an interview on 2/18/25 at 2:03 P.M., Unit Manager #2 reviewed Resident #1's documents and the concerns with the surveyor. She said the Resident has an ordered fluid restriction and a care plan that indicates they are on a fluid restriction and it is clear the staff have not followed the fluid restriction or implemented the care plan as they should have. During an interview on 2/19/25 at 10:42 A.M., the Director of Nurses (DON) said Resident #1 has a prescribed fluid restriction and a care plan for that fluid restriction. She said fluid restrictions and the manner in which they are documented and monitored is a work in progress and the facility needs to work on a better process to implement this part of the care plan. She said the care plan has not been implemented as it should have been. 2. Review of the facility's policy titled Catheter Care, Urinary, undated, indicated but was not limited to the following: - the purpose is to prevent catheter-associated urinary tract infections - maintain clean technique when handling or manipulating the catheter, tubing or drainage bag - do not clean the periurethral area with antiseptics to prevent catheter-associated UTIs while the catheter is in place, routine hygiene is appropriate - use a clean washcloth with warm soap to cleanse and rinse the catheter from insertion site to approximately four inches outward Resident #16 was admitted to the facility in August 2023 with diagnoses including: cerebral infarct (stroke), infection and inflammation due to an indwelling catheter, obstructive and reflux uropathy, and retention of urine. Review of the BIMS indicated the Resident was cognitively intact with a score of 14 out of 15. During an interview on 2/12/25 at 8:19 A.M., Resident #16 said he/she is pretty independent with their care. The Resident said he/she has had the urinary catheter since prior to admission and was told he/she would need it for the rest of their lives. The Resident said the CNAs empty the drainage bags and the Nurses change the catheter monthly but no one comes to clean the tubing. The Resident said he/she wasn't aware that it was something that should be done routinely. Review of the Resident activity for daily living (ADL) self-performance care plan indicated, but was not limited to the following: The Resident is independent with: ambulation, bed mobility, eating, bathing (assist with showers only), dressing, and grooming. Resident has a urinary catheter for urine output and is continent of bowel and independent with toileting; staff measure Foley output each shift. During an interview on 2/13/25 at 9:47 A.M., CNA #1 said Resident #16 has a catheter and the CNAs are required to empty the drainage bag at least once a shift and report the output to the Nurse. She said in general catheter care includes emptying the drainage bag and cleaning the catheter tubing around the insertion site every shift with warm soapy water and drying it to prevent germs on the tube. She said she does not provide any care like that for Resident #16 because catheter care is provided during ADL care and the Resident is independent with their ADLs. On 2/13/25, review of the CNA documentation for catheter care for the last 31 days for Resident #16 indicated out of 93 potential opportunities for catheter care the CNAs documented catheter care a total of 14 times. During an interview on 2/13/25 at 10:23 A.M., CNA #4 said Resident #16 is pretty independent with their ADLs and rarely requests any type of assistance. She said she has not provided any catheter care beyond emptying the drainage bag at the end of the shift. CNA #4 reviewed the CNA documentation for the last 31 days for catheter care and she said she would sign that off if she emptied the drainage bag since that is part of catheter care. She said she is unsure if the cleaning of the catheter tubing is done by the Nurses or the Resident but doesn't think any CNA has done that for this Resident. During an interview on 2/13/25 at 1:01 P.M., CNA #2 said Resident #16 really takes care of themselves and as far as she knows the CNAs are not providing any catheter care beyond emptying the drainage bag. She said she herself has never cleansed the catheter tubing for the Resident as part of catheter care and didn't realize that might be the indication when they sign off catheter care on the CNA documentation. She said she doesn't know if the Resident cleans their catheter tubing. Review of the current care plan for Resident #16's Indwelling Foley catheter indicated but was not limited to the following: Interventions: - 9/30/23: Assess for cloudy foul smelling urine, hematuria, elevated temperature, abdominal or flank discomfort - (Nurse (N) is responsible position) - 7/18/24: change Foley every month and as needed for blockage (no responsible position identified) - 9/30/23: Drain and empty catheter every shift and as needed (N and CNA) - 9/30/23: Foley catheter care every shift and as needed - assess (CNA and N) During an interview on 2/13/25 at 1:13 P.M., Nurse #2 said the CNAs provide catheter care to Resident #16 by emptying the catheter bag and ensuring the drainage bag is properly placed to prevent infection. She said the Licensed Nurses will flush, irrigate or change the catheter when it is due or as needed. She said the Resident is very independent and doesn't require much assistance and can be resistive to assistance, even changing from a standard drainage bag to a leg bag during the day independently. She said she does not believe anyone assists the Resident with cleaning the catheter tubing around the insertion site to prevent infections and said it is possible the Resident completes that themselves but does not know for a fact. On review of the care plan, she said she was not aware the care plan indicated the staff were to provide catheter care every shift and as needed and it does not accurately reflect the Resident since they are independent. During an interview on 2/13/25 at 3:44 P.M., Resident #16 said he/she changes between their catheter drainage bag and leg bag independently and uses alcohol wipes to clean the tip of each device prior to connecting the new one. He/She said on occasion there will be some build up on the catheter tubing near the insertion point and he/she will use those same wipes (alcohol wipes) to clean the tubing all around the insertion site when they notice that. The Resident said after cleaning the tubing with the alcohol wipe it does cause some discomfort at the insertion site but it is brief and he/she knows the tube shouldn't be dirty to prevent infection. The Resident said when he/she lived at home (over a year ago) the home care Nurse did tell him/her how to clean the tubing and keep it that way with soap wipes but he/she does not have those here so when he/she cleans the tubing he/she uses alcohol wipes that he/she stores in their drawer. The Resident said he/she was not aware that alcohol or any harsh chemical like that should not be used to clean the tubing or that doing so could actually contribute to an infection by irritating the urethra, but when he/she thinks of it that makes sense. The Resident said he/she has had a few urinary tract infections (UTIs), including one about a month ago, but assumed with a catheter it was pretty much unavoidable. The Resident said the staff do not assist with catheter care or help keep the tubing clean and he/she did not know that using just soap and water was an option for cleaning the catheter tubing or that it should be done routinely, not just when he/she notices it is visibly soiled. During an interview on 2/18/25 at 12:37 P.M., the Infection Preventionist said catheter care is provided each shift and as needed by the CNAs and includes cleaning the catheter tubing from the insertion site approximately four inches down with warm soapy water to ensure there are no germs on the catheter tubing and to assist in preventing UTIs. She said Resident #16 is very independent with their care and is likely performing their own catheter care. She reviewed the care plan for Resident #16 and said the care plan is not resident-specific and should not indicate the staff are assisting with catheter care, since the Resident is independent with their ADLs. During an interview on 2/18/25 at 2:28 P.M., Unit Manager #2 reviewed Resident #16's care plan and said if the Resident is providing their own catheter care, then the care plan should reflect that they were educated on catheter care and can demonstrate the care appropriately and that the staff are not providing the care. She said the care plan for Resident #16's indwelling urinary catheter was not individualized or resident-specific and required updating to reflect the actual care the Resident was receiving. During an interview on 2/19/25 at 11:36 A.M., the DON said her expectation is that care plans are individualized and reflect the current care and services the residents are receiving. The DON said the Resident should not be using alcohol wipes to perform catheter care and the care plan for indwelling urinary catheter was not person-centered and did not reflect Resident #16 or their urinary catheter care accurately. 34145 3A. Resident #78 was admitted to the facility in July 2024 and had diagnoses including major depressive disorder and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 12/8/24, indicated Resident #78 was cognitively intact as evidenced by a BIMS score of 13 out of 15, and received antianxiety and antidepressant medication daily. Review of the medical record indicated but was not limited to the following Physician's orders: - Fluoxetine HCl (antidepressant) 40 milligrams (mg) one time a day (8/7/24) - Remeron (antidepressant) 7.5 mg one time a day (10/27/24) - Buspirone HCl (antianxiety) 10 mg two times a day (10/27/24) - Trazodone (antidepressant) 50 mg three times a day (10/27/24) Review of November through February 2025 Medication Administration Records (MAR) indicated Fluoxetine, Remeron, Buspirone and Trazodone were administered as ordered by the physician. Review of comprehensive care plans failed to indicate any care plan had been developed for the use of psychotropic medications. B. Resident #43 was admitted to the facility in November 2020 and had diagnoses including major depressive disorder, anxiety and dementia. Review of the MDS assessment, dated 1/20/25, indicated Resident #43 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, and received antidepressant medication daily. Review of the medical record indicated but was not limited to the following Physician's orders: -Lexapro (used to treat anxiety) 20 mg one time a day (5/5/23) -Trazodone 50 mg in the evening (7/12/22) Review of November 2024 through February 2025 MAR indicated Lexapro and Trazodone were administered as ordered by the physician. Review of comprehensive care plans included but was not limited to: - Focus: I use antidepressant medication related to depression, antipsychotic medication (last revised 1/30/25) - Interventions: Administer antidepressant medication as ordered by the physician. Monitor/document side effects and effectiveness every shift (3/23/23); Monitor/document/report as needed (prn) adverse reactions to antidepressant therapy (3/23/23) - Goal: I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (last revised 11/17/24) Review of comprehensive care plans failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antianxiety and antidepressant medications to meet the Resident's needs. C. Resident #14 was admitted to the facility in August 2016 and had diagnoses including bipolar disorder. Review of the MDS assessment, dated 12/26/24, indicated Resident #14 had moderately impaired skills for daily decision making and received antidepressant medication daily. Review of the medical record indicated but was not limited to the following Physician's orders: - Trazodone 100 mg at bedtime (9/25/23) - Trazodone 25 mg two times a day (9/25/23) - Escitalopram (used for anxiety) 5 mg one time a day (4/19/24) - Topamax (used for depression) 25 mg, give 50 mg one time a day (5/28/24) Review of November 2024 through February 2025 MARs indicated Trazodone, Escitalopram, and Topamax were administered as ordered by the physician. Review of comprehensive care plans included but was not limited to: - Focus: Resident is on psychotropic medications related to behavior management, disease process, bipolar, panic attacks, insomnia. - Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness (8/12/16); Educate Resident's family/caregivers about risks, benefits and the side effects and/or toxic symptoms (last revised 2/23/23) - Goal: Resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date (last revised 7/3/24) Review of comprehensive care plans failed to identify specific targeted signs/symptoms, Resident specific interventions, including non-pharmacological approaches, and measurable goals for the use of antianxiety and antidepressant medications to meet the Resident's needs. During an interview on 2/19/25 at 12:33 P.M., Unit Manager #2 reviewed Residents #78, #43 and #14's medical records and said Resident #78 did not have a care plan to address his/her use of psychotropic medication. She said for Residents #43 and #14, the comprehensive care plans for the use of psychotropic medications do not identify what the target behaviors, signs/symptoms are for their use and do not include non-pharmacological interventions, and had no measurable goals of treatment, but should. 42742 4. Resident #50 was admitted to the facility in January 2025 and had diagnoses including nontraumatic intracerebral hemorrhage, end stage renal disease, hypertensive emergency, type 2 diabetes mellitus with diabetic chronic kidney disease, and dependence on renal dialysis. Review of the MDS assessment, dated 1/28/25, indicated Resident #50 was cognitively intact as evidenced by a BIMS score of 13 out of 15 and was receiving dialysis. Review of current Physician's Orders indicated the following: -1500 ml fluid restriction, no water to be left at bedside, 2/5/25 Review of Resident #50's comprehensive care plans indicated a care plan for: -Nutrition, initiated 1/30/25, with interventions including a 1500 milliliter (ml) fluid restriction per MD (physician), initiated 2/6/25. -Hemodialysis related to End Stage Renal Disease (ESRD), initiated 1/25/25, with interventions including 1500 cc fluid restriction, dietary to give 1200 cc ,nursing to give up to 300 cc/24 hour, 7-3 (120 cc), 3-11 (120 cc), 11-7 (60 cc), initiated 2/5/25 Further review of the care plans failed to indicate an intervention to not leave water at the Resident's bedside as indicated by the physician. During an observation with interview of 2/18/25 at 8:21 A.M., the surveyor observed Resident #50 in his/her room eating breakfast. A separate 8-ounce (oz.) (118 ml) plastic cup of water was observed on top of the Resident's overbed tray table with approximately 15 ml remaining. It was unclear how much water the Resident had originally been given. Resident #50 said he/she was on a fluid restriction but sometimes they give him/her too much. Review of the medical record and Intake and Output document failed to indicate documentation of the amount of fluid per 24 hours that was distributed to the Resident between the food and nutrition department and the nursing department to ensure the fluid restriction was being followed per care planned intervention. During an interview on 2/19/25 at 10:25 A.M., the FSD said he wasn't aware the Resident was on a fluid restriction until yesterday. During an interview on 2/19/25 at 12:28 P.M., the surveyor reviewed the medical record with Nurse #3 and Unit Manager (UM) #2 who said a supplemental order was not entered which would have prompted staff to enter fluid amounts and totals. When asked how staff know that they're following a fluid restriction without fluid amounts documented, UM #2 said they can't. During an observation with interview on 2/19/25 at 12:30 P.M., the surveyor observed Resident #50 sitting in his/her room. A large Styrofoam cup, approximately 20 ounces (591 ml) (exceeds care plan intervention for dietary/nursing fluids), was filled with water and left at the bedside on the Resident's overbed tray table. Approximately 1/4 had been consumed at the time of the observation. Resident #50 said staff give him/her too much, but he/she doesn't drink it all. During an interview on 2/19/25 at 12:32 P.M., CNA #5 said she gave the Resident the water but was not aware that he/she was on a fluid restriction until Nurse #3 told her. During an interview on 2/19/25 at 1:35 P.M., the DON said Resident #50 had a current order for a 1500 cc fluid restriction, dietary to give 1200cc, nursing to give up to 300cc/24hr- 7a-3p (120cc), 3p-11p (120cc), and 11p-7a (60cc) with a start date of 2/5/25. She said staff document by checkmark only on the MAR and she didn't think there would be any other I+O sheets for Resident #50, just the one dated 2/12/25 through 2/18/25 since it was just implemented. The DON said because staff just document with a checkmark on the MARs, there's no way to find out what the fluid amounts or totals were. She said Resident #50 was on a fluid restriction due to dialysis and could potentially have an extended dialysis session because of accumulating fluid. The DON further said fluid restrictions should be communicated to dietary staff via a diet request form for each resident and the nurse who takes the order is the one who should complete it. She said if the kitchen is not aware of fluid restriction orders, then they wouldn't know to abide by it when preparing meal trays. She said staff are expected to implement the care planned intervention for a fluid restriction. 5. Resident #72 was admitted to the facility in June 2024 and had diagnoses including cerebral infarction and dysphagia (difficulty swallowing) with a G-tube. Review of the MDS assessment, dated 12/24/24, indicated Resident #72 had severe cognitive impairment as evidenced by a BIMS score of 7 out of 15 and had a feeding tube. On 2/18/25 at 2:13 P.M., the surveyor observed Resident #72's G-tube site with Nurse #4. The tube was capped, indicating it was not in use. Review of Resident #72's care plans failed to indicate a care plan was developed and implemented for the Resident's G-tube that included measurable goals, timeframes, and interventions to meet the Resident's needs. During an interview on 2/18/25 at 2:31 P.M., the surveyor reviewed Resident #72's medical record with Nurse #4 who said there wasn't a care plan for the G-tube but there should have been. Nurse #4 said the Resident had a stroke and had the G-tube put in. During an interview on 2/18/25 at 4:17 P.M., the DON said the Resident had a care plan for the G-tube, but it was canceled on 12/31/24. She said as long as he/she still has the G-tube there should be a care plan in place for it that includes goals of treatment and interventions. During an interview on 2/19/25 at 1:08 P.M., the DON said the Dietitian accidentally cancelled the whole G-tube care plan on 12/31/24 when attempting to cancel one specific intervention. During an interview on 2/19/25 at 1:59 P.M., the Dietitian said she accidentally cancelled the G-tube care plan when she meant to just cancel the tube feeding intervention because the Resident was no longer receiving tube feedings. See F658

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for five Residents (#72, #50, #1, #43, and #78), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #72, to ensure Clonidine (antihypertensive drug) was administered within the parameter as prescribed by the physician to help prevent low blood pressure and heart rate; 2A. For Resident #50, who had end stage renal disease, to ensure the food service department was notified of the Resident's 1500 milliliter (ml) fluid restriction, fluids were not left at the bedside without being calculated into the daily fluid restriction, and fluid restriction for each shift was consistently followed per physician's orders; B. For Resident #1, to ensure that staff consistently implemented the prescribed fluid restriction of 1200 ml a day for the Resident who was on hemodialysis; 3. For Resident #43, to ensure injection sites for subcutaneous (SC-insertion of medications beneath the skin) insulin medication were rotated to prevent potential adverse effects; and 4. For Resident #78, to ensure a right upper extremity (RUE) resting hand roll splint (device designed to help with finger extension, prevent pressure, and reduce finger flexion contractures) was donned/doffed (put on/ taken off) in accordance with physician's orders. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Review of Lippincott Nursing Procedures, Eighth Edition, [Philadelphia: Wolters Kluwer, [2019], indicated but was not limited to the following: Safe Medication Administration Practices, General: -To promote a culture of safety and to prevent medication errors, nurses must avoid distractions and interruptions when preparing and administering medications and adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route. Recent literature identifies nine rights of medication administration, which in addition to the five rights includes the right documentation, the right action (or appropriate reason for prescribing the medication), the right form, and the right response. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #72 was admitted to the facility in June 2024 and had diagnoses including essential hypertension, chronic kidney disease stage 5, and was dependent on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 12/24/24, indicated Resident #72 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Review of current Physician's Orders indicated the following: -Clonidine HCL oral tablet 0.1 milligrams (mg), give 1 tablet by mouth three times a day for HTN (hypertension), for SBP >180 only **For SBP >180 only**, 12/15/24 Review of the January 2025 Medication Administration Record (MAR) indicated Clonidine was administered on the following dates/times with the systolic blood pressure (SBP - top number of your blood pressure, the pressure in your arteries when your heart contracts and ejects blood) readings as follows: January 2025 12:00 P.M.: 1/7/25 - 150 1/15/25 - 138 1/17/25 - 150 1/28/25 - 148 6:00 P.M.: 1/1/25 - 138 1/3/25 - 177 1/4/25 - 173 1/6/25 - 167 1/7/25 - 168 1/11/25 - 153 1/14/25 - 131 1/15/25 - 146 1/22/25 - 156 1/23/25 - 177 1/25/25 - 136 1/27/25 - 153 10:00 PM 1/3/25 - 171 1/4/25 - 141 1/7/25 - 168 1/14/25 - 143 1/19/25 - 164 1/20/25 - 155 1/21/25 - 175 1/22/25 - 156 1/23/25 - 177 1/25/25 - 140 1/27/25 - 153 Further review of the January 2025 MAR indicated Clonidine was administered below the parameter (SBP was < 180) and not >180 per physician's orders for 27 out of 93 total opportunities. Review of the February 2025 MAR indicated Clonidine was administered on the following dates/times with the SBP readings as follows: February 2025 12:00 P.M.: 2/3/25 - 156 2/4/24 - 148 2/11/25 - 176 6:00 P.M.: 2/6/25 - 160 2/9/25 - 136 2/10/25 - 174 2/11/25 - 149 10:00 P.M.: 2/3/25 - 149 2/5/25 - 180 2/10/25 - 164 Further review of the February 2025 MAR indicated Clonidine was administered below the parameter (SBP was < =180 and not >180) per physician's orders for 10 out of 52 total opportunities. During an interview on 2/18/25 at 2:42 P.M., Nurse #4 reviewed Resident #72's medical record and said, that's a problem, the parameters for Clonidine are there for a reason. She said the Resident could bottom out as he/she was also taking valsartan (antihypertensive drug) and amlodipine (calcium channel blocker, treats high blood pressure) and was on dialysis. She said nursing initials and a checkmark on the MAR indicate that the medication was administered on the specific dates/times but should have been held with a code number 5 documented for not being within the parameter of an SBP >180. Nurse #4 said she wasn't sure if nurses are just clicking the medication was administered when it really wasn't, but if it has the initials and a checkmark it means it was given. During an interview on 2/19/25 at 1:16 P.M., the Director of Nurses (DON) reviewed the medical record and said the physician's order is for Clonidine HCl Oral Tablet 0.1 MG, give 1 tablet by mouth three times a day for HTN, for SBP >180 ONLY with an order date of 12/15/24. She said the Resident is on Clonidine for hypertension and also takes Amlodipine, Metoprolol (beta blocker, treats high blood pressure), and Valsartan. The DON said the Resident has a history of hypertension and hypertensive chronic kidney disease, stage 5, and is on dialysis. She said if the medication was not given because it didn't meet the parameter there would be a code 5 for a hold and said if the medication was administered, there would just be the nurse's initials and a checkmark on the MAR. The surveyor reviewed the January and February 2025 MARs with the DON who said Clonidine was documented as being given for all the above dates and times when the SBP was below the parameter and should not have been documented as given. She said there is the danger of hypotension if given below range. The DON said nursing staff are expected to administer medications per physician's orders and if nursing is checking it off as given when it wasn't, that is not good practice, it's a safety issue. She said if it's documented as being given, then it was given. 2. Review of the facility's policy titled Fluid Restriction Policy, revised January 2025, indicated but was not limited to the following: -It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders. -Fluid restrictions are basically the restriction of fluid intake. This may be due to underlying medical conditions that may cause fluid build up such as congestive heart failure or end stage renal disease (ESRD), in addition to electrolyte imbalance disorders such as hyponatremia. Fluid restriction amounts can vary according to the resident's condition and the physician's judgement. -The nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department and will be recorded on the medication record or other format as per facility protocol. -The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. -The food and nutrition department will be notified by facility communication methods of the fluid restriction. -Water will not be provided at the bedside unless calculated into the daily total fluid restriction. -The resident has the right to refuse the fluid restriction, and if refused, documentation should support the reason for the refusal, the education of the risks and benefits, and any supporting documentation of the resident's continued refusal, assessment for any changes in condition related to the refusal, and the notification of the physician about the resident's refusal. Review of the facility's policy titled Intake, Measuring and Recording, dated as revised October 2010, indicated but was not limited to the following: - The purpose of the procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period - verify the physician order is in place; review the resident's care plan - record fluid intake as soon as possible after the resident has consumed the fluids - at the end of your shift total the amounts of all liquids consumed by the resident and record on the intake side of the intake and output record in milliliters (ml) A. Resident #50 was admitted to the facility in January 2025 and had diagnoses including non-traumatic intracerebral hemorrhage, ESRD, hypertensive emergency, type 2 diabetes mellitus with diabetic chronic kidney disease, and dependence on renal dialysis. Review of the MDS assessment, dated 1/28/25, indicated Resident #50 was cognitively intact as evidenced by a BIMS score of 13 out of 15 and was receiving dialysis. Review of current Physician's Orders indicated the following: -1500 ml fluid restriction, dietary to give 1200 cc (also called ml), nursing to give up to 300 cc/24 hour - 7-3 (120 cc), 3-11 (120 cc), 11-7 (60 cc) every shift. Fluids to be given with medications, no water to be left at bedside, 2/5/25 During an observation with interview on 2/18/25 at 8:21 A.M., the surveyor observed Resident #50 sitting in his/her room eating breakfast. Fluids provided on the breakfast tray consisted of a small bowl of corn flakes cereal with milk (90% consumed), one hard plastic cup of milk (75% consumed), and one 4-ounce (oz.) (118 ml) container of apple juice (75% consumed). One separate small thin plastic cup of water was observed on top of the overbed tray table with approximately 15 ml remaining. Resident #50 said he/she was on a fluid restriction but sometimes they give him/her too much. On 2/18/25 at 11:55 A.M., the surveyor observed Resident #50 sitting in his/her room eating lunch. Fluids provided on the tray included one 4 oz. (118 ml) container of apple juice and a cup of coffee that were being consumed. Review of the February 2025 MAR indicated documentation of the 1500 cc fluid restriction consisted of a checkmark and nursing initials for the day, evening, and night shifts. The MAR did not indicate amounts of fluid intake for each shift. On 2/19/25 at 9:37 A.M., the surveyor reviewed Resident #50's Intake and Output (I+O) document located in the I+O binder at the [NAME] Unit nurses' station. The document was dated 2/12/25 through 2/18/25 and indicated the following: -only one documented entry of fluid intake out of 21 opportunities from all three shifts (11:00 A.M.-7:00 P.M., 7:00 A.M.-3:00 P.M., and 3:00 P.M.-11:00 P.M.) Further review of the medical record and I+O document failed to indicate documentation of the amount of fluid per 24 hours that was distributed to the Resident between the Food and Nutrition Department and the Nursing Department. During an interview on 2/19/25 at 9:25 A.M., Nurse #8 said Certified Nursing Assistants (CNAs) document I+O in the electronic record only. During an interview on 2/19/25 at 9:33 A.M., Nurse #3 said the facility had just started using the I+O documents in the I+O binder which are specific to each resident who is on a fluid restriction. The surveyor reviewed the I+O binder with Nurse #3 who said it's a new thing and said Resident #50's I+O sheet was dated 2/12/25 through 2/18/25 but it didn't look like it was being documented on. She said this was the only place she knew of where fluid intake was being documented for the Resident. She said if it's not documented anywhere then she wouldn't know what the fluid intake totals were. Nurse #3 said the Resident was on a fluid restriction due to dialysis. During an interview on 2/19/25 at 9:40 A.M., CNA #5 said the I+O sheets are new, but CNAs don't document on them, they just tell the nurse how much fluid intake there was after each meal, and the nurses document it in the record. She said there is nowhere in the record where CNAs document fluid intake and output. During an interview on 2/19/25 at 9:44 A.M., Nurse #3 said nurses used to document fluid totals on the MAR per verbal communication by the CNAs, but they stopped doing that recently and now are expected to document on the I+O sheets as of 2/12/25. She said she worked the 7:00 A.M.-3:00 P.M. shift on 2/14/25 and 2/17/25, but didn't document fluid intake on the sheet as required. She said a new I+O sheet had not been started yet for today for Resident #50. During an interview on 2/19/25 at 10:25 A.M., the Food Service Director (FSD) said the Resident's fluid restriction was ordered on 2/5/25 but he didn't know about it; no one told him until yesterday. He said he had printed out a list of all residents yesterday but there weren't any residents that were on a fluid restriction. The FSD said the Resident's meal trays should have reflected the fluid restriction order, but he didn't know about it. He said a coffee mug is 160 ml, a hard plastic cup of milk or apple juice is 240 ml and believes the small thin plastic cups are 8 ounces (118 ml). During an interview on 2/19/25 at 12:28 P.M., the surveyor reviewed the medical record with Nurse #3 and Unit Manager (UM) #2 who said a checkmark and nurses initials on the MAR just means that the nurse is following the fluid restriction, but a supplemental order was not entered which would have prompted staff to enter fluid amounts and totals. When asked how staff know that they're following a fluid restriction without fluid amounts documented, UM #2 said they can't. During an observation with interview on 2/19/25 at 12:30 P.M., the surveyor observed Resident #50 sitting on a chair in his/her room. A large Styrofoam cup, approximately 20 ounces (591 ml), was filled with water and left at the bedside on the Resident's overbed tray table. Approximately 1/4 had been consumed. Resident #50 said staff give him/her too much, but he/she doesn't drink it all. During an interview on 2/19/25 at 12:32 P.M., CNA #5 said she gave the Resident the water but was not aware that he/she was on a fluid restriction until Nurse #3 told her. During an interview on 2/19/25 at 1:35 P.M., the DON said Resident #50 had a current order for a 1500 cc fluid restriction, dietary to give 1200 cc, nursing to give up to 300 cc/24 hr- 7a-3p (120 cc), 3p-11p (120 cc), and 11p-7a (60 cc) with a start date of 2/5/25. She said staff document by checkmark only on the MAR and the I+O sheets were just implemented last week so she didn't think there would be any other I+O sheets for Resident #50, just the one dated 2/12/25 through 2/18/25. The DON said because staff just document with a checkmark on the MARs, there's no way to find out what the fluid amounts or totals were. She said staff are now expected to complete the I+O sheets for each shift daily. Said she Resident #50 was on a fluid restriction due to dialysis and could potentially have an extended dialysis session because of accumulating fluid. The DON further said fluid restrictions should be communicated to dietary staff via a diet request form for each resident and the nurse who takes the order is the one who should complete it. She said if the kitchen is not aware of fluid restriction orders, then they wouldn't know to abide by it when preparing meal trays. During an interview on 2/19/25 at 1:54 P.M., the Dietitian said she was aware the Resident was on a fluid restriction and said the Resident is on dialysis. She said although she wouldn't necessarily look at I+O totals, she would need to know if the Resident was being provided with large amounts of water due to a concern of increased fluid volume and weight gain. 43935 B. Review of the [NAME] Concise Medical Dictionary, 8th Edition, 2010: one cubic centimeter (cc) is equal to one milliliter (ml) and one ounce is equal to 30ml Resident #1 was admitted to the facility in October 2024 with diagnoses including chronic kidney disease stage 5 and ESRD. Review of the BIMS, dated 2/9/25, indicated the Resident was cognitively intact with a score of 15 out of 15. During an interview on 2/13/25 at 8:29 A.M., the surveyor observed Resident #1 consuming their breakfast. There was a 160ml cup of coffee, a 5 ounce (oz.)(150ml) plastic cup with water, an empty (used) plastic juice cup that the Resident said contained apple juice and a large 16 oz. (480 ml) styrofoam cup of a light orange-brown liquid in it that was 3/4 of the way empty and smelled like tea. The Resident said he/she does not have any food or fluid concerns and does not have any fluid restrictions that he/she recalls and can drink whatever he/she wants. The Resident said after breakfast he/she usually heads downstairs for a cigarette and then gets a snack or drink on the way up and requests it from the staff who provides him/her with anything he/she asks for. Review of the current Physician's Orders from 2/13/25 for Resident #1 indicated but were not limited to the following: - Diet: Regular textures, thin liquids, comment: Renal (10/31/24) - 1200cc fluid restriction- Dietary to give 900cc; nursing to give up to 300cc in 24 hours. 7:00 A.M. - 3:00 P.M. shift 120cc; 3:00 P.M. - 11:00 P.M., shift 120cc; 11:00 P.M., to 7:00 A.M., shift 60cc. every shift fluids to be given with medications, no water to be left at bedside (2/5/25) - Resident to have dialysis on days: Monday, Wednesday, Friday. (11/27/24) During an interview on 2/13/25 at 1:11 P.M., Nurse #2 said Resident #1 is on a prescribed fluid restriction, but is not very compliant with it and that she often finds the Resident with extra drinks. She said she doesn't think the Resident understands the fluid restriction and even though they try to limit the Resident it is hard to do. She said she previously wrote a note on the Resident not being compliant with the restriction and provided education to the Resident at that time. Review of Resident #1's current care plans on 2/13/25 with focus areas of: Acute on chronic stage 5 renal failure and nutritional problems failed to indicate the Resident was non-compliant with their prescribed fluid restriction. During the survey, the surveyor made the following observations: 2/13/25 at 8:29 A.M., the Resident had 1,030ml of fluid available at the bedside including their medication water and dietary beverages 2/13/25 at 2:19 P.M., a 5oz. cup of water was at the bedside with approximately 1-2 sips remaining in it 2/13/25 at 3:38 P.M., a 480ml cup of ginger ale and ice was at the bedside with only approximately a 1/2 inch of fluid remaining in the bottom 2/18/25 at 8:08 A.M., 160ml of coffee and 240ml of apple juice 2/18/25 at 9:22 A.M., Resident walking to his/her room drinking a 480ml full cup of ginger ale 2/18/25 at 1:42 P.M., a 480ml cup that has a few drops of fluid in the bottom and a 480ml cup filled with ginger ale and ice Review of the I+O sheets for Resident #1 from 2/5/25 through 2/18/25 indicated but were not limited to the following intakes: 2/5: 3:00 - 11:00 P.M. (evening) shift - 300cc, all other shifts and total were blank 2/7 and 2/8: 360cc on both the day and evening shift - no documentation on the night shift or total (with documentation total would have been 720cc) 2/9: 320cc on evening shift, all other shifts and total were blank 2/11: 360cc on the evening shift, all other shifts and total were blank 2/12: all shifts and total were blank 2/13 and 2/14: 120cc on the night shift, all other shifts and total were blank 2/15: 120cc plus unknown, all other shifts and total were blank The I+O sheets did not have any documentation available on 2/6, 2/10, 2/16, 2/17 or 2/18/25 and were incomplete for all other days since the fluid restriction was started on 2/5/25 During an interview on 2/18/25 at 8:17 A.M., Nurse #5 said Resident #1 had an ordered fluid restriction of 1200ml a day and nursing was only allowed to provide 120ml on the day and evening shift with meds and 60ml on the night shift, she said the order also indicated no additional fluids should be left at the bedside. She said the Resident should not be having additional drinks throughout the day and the staff should not be providing them. She said the unit kitchenette is locked and not accessible to the residents without staff assistance. She said the fluid restriction was not part of a diet order and is signed off by a check mark indicating the Nurse only provided 120ml of water and did not observe or leave any fluids at the bedside. On review of the I+O sheets she said they were incomplete and did not indicate Resident #1 was on a fluid restriction. During an interview on 2/18/25 at 8:21 A.M., CNA #3 said the CNAs are supposed to complete I+O sheets and the Nurses total them daily. She said the I+O sheets for this Resident are incomplete and don't provide any information on a fluid restriction. During an interview on 2/18/25 at 9:22 A.M., the surveyor observed Resident #1 walking towards his/her room drinking from a 16-oz. cup. The Resident said he/she requested a drink while downstairs and was given the large cup of ginger ale. The Resident said he/she does recall being told something about a fluid restriction in the past but doesn't think it's a problem anymore since the staff always give him/her the drinks when he/she asks for them. During an interview on 2/18/25 at 2:03 P.M., Unit Manager #2 reviewed Resident #1's I+O sheets, MAR, orders and nursing notes and said the facility is not documenting or following the Resident's prescribed fluid restriction as they should be. She said there is no evidence that the unit had ever provided the dietary department with a communication notifying them of the fluid restriction and it was not part of the Resident's diet order and was put in as a regular order. She said the MAR sign off by the Nurses should indicate a total that was provided by nursing each shift for clarity since the I+O sheets are incomplete and the sign off that the Resident is on a restriction is not enough to prove the restriction is being followed. She said there is no place she could locate the total amount of fluids the Resident was consuming by nursing each day and it did not appear the facility was tracking or monitoring the Resident's intake to ensure he/she did not exceed the 1200ml restriction as ordered. She was made aware of the surveyor's observations of Resident #1 with 16 oz. cups of fluid and said the staff were clearly not following the fluid restriction as ordered. She said the process for monitoring and documenting a fluid restriction and fluid intake seemed to be problematic and required more attention. During an interview on 2/19/25 at 10:42 A.M., the DON said Resident #1 has a prescribed fluid restriction of 1200ml a day that was ordered by the physician on 2/5/25. She said the expectation is that physician's orders are followed as written. On review of the documentation and observations the surveyor had made she said the fluid restriction order appears to not be being followed as it should be. She said fluid restrictions and the manner in which they are documented and monitored is a work in progress and the facility needs to work on a better process to implement and document them. 34145 3. According to the National Institute of Health, July 2019 and February 2022, it is crucial to rotate injection sites when administering medications to prevent the development of lumps or hardened tissue under the skin, known as lipohypertrophy, which can interfere with proper medication absorption; this means moving the injection site to a different area of the body with each injection, such as between the abdomen, thigh, and upper arm, while ensuring to space injections at least one finger width apart within each area. These cutaneous complications could be one of the causes of unexplained blood glucose fluctuation as insulin absorption is impaired under these pathological conditions. Review of the facility's policy, Administering Medications, undated, included but was not limited to: -As required or indicated for a medication, the individual administering the medication records in the resident's medical record: The injection site (if applicable). Resident #43 was admitted to the facility in November 2020 and had diagnoses including diabetes mellitus, type 2 (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). Review of the MDS assessment, dated 1/20/25, indicated Resident #43 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, and received insulin injections daily. Review of the medical record indicated but was limited to the following physician's orders: -Novolog Solution (insulin) inject as per sliding scale: If 200 - 249=4 units 250 - 299= 6 units 300 - 349=8 units 350 - 400=10 units 401 - 450=12 units 451 - 500=14 units call MD for Capillary Blood Glucose (CBG) >500, SC with meals (2/19/23) -Novolog Solution 100 unit/ml, inject 16 units SC two times a day with breakfast and dinner; hold <50% meal (9/25/23) -Novolog Solution 100 unit/ml, inject 8 units SC one time a day with lunch (9/25/23) Review of December 2024 through February 2025 Medication/Treatment Administration Records (MAR/TAR) indicated but was not limited to: December 2024 -Novolog Solution 100 unit/ml, inject 8 units SC one time a day with lunch was administered as ordered by the physician; no injection sites were recorded. -Novolog Solution 100 unit/ml, inject 16 units SC twice a day with breakfast and dinner; hold for <50% meal was administered as ordered by the physician; no injection sites were recorded. -Novolog Solution (insulin) inject as per sliding scale with meals was administered on 29 occasions; no injection sites were recorded. January 2025 -Novolog Solution 100 unit/ml, inject 8 units SC one time a day with lunch was administered as ordered by the physician; no injection sites were recorded. -Novolog Solution 100 unit/ml, inject 16 units SC twice a day with breakfast and dinner; hold for <50% meal was administered as ordered by the physician; no injection sites were recorded. -Novolog Solution (insulin), inject as per sliding scale with meals was administered on 37 occasions; no injection sites were recorded. February 2025 -Novolog Solution 100 unit/ml, inject 8 units SC one time a day with lunch was administered as ordered by the physician; no injection sites were recorded. -Novolog Solution 100 unit/ml, inject 16 units SC twice a day with breakfast and dinner; hold for <50% meal was administered as ordered by the physician; no injection sites were recorded. -Novolog Solution (insulin) inject as per sliding scale with meals was administered on 15 occasions; no injection sites were recorded. Further review of the medical record failed to indicate staff identified and documented injections sites for the subcutaneous injection of Novolog insulin to prevent potential complications which can interfere with proper medication absorption. During an interview on 2/13/25 at 1:15 P.M., Nurse Practitioner #1 said insulin administration and rotation of injection sites should be rotated according to professional standards of practice. During an interview with Physician #1 and the DON on 2/14/25 at 7:42 A.M., Physician #1 said nurses should be administering insulin according to standards of practice which include rotation of injection sites. The DON agreed that insulin injection sites should be rotated. The DON reviewed Resident #43's medical record and confirmed that injection sites for Novolin were not documented, and they should be to ensure injection sites are rotated to prevent complications. 4. Resident #78 was admitted to the facility in July 2024 and had diagnoses including hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness or loss of muscle function) following a stroke affecting the right dominant side. Review of the MDS assessment, dated 12/8/24, indicated Resident #78 was cognitively intact BIMS score of 13 out of 15, had right upper extremity range of motion (ROM) impairment and required maximum assistance for activities of daily living. Review of Physician's Orders indicated but was not limited to the following: -Please don patient's RUE resting hand roll splint with A.M. care. Patient to wear as tolerated throughout the day. Doff with P.M. care. Provide skin checks prior to donning and after doffing. Adjust as needed throughout the day, every day and evening shift (1/23/25) Review of a white, 3-ringed binder labeled [NAME] Splint Binder on a shelf at the nursing station indicated that it contained instructions for splints for three residents on the unit including Resident #78's RUE resting hand splint as follows: -Please don patient's right hand roll splint with morning care -Patient to wear as tolerated throughout the day. -Re-adjust splint as needed throughout the day. -Provide skin checks every 2 hours. -Doff splint with evening care. The surveyor observed Resident #78 with no RUE resting hand roll splint in his/her hand as follows: - On 2/12/25 at 9:11 A.M. - On 2/12/25 at 10:40 A.M. - On 2/12/25 at 1:08 P.M. During an interview on 2/12/25 at 1:08 P.M., the surveyor observed Resident #78 reclining in bed awake with his/her hands folded across his/her chest with no RUE resting hand roll splint in place. The hand splint was noted on a chair in the Resident's room underneath two wheelchair foot pedal assemblies. The Resident said he/she cannot remember the last time staff put the splint on his/her hand. The surveyor observed Resident #78 with no RUE resting hand roll splint in his/her hand as follows: - On 2/13/25 at 11:49 AM - On 2/13/25 at 12:55 P.M. - On 2/13/25 at 2:01 P.M. - On 2/14/25 at 11:40 A.M. Review of Resident #78's TAR for January and February 2025 indicated Resident #78's RUE resting hand roll splint was donned and doffed with A.M./P.M. care since 1/23/25 twice daily. Review of Resident #78's medical record failed to indicate refusal to wear the RUE resting hand roll splint and/or inability to tolerate wearing the RUE splint. The medical record also failed to indicate any attempts by the Resident to self-remove the RUE splint. During an interview with Unit Manager #2 and Resident #78 on 2/14/25 at 12:25 P.M., Unit Manager #2 said she donned the RUE resting hand roll splint to Resident #78's hand this morning documented it on the TAR. The surveyor and Unit Manager #2 entered Resident #78's room and noted the RUE splint on the Resident's bedside [TRUNCATED]

Based on record review and interview, the facility failed to ensure the Physician signed and dated all orders for one Resident (#14), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Medication Orders, undated, indicated but was not limited to: -Supervision by a Physician: -Physician orders/Progress notes must be signed and dated every thirty (30) days. (Note: this may be changed to every sixty (60) days after the first ninety (90) days of the resident's admission) Resident #14 was admitted to the facility in August 2016 and has diagnoses including diabetes mellitus, chronic kidney disease, major depression with severe psychotic symptoms, and bipolar disorder. Review of the medical record, Electronic Medical Record (EMR), and the Order Review History report, indicated the Resident's Physician last signed the Resident's orders on 11/8/24. There were no additional orders signed by the Physician. During an interview on 2/19/25 at 1:59 P.M., the Director of Nursing (DON) reviewed Resident #14's medical record and said the last signed physician's orders in the medical record were for November 2024. She said physician's orders are to be signed every 30 or 60 days.

Based on document review and interview, the facility failed to ensure residents were provided Physician/Nurse Practitioner (NP) visits every 30 days within the first 90 days of admission and then every 60 days thereafter for three Residents (#1, #43, and #14), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #1, to ensure the Resident was seen at least every 30 days for the first 90 days of his/her admission to the facility; 2. For Resident #43, to have visits completed by the Physician or NP every 60 days; and 3. For Resident #14, to ensure the Resident was provided oversight of their care and visits by a clinician. Findings include: Review of the facility's policy titled Physician Visits and Physician Delegation Policy, dated as revised January 2025, indicated but was not limited to the following: - It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents - the physician should see the residents within 30 days of admission, and the resident must be seen at least once every 30 calendar days for the first 90 days by the physician or physician's delegate - after the first 90 days the resident must be seen at least every 60 calendar days by the physician or physician delegate - the physician should date, write and sign a progress note for each visit and review the resident's total program of care 1. Resident #1 was admitted to the facility in October 2024 with diagnoses including chronic kidney disease stage 5, end stage renal disease, Bipolar disorder, and generalized anxiety. During an interview on 2/13/25 at 1:10 P.M., Nurse #3 said all Physician and NP progress notes are scanned into the electronic medical record under the tab labeled Miscellaneous. Review of the Miscellaneous section of Resident #1's medical record on 2/13/25 indicated only one progress note was available since the Resident's admission, completed by NP #2 and dated 11/27/24. Review of the census section of Resident #1's medical record indicated that he/she had a paid hospital leave since their admission in October 2024 but has remained an active Resident since that admission. During an interview on 2/18/25 at 10:32 A.M., the Medical Records Clerk said the Physician's and NP's send their progress notes to the facility receptionist by email and then the receptionist places them in the correct resident records. She said although she is responsible for medical records she does not receive any physician or clinician progress notes and to check for potentially missing notes with the receptionist. During an interview on 2/18/25 at 12:54 P.M., the Receptionist said all the Physician and NP progress notes are sent to her by email and she then scans them into the correct resident record under the miscellaneous section immediately. She said on review that she did not have any other notes in her email for Resident #1 at this time and everything she had was in the Resident's medical record. During an interview on 2/18/25 at 5:12 P.M., NP #2 reviewed the medical record for Resident #1 and said she is surprised that her note from 11/27/24 is the only progress note in the medical record and wonders if anyone at the facility has records they may not have uploaded yet, since this couldn't be possible. She was informed the person who receives the emails confirmed they did not have any additional documents for Resident #1's record and she said she would speak with the team. Review of the medical record on 2/19/25 indicated additional Physician and NP notes were placed in Resident #1's medical record and the Resident had visits on the following dates: 11/4/24, 11/7/24, 11/18/24, 11/27/24 No visits were documented in the month of December 2024 1/27/25 (61 days after the last visit in November 2024) 2/17/25 The physician/NP visits indicated a gap of 61 days in visits from 11/27/24 through 1/27/25 During an interview on 2/19/25 at 10:12 A.M., the Director of Nurses (DON) said the Resident should have been seen at least once every 30 days in his/her first 90 days since admission and it appears that did not occur and the regulatory requirements were not met. 34145 2. Resident #43 was admitted to the facility in November 2020. During an interview on 2/13/25 at 1:10 P.M., Nurse #3 said all Physician and NP progress notes are scanned into the electronic medical record under the tab labeled Miscellaneous. Review of the Physician's Progress Notes indicated Resident #43 was seen by the Physician on 12/17/23. The next visit from the MD occurred on 12/23/24, 372 days since the previous MD visit. Resident #43 was only seen by the NP between 12/27/23 and 12/23/24. During an interview with the DON and Physician #1 on 2/14/25 at 7:34 A.M., the DON and Physician reviewed Resident #43's medical record with the surveyor. The DON said all Physician progress notes are scanned and filed in the Miscellaneous tab in the electronic medical record. The DON pulled up Resident #43's medical record on her computer and reviewed Physician progress notes. She was unable to find any other Physician progress notes between the dates of 12/17/23 and 12/23/24. The DON said she contacted Resident #43's Physician's office last evening to request all progress notes be sent to the facility right away. She said she received a fax with two additional Physician progress notes dated 12/26/24 and 1/20/25. Physician #1 said he is aware that residents needed to be seen at least every 60 days and can alternate with the NP. During an interview on 2/19/25 at 1:59 P.M., the DON said she had not received any additional Physician progress notes from Physician #1. 3. Resident #14 was admitted to the facility in August 2016. Review of the medical record indicated Resident #14 was last seen by the Physician on 11/1/24. Further review of the medical record failed to indicate Resident #43 had been seen by either the Physician or NP since 11/1/24, a lapse of 110 days. During an interview on 2/19/25 at 1:59 P.M., the DON reviewed Resident #14's medical record and said there were no Physician visit notes to indicate Resident #14 had been seen by the Physician since 11/1/24. No further documentation was provided to the survey team by the time of the exit conference.

Based on record review and interview, the facility's Consultant Pharmacist failed to identify irregularities in medications during the monthly Medication Regimen Review (MRR) for two Residents (#30 and #1), out of a total sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #30, the Pharmacist reviewed and reported irregularities related to the administration of a pain medication; and 2. For Resident #1, the Pharmacy consultant identified a lack of rationale documentation for the ongoing use of an as needed (PRN) psychotropic benzodiazepine/anti-anxiety medication. Findings include: Review of the facility's policy titled Consultant Pharmacist Services Provider Requirements, effective date January 2024, indicated but was not limited to: - The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff, the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This includes, but is not limited to: - Assisting in the identification and evaluation of medication related issues including the prevention, and reporting of medication errors and the provision and monitoring the use of medication related devices. - Identifying one or more current medication references to facilitate the identification of medications and information on contraindications, side effects and or adverse effects dosage levels and other pertinent information. - Providing oversight and instruction on regulatory compliance issues. - Specific activities that the consultant pharmacist performs includes, but is not limited to: - Reviewing the medication regimen (medication regimen review) of each resident at least monthly, and or more frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards was outlined in the procedure for medication regimen review, and documenting the review and findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation. - Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy as well as regulatory compliance issues at least monthly. - Reviewing medication administration records (MARs), treatment administration records (TARs) and physician orders at least monthly to ensure proper documentation of medication orders and administration of medications to residents. 1. Resident #30 was admitted to the facility in January 2025 with diagnoses including chronic pain syndrome (a condition characterized by persistent pain that lasts for at least 3-6 months and significantly impacts a person's life) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness). Review of Resident #30's current Physician's Orders indicated but was not limited to: - Ultram (opioid used to relieve moderate to moderately severe pain) 50 milligram (mg) tab, give 1 tablet by mouth every 8 hours as needed for severe pain (7-10), dated 1/22/2025 - Tylenol 650 mg, by mouth every 6 hours as needed for pain, dated 1/27/25 Review of the January 2025 MAR for Resident #30 indicated Ultram had been administered five times. Further review of Resident #30's January MAR indicated Ultram was administered two times for pain below parameters: - 1/24/25, pain level 4 - 1/30/25, pain level 5 Review of the February 2025 MAR for Resident #30 indicated Ultram had been administered 10 times. Further review of Resident #30's February MAR indicated Ultram was administered five times for pain below parameters: - 2/1/25, pain level 2 - 2/6/25, pain level 6 - 2/7/25, pain level 5 - 2/13/25, pain level 3 - 2/15/25, pain level 3 Review of Resident #30's MRR, dated 2/5/25, indicated but was not limited to: - Ultram utilized - No new recommendation During a telephonic interview on 2/19/25 at 9:45 A.M., Consultant Pharmacist #1 said he electronically reviewed each residents' medication orders monthly. Consultant Pharmacist #1 said he would review residents' orders for things such as the indication for use, appropriate dose, and utilized per physician orders. Pharmacist #1 said he would review residents' MARs and TARs monthly as part of the MRR. Consultant Pharmacist #1 said he reviewed Resident #30's MAR during the MRR, on 2/5/25, but had not made reference to Ultram administration below the prescribed pain level but should have. During an interview on 2/19/25 at 12:35 P.M., the Director of Nursing (DON) said Resident #30 was administered Ultram outside of the Physician prescribed pain level parameters and should not have been. The DON said the expectation was for the Consultant Pharmacist to double check the MAR for medication administration as ordered and should communicate discrepancies to the facility but he had not. 43935 2. Resident #1 was admitted to the facility in October 2024 with diagnoses including chronic kidney disease stage 5, End Stage Renal Disease, bipolar disorder, and generalized anxiety. Review of the last completed Minimum Data Set (MDS) assessment, dated 11/18/24, indicated the Resident did not suffer from any behaviors (Section E). Review of the current Physician's Orders, as of 2/13/25, for Resident #1 indicated but were not limited to the following: Alprazolam (Xanax) (an anti-anxiety/benzodiazepine psychotropic medication) 0.5 mg by mouth every 12 hours as needed (PRN) for anxiety until 2/26/25 (12/26/24) Review of the history of Xanax orders for Resident #1 from November 2024 to February 2025 indicated the following: November 2024: Ordered: 11/1/24 Xanax 0.5 mg one tab by mouth every 12 hours PRN for anxiety (no stop date) - discontinued 11/2/24 Ordered: 11/2/24 Xanax 0.5 mg one tab by mouth every 12 hours PRN for anxiety for 13 days - held from 11/9-11/13 for medical leave - then discontinued 11/15/24 Ordered: 11/15/24 Xanax 0.5 mg one tab by mouth every 12 hours PRN for anxiety (no stop date) - discontinued 11/20/24 Ordered: 11/20/24 Xanax 0.5 mg one tab by mouth every 12 hours PRN for anxiety for 10 days - discontinued 11/27/24 Ordered: 11/27/24 Xanax 0.5 mg one tab by mouth every 12 hours PRN for anxiety until 12/26/24 - discontinued 12/26/24 Ordered: 12/26/24 Xanax 0.5 mg one tab by mouth every 12 hours PRN for anxiety until 2/26/25 Review of Attending Physician and Nurse Practitioner (NP) progress notes from 11/4/24 through 2/17/25 indicated the following: 11/4/24: New Admit: Alert and oriented, forgetful; psych stable, alert oriented and cooperative with exam. There was no documentation regarding Resident #1's anxiety or need for PRN Xanax. 11/7/24: Follow up- short term rehab (STR): Pleasant, in no acute distress. There was no documentation regarding Resident #1's anxiety or need for PRN Xanax 11/7/24: Hospital follow up note: Xanax 0.5mg twice a day as needed: temporary supply until seen by NP; pleasant in no acute distress 11/18/24: Re-admission History and Physical: In no acute distress, mildly confused. There was no documentation regarding Resident #1's anxiety or need for PRN Xanax. 11/27/24: STR follow-up: Anxiety, increase restlessness at dialysis, they are requesting they receive a dose of Xanax prior to coming to dialysis. Refill Xanax 0.5 mg twice a day PRN for 30 days for treatment of anxiety. 1/27/25: 30 day evaluation #2: There was no documentation regarding Resident #1's anxiety or need for PRN Xanax; an Addendum on 2/18/25 for this note indicated the resident needs a benzodiazepine (Xanax), the benefits are more than the risk. 2/17/25: Follow-up: Alert, pleasant, smiling, good eye contact, good speech. Bipolar affect disorder notes: continue Xanax. Review of the Psychiatric progress notes for Resident #1 from 11/19/24 through 1/22/25 indicated the Resident took Xanax on a PRN basis for anxiety but failed to indicate a risk versus benefit rationale or any indication if the medication was still necessary or effective for the Resident. Review of the Consultant Pharmacist monthly MRR for Resident #1 from November 2024 to February 2025 indicated but were not limited to the following: 11/5/24: 11/2/24 re-authorized Xanax 0.5 mg every 12 hours PRN x 14 days; Nursing recommendation for rinse of mouth 12/3/24: 11/27/24 re-authorized Xanax 0.5 mg every 12 hours PRN x 30 days, 11/2 Xanax 0.5 mg every 12 hours PRN x 14 days; No new recommendations today 1/6/25: 12/26/24 re-authorized Xanax 0.5 mg every 12 hours PRN x 60 days, 11/27/24 re-authorized Xanax 0.5 mg every 12 hours PRN x 30 days, 11/2 Xanax 0.5 mg every 12 hours PRN x 14 days; MD recommendation today to review continued need for Heparin 2/5/25: 12/26/24 re-authorized Xanax 0.5 mg every 12 hours PRN x 60 days, 11/27/24 re-authorized Xanax 0.5 mg every 12 hours PRN x 30 days, 11/2 Xanax 0.5 mg every 12 hours PRN x 14 days; No new recommendations today The Pharmacy consultant failed to identify that there was no documented rationale for the extension of the PRN Xanax. During an interview on 2/19/25 at 9:23 A.M., the Pharmacy consultant said he completes MRRs monthly and the psychiatric and psychotropic medication review and profile is looked at holistically with a goal of getting rid of medications for the residents that may not be necessary or have had a change in their needs. He reviewed the PRN Xanax use specifically for Resident #1. He said he does not always look for the rationale documentation for a PRN psychotropic medication extension and would only look if he thought the usage seemed excessive or very minimal for a period of three months or more. He said he assumes the Physicians and Nurse practitioners (NP) know that documenting a clinical rationale for the ongoing use of a PRN psychotropic medication is required and he just ensures a stop date is in place on those PRN orders. He said he does not have time to review and check that the prescriber is completing an extension of a psychotropic PRN medication in line with the regulation and he has not documented any recommendations for this to be done for Resident #1. He said it is the Physician or NP's responsibility to provide all the necessary supporting documentation for extending PRN psychotropics to be in line with the regulatory requirements and he does not review that or any documentation potentially supporting the ongoing need for the medication by the licensed nurses. During an interview on 2/19/25 at 10:27 A.M., the DON reviewed the medical record for Resident #1 and said the Physician or NP is supposed to document a thorough clinical rationale for the extended and ongoing use of a PRN psychotropic medication, such as Xanax, each time the order is extended and it does not appear that has occurred. She said she would expect the Pharmacy consultant to pick up on the lack of documented rationale and leave a recommendation to address it, but on review that did not occur. She said she was not aware the Pharmacy consultant had any time constraints and was not ensuring all the regulatory pieces of documentation were in place to ensure any PRN psychotropics were being extended within the guidance. She thinks of the Pharmacy consultant as a second set of eyes for the facility to ensure all pieces are in place and cannot explain how this issue was missed. She said this issue should have been identified by the Pharmacy consultant and placed on a recommendation but was not.

Based on observation, interview, and document review, the facility failed to follow professional standards of practice for food safety to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Properly label and date food products stored in the free-standing refrigerators in the main kitchen and discard food when past their use by date; 2. Ensure food was properly stored in the walk-in freezer in the main kitchen; and 3. Ensure food was discarded when past their manufacturer's expiration date in one of two resident nourishment kitchen refrigerators reviewed. Findings include: Review of a facility document titled Labeling and Dating Inservice, undated, indicated but was not limited to the following: Guidelines for Labeling and Dating: -All foods should be dated upon receipt before being stored. Food labels must include: -The food item name -The date of preparation/receipt/removal from freezer -The use by date as outlined in the attached guidelines -Leftovers must be labeled and dated with the date they are prepared and the use by date Use By Dating Guidelines: -All Ready-to-Eat, Time/Temperature Control for Safety (TCS) foods that are to be held for more than 24 hours at a temperature of 40 degrees or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7) Review of a facility document affixed to the front of the refrigerator in the main kitchen indicated the following: Put a Label on the Tray With the Name of the Product/Day Produced/Use by Date: -Prepped trays of poured juice and milks, Example: Lunch drinks [DATE], UB (Use By) [DATE] -Prepped trays of desserts, Example: Fruit cocktail [DATE], UB [DATE] 1a. On [DATE] at 7:40 A.M., the surveyor reviewed the free-standing double door refrigerator in the main kitchen and observed the following inside: Left door, top shelf: -one tray of poured beverages including orange juice (OJ) (7) and milk (1) in plastic cups with lids, and two 4-ounce (oz.) vanilla shake cartons, tray not labeled with name of product, day prepared, or use by date Left door, second shelf: -one tray of poured juices (25) and milk (3) in plastic cups with lids, tray not labeled with name of product, day prepared, or use by date Right Door, top shelf: -one container of thick & easy 32 oz. thickened dairy beverage, opened, approximately ,d+[DATE] full, not labeled with the date when opened or the use by date -one plastic container of thick & easy 46 oz. thickened OJ, opened, approximately ,d+[DATE] full, not labeled with the date when opened or the use by date -one container of imperial 46 oz. thickened lemon flavor water, opened, approximately ,d+[DATE] full, opened, not labeled with the date when opened or the use by date b. On [DATE] at 8:03 A.M., the surveyor reviewed the free-standing triple door refrigerator in the main kitchen and observed the following inside: Left door: -one tray of 11 prepared dessert bowls with lids, tray not labeled with name of product, day prepared, or use by date -one large plastic container of cranberry sauce labeled ,d+[DATE], not labeled with name of product, use by date 2. On [DATE] at 7:55 A.M., the surveyor reviewed the walk-in freezer and observed one large cardboard box opened with frozen omelets stored inside a plastic bag. The bag was not sealed and open to air, potentially exposing the contents to environmental contaminants. On [DATE] at 1:45 P.M., the surveyor reviewed the findings with the Food Service Director (FSD) and Consulting Staff #2. The FSD said when staff prepare liquid beverage trays, they pour the liquids in cups and are supposed to place a sticker on the tray that says the product name and the expiration date. He said beverage containers, once opened, also have to be labeled when opened and the use by date. The FSD said the use by date for pre-poured beverages and prepared desserts is three days. He said, once opened, containers of milk are only good for four days and containers of juices are only good for seven days. He said if it's not labeled then staff cannot determine when it was opened or the use by date. The FSD said the cardboard box of frozen omelets in the walk-in freezer should have been sealed and was no longer good. The FSD and Consulting Staff #2 said the cranberry sauce was beyond the use by date so needed to be discarded. 3. On [DATE] at 9:08 A.M., the surveyor reviewed the First Floor Unit nourishment kitchenette and observed the following stored inside the refrigerator: -one Yoplait yogurt, unopened, manufacturer's expiration [DATE], yogurt not disposed of -four Oikos yogurts, unopened, three of four labeled as prepared on [DATE], no use by date, manufacturer's expiration date for all four yogurts [DATE], yogurts not disposed of During an interview on [DATE] at 9:16 A.M., the surveyor reviewed the findings with Nurse #6 who said the yogurts were all expired and should have been disposed of. She said dietary staff label the foods, but if a family member brings in food and dietary staff aren't there, then unit staff will label. She said anything that's open is only good for three days, otherwise they go by the manufacturer's expiration. During an interview on [DATE] at 11:00 A.M., the FSD said dietary staff are responsible for checking for food expirations in the nourishment kitchenettes and said the yogurts should have been disposed of.

Based on observation, record review, and interview, the facility failed to ensure medications were not self-administered without a physician's order and an assessment for self-administration was completed for two Residents (#58 and #73), out of a total sample of 21 residents. Findings include: Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: - Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's policy titled Self-Administration of Medications, undated, indicated but was not limited to: - Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for residents to do so. - As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. - The staff and practitioner will document their findings and the choices of the residents who are able to self-administer medications. - Self-administered medications must be stored in a safe and secure place which is not accessible by other residents. 1. Resident #58 was admitted to the facility in September 2024 with diagnoses including Herpes viral keratitis (an infection of the cornea, the clear front part of the eye, caused by the herpes simplex virus). Review of the Minimum Data Set (MDS) assessment, dated 12/12/24, indicated Resident #58 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the MDS indicated the Resident was independently able to perform activities of daily living. During an observation with interview on 2/12/25 at 9:36 A.M., the surveyor observed Resident #58 lying in bed; a bottle of Prednisolone Ophthalmic Suspension (a steroid medicine that is used to relieve the redness, itching, and swelling caused by eye infections and other conditions) was on Resident #58's overbed table. Resident #58 said he/she uses the Prednisolone Ophthalmic Suspension daily in the evening in his/her left eye. On 2/12/25 at 1:49 P.M., the surveyor observed Resident #58 sitting on the edge of his/her bed with the Prednisolone Ophthalmic Suspension on his/her overbed table. On 2/13/25 at 9:01 A.M., the surveyor observed Resident #58 sitting on the edge of his/her bed eating breakfast with the Prednisolone Ophthalmic Suspension on his/her overbed table. During an interview on 2/13/25 at 11:48 A.M., Resident #58 said he/she used the Prednisolone Ophthalmic Suspension nightly. Resident #58 said he/she had been diagnosed with herpes viral keratitis in the past and the Prednisolone Ophthalmic Suspension was prescribed to decrease swelling in his/her left eye. Resident #58 said they (facility staff) took his/her eye drops away because the surveyor asked him/her what he/she used them for, but he/she would like them because he/she wanted to administer them himself/herself. Resident #58 said the nurses knew he/she administered the Prednisolone Ophthalmic Suspension. Review of Resident #58's current Physician's Orders included but was not limited to: - Prednisolone Ophthalmic Suspension 1%, Instill 1 drop in the left eye, dated 12/16/24 Review of Resident #58's January and February Medication Administration Record (MAR) indicated Resident #58 received the Prednisolone Ophthalmic Suspension daily. Review of Resident #58's medical record failed to indicate the facility completed any additional Self-Administration of Medication Assessments. During an interview on 2/18/25 at 12:15 P.M., Nurse #9 said if a resident wanted to administer their own medications, then the Physician would have to give an order for them to self-administer the medication and the Resident should have been evaluated to ensure he/she was able to safely administer the medication. Nurse #9 reviewed Resident #58's medical record and said Resident #58 did not have an order to self-administer Prednisolone Ophthalmic Suspension and an evaluation had not been completed and documented. Nurse #9 said for residents who were able to self-administer, they should have a locked and secure place to store the medications. During an interview on 2/18/25 at 2:30 P.M., Unit Manager (UM) #1 said an assessment for self-administration, teaching with return demonstration, and an order should have been obtained from the Physician for Resident #58 to self-administer his/her Prednisolone Ophthalmic Suspension, but it had not been done. Medications stored at the beside should have been stored in a secure way. UM #1 said Resident #58 should have an assessment and orders to self-administer the Prednisolone Ophthalmic Suspension but did not. During an interview on 2/19/25 at 12:35 P.M., the Director of Nursing (DON) said the expectation was for all residents who expressed a desire to self-administer medication(s) to have an assessment completed, teaching and return demonstration completed, and a physician's order must be obtained. The DON said without an order medications should not be left in a resident's room. The DON said for those residents that were able to have medications at their bedside, they should be stored in a secure place. 2. Resident #73 was admitted to the facility in May 2023 with diagnoses including post-polio syndrome. Review of the MDS assessment, dated 11/15/24, indicated Resident #73 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated the Resident was dependent on staff to perform activities of daily living. On 2/13/25 at 9:27 A.M., the surveyor observed Nurse #2 administer Fluticasone Nasal Spray to Resident #73. Resident #73 told Nurse #2 that he/she had a bottle of the Fluticasone Nasal Spray on his/her overbed table. Nurse #2 said she had brought the Fluticasone Nasal Spray with her and administered the Fluticasone Nasal Spray to Resident #73. During an interview on 2/13/25 at 9:32 A.M., Resident #73 said he/she utilized the Fluticasone Nasal Spray as needed when he/she had a dry nose. Resident #73 said he/she did not notify the nursing staff when he/she self-administered the Fluticasone Nasal Spray. Resident #73 said he/she wanted to be able to administer his/her Fluticasone Nasal Spray and not have the nurses do it. During an interview on 2/13/25 at 11:32 A.M., Nurse #2 said Resident #73 had not had an evaluation and did not have an order to self-administer Fluticasone Nasal Spray. Nurse #2 said if a resident voiced that they wanted to self-administer medications then they should have had teaching done, were able to do a return demonstration, had a medication-self administration assessment with documentation and a physician's order but Resident #73 did not have these documents completed. During an interview on 2/19/25 at 8:56 A.M., UM #2 said Resident #73 did not have an order to self-administer Fluticasone Nasal Spray and had not been evaluated to administer his/her Fluticasone Nasal Spray but should have had. During an interview on 2/19/25 at 12:35 P.M., the DON said the expectation was for all residents who expressed a desire to self-administer medication(s) to have an assessment completed, teaching and return demonstration completed, and a physician's order must be obtained. The DON said without an order medications should not be left in a resident's room. The DON said for those residents that were able to have medications at their bedside, they should have stored them in a secure place.

Based on interviews, observations and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent Resident #1 form being neglected and abused by staff when: - on 9/15/18, in response to Resident #1's repeated attempts to stand up from his/her wheelchair unassisted, CNA #1 roughly pushed or pulled Resident #1 into a seated position in his/her wheelchair twenty two times with sufficient force on at least six occasions to cause Resident #1's unlocked wheelchair to roll and/or his/her feet to come up off of the floor. Contact with CNA #1 provoked Resident #1 to gesture toward CNA #1 with a raised fist on two occasions and to display distressed body language and facial expression, and - Nurse #1 and Nurse #2 placed Resident #1 on a mat on the floor, dressed only in an incontinence brief, where he/she remained for approximately two hours and twenty-two minutes. During that time, Resident #1 was intermittently restless, sleeping and scooted across the floor on his/her buttocks, in full view of at least six residents and ten staff members. Findings include: Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, completed 7/20/18, indicated that his/her cognitive patterns were severely impaired. Resident #1's MDS indicated he/she required extensive assistance of two staff members with bed mobility, transfers between surfaces and ambulation. Resident #1's care plan indicated he/she exhibited behavioral symptoms and agitation related to dementia and interventions included, offering Resident #1 his/her Portuguese Audio Bible, medications administered as ordered, offering tasks to divert his/her attention and assessing and anticipating Resident #1's needs such as food, thirst, toileting, comfort, body position and pain. Resident #1's care plan indicated he/she was at risk for falls and interventions included that staff members would encourage Resident #1 to request assistance prior to ambulation. Resident #1's care plan indicated that had communications issue related to Resident #1's primary language being Portuguese, interventions included staff would allow adequate time for him/her to respond, repeat as necessary and face Resident #1 when speaking. Resident #1's Dementia care plan indicated that interventions included staff should allow him/her to wander safely. Resident #1's CNA Care Card indicated that Resident #1 ambulated with a gait belt and a staff member following behind him/her with a wheelchair. 1.) The Surveyor viewed video footage provided by the Administrator. The Footage is date and time stamped from 6:47 P.M. to 10:10 P.M. on 9/15/18. The video depicted the following: -19:06:02 Resident#1 disrobed in his/her wheelchair in front of the nurses' station -19:12:54 CNA #1 roughly pushed Resident #1 back to seated from standing -19:13:21 CNA #1 roughly pushed Resident #1 back to seated from standing -19:17:09 CNA #1 roughly pushed Resident #1 back to seated from standing -19:17:31 CNA #1 roughly pushed Resident #1 back to seated from standing -19:20:25 CNA #1 roughly pushed Resident #1 back to seated from standing -19:20:45 CNA #1 roughly pushed Resident #1 back to seated from standing. Resident #1 reacted by raising his/her fist toward CNA #1 -19:21:10 CNA #1 roughly pushed Resident #1 back to seated from standing -19:23:07 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:23:50 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:24:12 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:25:20 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:26:41 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:26:55 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:27:04 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacts by clenching his/her first toward toward CNA #1. -19:27:38 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:27:54 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted and pulled his/her arm away from CNA and CNA #1 grabbed and held Resident #1's right wrist as he/she resisted her grasp. -19:28:20 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted by attempting to strike CNA #1's legs and CNA #1 held Resident #1's right wrist -19:28:41 Resident #1 stands falls to the floor, unassisted by anyone for one minute when CNA #2 moved Resident #1 from the floor to his/her wheelchair without an assessment by a nurse -19:30:14 CNA #1 roughly reclined Resident #1 in his/her wheelchair -19:32:55 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:33:16 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:33:36 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:34:15 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted by trying to hit CNA #1 and CNA #1 grabbed Resident #1's right wrist Certified Nurse Aide (CNA) #1 did not respond to telephone messages left by the Surveyor on 9/24/18 and 10/1/18, and was unable to be interviewed. CNA #1's written statement provided by the Director of Nurses' indicated that she worked on Resident #1's unit during there 3:00 P.M. to 11:00 P.M. shift on 9/15/18. CNA #1's written statement indicated that she was standing by Resident #1's chair when Resident #1 fell . CNA #1's written statement indicated that after Resident #1 fell , Nurse #2 assessed Resident #1 and Resident #1 was assisted back to his/her wheelchair. Although Resident #1's impaired cognition limited his/her ability to recall having contact with CNA #1, an unimpaired individual would experience physical pain and mental anguish when pushed or pulled by a caregiver about twenty-two times over thirty minutes. 2.) The Surveyor viewed video footage provided by the Administrator. The Footage is date and time stamped from 18:47 P.M. to 22:10 P.M. on 9/15/18. The video depicted the following: -19:44:45 Resident #1 slid to sit on his/her wheelchair footrests -19:47:23 CNA #5 tilted Resident #1's wheelchair forward and Resident #1 moved from being seated on the wheelchair footrests to lay on his/her left side on the floor -19:47:50 Nurse #2 arranged mat and pillow on floor against the wall across from the nurses' station. Nurses #1 and #2 and CNA #5 positioned Resident #1 onto the mat on the floor across from the nurses' station. Resident #1 was still dressed in only an incontinence brief. -20:39 CNA #3 dressed Resident #1 on the mat on the floor in a Johnny -20:44:45 Resident #1 rolled off of the mat and onto floor. Although the Johnny remained in place around Resident #1's neck his/her torso and legs were entirely visible -20:46:28 CNA #3 placed a pillow beneath Resident #1's head on the floor -20:52:40 Nurse #4 repositioned Resident #1 on mat pulled the Johnny to cover Resident #1's torso and legs -21:31:22 Resident #1 became restless on the mat on the floor and disrobed -21:55 Resident #1 pulled him/herself to a seated position -21:56 Resident #1 moved off of the mat began to scooted him/herself across floor on his/her buttocks toward the nurses' station until 22:06 when Nurses #1 and #2 and CNAs #1, #2 and #5 assisted Resident #1 back to his/her wheelchair. The video depicted that Resident #1 spent approximately two hours and twenty-two minutes on floor, ninety of which he/she was dressed only in an incontinence brief. The Surveyor interviewed Nurse #2 at 1:45 P.M. on 9/24/18. Nurse #2 said that he was Resident #1's nurse during the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. Nurse #2 said that Resident #1 was combative and agitated during the shift. Nurse #2 said that he placed Resident #1 on the mat on the floor across from the nurses' station to prevent falls. Nurse #2 said that although he was aware that Resident #1 had disrobed, he said he did not think any residents saw Resident #1 on the floor dressed only in an incontinence brief because staff members were putting residents to bed. Nurse #2 said that he did not know how long Resident #1 had been on the floor. The Surveyor interviewed Nurse #1 at 10:45 A.M. on 9/25/18. Nurse #1 said that she worked during the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. Nurse #1 said that she and Nurse #2 discussed and agreed to put Resident #1 onto a mat, on the floor in front of the nurses' station when Resident #1 continued to stand up from his/her wheelchair unassisted. Nurse #1 said she felt relieved because Resident #1 was safe on the floor. Nurse #1 said she was behind in her work and once Resident #1 was safe she focused on other tasks. Nurses #1 and Nurse #2 said that they were not aware of Resident #1's care plan interventions related to dementia such as offering Resident #1 his/her Portuguese Audio Bible and as needed medications for agitation. Nurses #1 and Nurse #2 said they did not know whether Resident #1 was offered tasks to divert his/her attention or if an assessment was made of his/her unmet needs such as for food, thirst, comfort, body position or pain. Nurse #2 said that the only intervention attempted to address Resident #1's repeated attempts to stand was placing him/her on one to one supervision with CNA #1, which was ineffective because Resident #1 tried to hit CNA #1. Although Resident #1's care plan identified that staff members would encourage Resident #1 to request assistance prior to ambulation, that staff would allow him/her to wander safely and ambulate with Resident #1, Nurses #1 and Nurse #2 said that they did not know that Resident #1 could walk and said they did not attempt to have staff members ambulate with Resident #1. Although Resident #1's impaired cognition limited his/her ability to understand and recall the experience of being left on the floor, an unimpaired individual would experience emotional distress when left on the floor and deprived of assistance, including specific interventions developed to address agitation and symptoms of dementia, for two hours and twenty-two minutes.

Based on interviews, observations and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure that five staff members (Nurses #1 and #2 and Certified Nurse Aides #1, #2 and #3) treated Resident #1 with respect and dignity when: - On 9/15/18, between 7:00 P.M. and 11:00 P.M., in response to Resident #1's repeated attempts to stand up from his/her wheelchair and after a fall, Nurses #1 and #2 placed Resident #1 on a mat on the floor, dressed only in an incontinence brief. Resident #1 remained on the mat and/or on the floor near the mat across from the nurses' station intermittently restless, sleeping and scooting across the floor on his/her buttocks for approximately two hours and twenty-two minutes, in full view of at least six residents and ten staff members. Despite ten staff members passing by Resident #1 as he/she sat or laid on the floor undressed, no staff member intervened to protect Resident #1's dignity. Findings include: Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, completed 7/20/18, indicated that his/her cognitive patterns were severely impaired. Resident #1's MDS indicated he/she required extensive assistance of two staff members with bed mobility, transfers between surfaces and ambulation. Resident #1's care plan indicated he/she exhibited behavioral symptoms and agitation related to dementia and interventions included offering Resident #1 his/her Portuguese Audio Bible, medications administered as ordered, offering tasks to divert his/her attention and assessing and anticipating Resident #1's needs such as food, thirst, toileting, comfort, body position and pain. Resident #1's care plan indicated he/she was at risk for falls and interventions included that staff members would encourage Resident #1 to request assistance prior to ambulation. Resident #1's care plan regarding communication concerns indicated that Resident #1's primary language was Portuguese and interventions included staff would allow adequate time for him/her to respond, repeat as necessary and face Resident #1 when speaking. Resident #1's Dementia care plan indicated that interventions included that staff should allow him/her to wander safely. Resident #1's Certified Nurse Aide (CNA) Care Card indicated that Resident #1 ambulated with a gait belt and a staff member following behind him/her with a wheelchair. The Surveyor viewed video footage provided by the Administrator. The Footage is date and time stamped from 18:47 to 22:10 on 9/15/18. The video depicted the following: -19:06:02 Resident#1 disrobed in his/her wheelchair in front of the nurses' station -19:12:54 CNA #1 roughly pushed Resident #1 back to seated from standing -19:13:21 CNA #1 roughly pushed Resident #1 back to seated from standing -19:17:09 CNA #1 roughly pushed Resident #1 back to seated from standing -19:17:31 CNA #1 roughly pushed Resident #1 back to seated from standing -19:20:25 CNA #1 roughly pushed Resident #1 back to seated from standing -19:20:45 CNA #1 roughly pushed Resident #1 back to seated from standing. Resident #1 reacted by raising his/her fist toward CNA #1 -19:21:10 CNA #1 roughly pushed Resident #1 back to seated from standing -19:23:07 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:23:50 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:24:12 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:25:20 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:26:41 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:26:55 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:27:04 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacts by clenching his/her first toward toward CNA #1. -19:27:38 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:27:54 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted and pulled his/her arm away from CNA and CNA #1 grabbed and held Resident #1's right wrist as he/she resisted her grasp. -19:28:20 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted by attempting to strike CNA #1's legs and CNA #1 held Resident #1's right wrist -19:28:41 Resident #1 stands falls to the floor, unassisted by anyone for one minute when CNA #2 moved Resident #1 from the floor to his/her wheelchair without an assessment by a nurse -19:30:14 CNA #1 roughly reclined Resident #1 in his/her wheelchair -19:32:55 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:33:16 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:33:36 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:34:15 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted by trying to hit CNA #1 and CNA #1 grabbed Resident #1's right wrist -19:44:45 Resident #1 slid to sit on his/her wheelchair footrests -19:47:23 CNA #5 tilted Resident #1's wheelchair forward and Resident #1 moved from being seated on the wheelchair footrests to lay on his/her left side on the floor -19:47:50 Nurse #2 arranged mat and pillow on floor against the wall across from the nurses' station. Nurses #1 and #2 and CNA #5 positioned Resident #1 onto the mat on the floor across from the nurses' station. Resident #1 was still dressed in only an incontinence brief. -20:39 CNA #3 dressed Resident #1 on the mat on the floor in a Johnny -20:44:45 Resident #1 rolled off of the mat and onto floor. Although the Johnny remained in place around Resident #1's neck his/her torso and legs were entirely visible -20:46:28 CNA #3 placed a pillow beneath Resident #1's head on the floor-20:52:40 Nurse #4 repositioned Resident #1 on mat pulled the Johnny to cover Resident #1's torso and legs -21:31:22 Resident #1 became restless on the mat on the floor and disrobed -21:55 Resident #1 pulled him/herself to a seated position -21:56 Resident #1 moved off of the mat began to scooted him/herself across floor on his/her buttocks toward the nurses' station until 22:06 when Nurses #1 and #2 and CNAs #1, #2 and #5 assisted Resident #1 back to his/her wheelchair. The video depicted that Resident #1 spent about two hours and twenty-two minutes on floor, ninety of which he/she was dressed only in an incontinence brief. At least 6 Residents (Residents #2 and #3 and non-sampled Residents A, B, C and D) observed Resident #1 undressed on the floor. At least 10 staff members (Nurses #1, #2, #3, #4 and #5 and CNAs #1, #2, #3, #4 and #5) observed Resident #1 undressed and on the floor and failed to act to ensure he/she was treated with dignity and respect. The video depicted that the following: - CNA #1 roughly pushed Resident #1 back from standing to a seated position in the wheelchair approximately eight times (19:12:54, 19:13:21, 19:17:09, 19:17:31, 19:20:25, 19:20:45 and 19:21:10) - CNA #1 grabbed Resident #1's arm from behind him/her and pulled him/her roughly back into the wheelchair to sit fourteen times (19:23:07, 19:23:50, 19:24:12, 19:25:20, 19:26:41, 19:26:55, 19:27:04, 19:27:38, 19:27:53, 19:27:20, 19:32:55, 19:33:16, 19:33:36 and 19:34:15). - CNA #1's pushing or pulling of Resident #1 is with sufficient force to cause Resident #1's unlocked wheelchair to roll and/or his/her feet to come up off of the floor on six occasions (19:12:50, 19:17:31, 19:20:25, 19:20:45, 19:21:10 and 19:23:07). - Resident #1 gestured toward CNA #1 with a raised fist or facial expression/body language which appeared to display agitation with CNA #1's approach (19:20:45, 19:26:55, 19:27:04, 19:28:03, 19:28:26 and 19:34:15). - Resident #1 struggled against CNA #1's grasp on his/her wrist on two occasions (19:28:03 and 19:34:15). The Surveyor interviewed CNA #9 at 3:30 P.M. on 9/23/18. CNA #9 said that around 8:00 P.M. on 9/15/18 she went to Resident #1's unit to deliver a meal to a staff member and saw Resident #1 dressed only in an incontinence brief and seated on a mat on the floor in front of the nurses' station. CNA #9 said that she asked Nurse #1 and Nurse #2, who were standing at the nurses' station about Resident #1 and said Nurse #1 and Nurse #2 told her that they intended to leave him/her there. CNA #9 said that she did not think that it was right that Nurse #1 and Nurse #2 left Resident #1 on the floor and she reported the incident to the Director of Nurses by leaving an unsigned note under the Director of Nurses' office door. The Surveyor interviewed the Director of Nurses at 1:00 P.M. on 9/23/18. The Director of Nurses said that she received CNA #9's unsigned note around 8:00 A.M. on 9/17/18 and initiated an investigation which included review of the video footage from the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. The Surveyor interviewed Nurse #2 at 1:45 P.M. on 9/24/18. Nurse #2 said that he was Resident #1's nurse during the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. Nurse #2 said that Resident #1 was combative and agitated during the shift. Nurse #2 said that he placed Resident #1 on the mat on the floor across from the nurses' station to prevent falls. Nurse #2 said that although he was aware that Resident #1 had disrobed, he did not think any residents saw Resident #1 on the floor dressed only in an incontinence brief because staff members were putting residents to bed. Nurse #2 said that he did not know how long Resident #1 had been on the floor. The Surveyor interviewed Nurse #1 at 10:45 A.M. on 9/25/18. Nurse #1 said that she worked during the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. Nurse #1 said that she and Nurse #2 discussed and agreed to put Resident #1 onto a mat on the floor in front of the nurses' station when Resident #1 continued to stand up from his/her wheelchair unassisted. Nurse #1 said she felt relieved because Resident #1 was safe on the floor. Nurse #1 said she was behind in her work and once Resident #1 was safe she focused on other tasks. The Surveyor interviewed Nurse #4 at 3:00 P.M. on 9/24/18. Nurse #4 said that he worked at the Facility during the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. Nurse #4 said that although he did not work on Resident #1's unit, at one point a staff member asked him to come to Resident #1's unit. Nurse #4 said that on Resident #1's unit he saw Resident #1 naked, only in an incontinence brief, on the floor and asked Nurse #1 what happened. Nurse #4 said that Nurse #1 told him that Resident #1 was at risk for falls. Nurse #4 said because Resident #1 resided on Nurse #1's unit, he could not tell her what to do. Nurse #4 said that he asked Nurse #1 why Resident #1 could not be put into bed in his/her room for privacy and said Nurse #1 did not answer Nurse #4's question. Nurse #4 said that he covered Resident #1 and repositioned him/her on the mat on the floor. Nurse #4 said that Nurse #1 acted as though she did not care that Resident #1 was exposed and although he offered to help, Nurse #1 said that she did not want his help. Nurse #1, Nurse #2 and Nurse #3 said that although telephone numbers for the Administrator, the Director of Nurses' and an on-call supervisor were available, they did not notify anyone that Resident #1 was left on the floor, undressed for more than two hours.

Based on interviews, observations and records reviewed, for one of three sampled residents (Resident #1), Facility failed to ensure that five staff members (Nurses #1, Nurse #2 and #2 and Certified Nurse Aides (CNA) #1, #2 and #3) provided care in accordance with Resident #1's care plan when, on 9/15/18 between 18:47 P.M. and 22:06 P.M., staff members failed to implement Resident #1's behavioral care plan interventions during an episodes of agitation. Findings include: Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, completed 7/20/18, indicated that his/her cognitive patterns were severely impaired. Resident #1's MDS indicated he/she required extensive assistance of two staff members with bed mobility, transfers between surfaces and ambulation. Resident #1's care plan regarding decreasing behavioral symptoms indicated that interventions included that staff would offer Resident #1 his/her Portuguese Audio Bible to decrease his/her behaviors. Resident #1's care plan regarding falls indicated that interventions included that staff members would encourage Resident #1 to request assistance prior to ambulation. Resident #1's care plan regarding behavioral symptoms and dementia indicated that interventions included medications should be administered as ordered and tasks would be offered to divert his/her attention. Resident #1's care plan regarding agitation indicated that interventions included assessing and anticipating Resident #1's needs such as food, thirst, toileting, comfort, body position and pain. Resident #1's care plan regarding communication indicated that Resident #1's primary language was Portuguese and interventions included staff would allow adequate time for him/her to respond, repeat as necessary and face Resident #1 when speaking. Resident #1's Dementia care plan indicated interventions included staff to allow Resident #1 to wander safely. Resident #1's CNA Care Card indicated that Resident #1 ambulated with a gait belt, with staff member following behind him/her with a wheelchair. The Surveyor viewed video footage provided by the Administrator. The Footage is date and time stamped 18:47 P.M. to 22:10 P.M. on 9/15/18. The video depicted the following: -19:06:02 Resident#1 disrobed in his/her wheelchair in front of the nurses' station -19:12:54 CNA #1 roughly pushed Resident #1 back to seated from standing -19:13:21 CNA #1 roughly pushed Resident #1 back to seated from standing -19:17:09 CNA #1 roughly pushed Resident #1 back to seated from standing -19:17:31 CNA #1 roughly pushed Resident #1 back to seated from standing -19:20:25 CNA #1 roughly pushed Resident #1 back to seated from standing -19:20:45 CNA #1 roughly pushed Resident #1 back to seated from standing. Resident #1 reacted by raising his/her fist toward CNA #1 -19:21:10 CNA #1 roughly pushed Resident #1 back to seated from standing -19:23:07 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:23:50 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:24:12 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:25:20 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:26:41 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:26:55 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:27:04 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacts by clenching his/her first toward toward CNA #1. -19:27:38 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:27:54 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted and pulled his/her arm away from CNA and CNA #1 grabbed and held Resident #1's right wrist as he/she resisted her grasp. -19:28:20 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted by attempting to strike CNA #1's legs and CNA #1 held Resident #1's right wrist -19:28:41 Resident #1 stands falls to the floor, unassisted by anyone for one minute when CNA #2 moved Resident #1 from the floor to his/her wheelchair without an assessment by a nurse -19:30:14 CNA #1 roughly reclined Resident #1 in his/her wheelchair -19:32:55 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:33:16 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:33:36 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair -19:34:15 CNA #1 roughly pulled Resident #1 back to seated from standing while standing behind his/her wheelchair. Resident #1 reacted by trying to hit CNA #1 and CNA #1 grabbed Resident #1's right wrist -19:44:45 Resident #1 slid to sit on his/her wheelchair footrests -19:47:23 CNA #5 tilted Resident #1's wheelchair forward and Resident #1 moved from being seated on the wheelchair footrests to lay on his/her left side on the floor -19:47:50 Nurse #2 arranged mat and pillow on floor against the wall across from the nurses' station. Nurses #1 and #2 and CNA #5 positioned Resident #1 onto the mat on the floor across from the nurses' station. Resident #1 was still dressed in only an incontinence brief. -20:39 CNA #3 dressed Resident #1 on the mat on the floor in a Johnny -20:44:45 Resident #1 rolled off of the mat and onto floor. Although the Johnny remained in place around Resident #1's neck his/her torso and legs were entirely visible -20:46:28 CNA #3 placed a pillow beneath Resident #1's head on the floor -20:52:40 Nurse #4 repositioned Resident #1 on mat pulled the Johnny to cover Resident #1's torso and legs -21:31:22 Resident #1 became restless on the mat on the floor and disrobed -21:55 Resident #1 pulled him/herself to a seated position -21:56 Resident #1 moved off of the mat began to scooted him/herself across floor on his/her buttocks toward the nurses' station until 22:06 when Nurses #1 and #2 and CNAs #1, #2 and #5 assisted Resident #1 back to his/her wheelchair. The Facility's Scheduled was reviewed and indicated that Nurse #1, Nurse #2 and CNA's #1, #2 and #3 worked on Resident #1's unit from 7:00 P.M. until 11:00 P.M. on 9/15/18. Review of the video footage does not show any staff member offering Resident #1 his/her Portuguese Audio Bible to decrease his/her behaviors, offering tasks to divert his/her attention, offering food or drink or ambulating with Resident #1. CNA #1 did not respond to telephone messages left by the Surveyor on 9/24/18 and 10/1/18, and could not be interviewed. CNA #1's written statement provided by the Director of Nurses' indicated that she worked on Resident #1's unit during there 3:00 P.M. to 11:00 P.M. shift on 9/15/18. CNA #1's written statement indicated that she was standing by Resident #1's chair when Resident #1 fell . CNA #1's written statement indicated that after Resident #1 fell , Nurse #2 assessed Resident #1 and Resident #1 was assisted back to his/her wheelchair. The Surveyor interviewed CNA #3 at 9:20 A.M. on 9/24/18. CNA #3 said that she was on light duty due to an injury and was not able to physically assist with Resident #1's care. CNA #3 said that she saw Resident #1 on the floor on the mat. CNA #3 said that she did not offer Resident #1 his/her Portuguese Audio Bible, diversionary tasks, food or drink or ambulate with Resident #1. The Surveyor interviewed CNA #2 at 11:55 A.M. on 9/24/18. CNA #2 said that she saw Resident #1 on the mat on the floor during the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. CNA #2 said that she told Nurse #1 that it looked kind of bad for Resident #1 to be on the mat on the floor. CNA #2 said that she did not offer Resident #1 his/her Portuguese Audio Bible, diversionary tasks, food or drink or ambulate with Resident #1. The Surveyor interviewed Nurse #2 at 1:45 P.M. on 9/24/18. Nurse #2 said that he was Resident #1's nurse during the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. Nurse #2 said that Resident #1 was combative and agitated during the shift. Nurse #2 said that staff did not did not offer Resident #1 his/her Portuguese Audio Bible, diversionary tasks, food or drink or ambulate with Resident #1. Nurse #2 said that he was not aware that Resident #1 could ambulate. The Surveyor interviewed Nurse #1 at 10:45 A.M. on 9/25/18. Nurse #1 said that she worked during the 3:00 P.M. to 11:00 P.M. shift on 9/15/18. Nurse #1 said that she and Nurse #2 discussed and agreed to put Resident #1 onto a mat on the floor in front of the nurses' station when Resident #1 continued to stand up from his/her wheelchair unassisted. Nurse #1 said that she did not offer Resident #1 his/her Portuguese Audio Bible, diversionary tasks, food or drink or ambulate with Resident #1. Nurse #1 said that she was not aware that Resident #1 could ambulate.

Based on records reviewed and interviews, for one of 10 sampled residents, (Resident #1) the facility failed to ensure safety interventions, including the use supportive devices to assist with seated posture while in his/her wheelchair, were in place for Resident #1, as a result Resident #1 experienced two falls, the first on 9/15/18 with no injuries noted, and the second on 9/18/18, in which he/she sustained a two centimeter (cm) abrasion above his/her right eye. Findings include: Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment, completed 7/20/18, indicated that his/her cognitive patterns were severely impaired. Resident #1's MDS indicated he/she required extensive assistance of two staff members with bed mobility, transfers between surfaces and ambulation. Resident #1's Occupational Therapy Discharge Summary for services between 9/4/18 and 9/17/18 indicated that Occupational Therapy provided Resident #1 with a high back wheelchair with a left lateral support and a right arm tray for optimal postural alignment while seated. The Surveyor interviewed the Physical Therapist and the Rehabilitation Services Manager at 10:15 A.M. on 9/25/18. The Surveyor reviewed video surveillance footage from 9/15/18 and 9/18/18 provided by the Administrator which depicted Resident #1's falls. The video depicted that at 19:28:41 on 9/15/18 Resident #1 stands up from his/her wheelchair unassisted and falls to the floor. The Physical Therapist and Rehabilitation Services Manager viewed the video footage and said that the left lateral support and right arm tray were not in place on Resident #1's wheelchair when he/she stood unassisted and fell . The video depicted that at 19:43:10 on 9/18/18 Resident #1 stood up from his/her wheelchair unassisted and fell to the floor. The Physical Therapist and Rehabilitation Services Manager viewed the video footage and said that the left lateral support and right arm tray were not in place on Resident #1's wheelchair when he/she stood unassisted and fell . The Incident Report dated 9/18/18 indicated that Resident #1 sustained a two centimeter abrasion around his/her right eye. The Incident Report indicated that Resident #1 was transferred to the Hospital Emergency Department , where the abrasion was treated with two steri-strips. The Surveyor interviewed the Director of Nurses at 10:30 A.M. on 9/25/18. The Director of Nurses said that Resident #1's the left lateral support and right arm tray were not in place on Resident #1's wheelchair as per the care plan, when he/she fell on [DATE] and 9/18/18.

Based on Record Review and staff interview, the Facility failed to ensure that for 1 Resident (#5), of a total sample of 26 Residents, that care and treatment was provided in accordance with professional standards of practice. Resident #5 was reportedly injected with an unidentified substance by a licensed agency nurse, which necessitated the Resident being transferred for treatment at the Hospital Emergency Department. Record Review on 12/8/17, revealed that the Resident was admitted in 6/2016 According to the most recent Quarterly MDS, signed as being completed 11/13/17, the Resident experienced short-term memory impairment and required modified independence for cognitive skills for daily decision making. Record Review on 12/08/17 at 11:44 AM, revealed a progress note that indicated on 6/3/17, that a significant medication error was made by an Agency Nurse on 6/3/17 at 8:30 A.M. The Agency Nurse was observed by a staff nurse injecting 100 units of an unknown substance into the Resident. The on-call Physician was contacted and the Resident was sent out to the Hospital emergency room for evaluation. According to the emergency room report, the Resident's blood pressure rose dangerously high, which required the administration of multiple doses of antihypertensive and diuretic medications. The Resident's blood pressures, and medications administered in the Hospital R.R., were as follows: Blood Pressures: -6/3/17, 10:56 A.M., 201/74 mm/Hg -6/3/17, 11:00 A.M., 210/67 mm/Hg -6/3/17, 11:58 A.M., 201/74 mm/Hg -6/3/17, 12:00 P.M., 223/99 mm/Hg -6/3/17, 12:14 P.M., 223/99 mm/Hg -6/3/17, 3:01 P.M., 145/77 mm/Hg -6/3/17, 3:03 P.M., 145/77 mm/Hg -6/3/17, 4:21 P.M., 166/54 mm/Hg Medications Administered: -11:58 A.M., [MEDICATION NAME] 5 mg -11:58 A.M., [MEDICATION NAME] 50 mg -12:14 P.M., [MEDICATION NAME] Hcl ([MEDICATION NAME]) 50 mg -2:54 P.M., [MEDICATION NAME] 20 mg -3:03 P.M., [MEDICATION NAME] Hcl 50 mg Per interview with the DON and Administrator on 12/8/17 at 10:25 A.M., both the DON and Administrator said that the Facility failed to conduct an investigation into what had occurred, and failed to determine what it was that the agency nurse injected into the Resident. The Facility's only documentation of the serious medication error, was a Medication Variance Report, filled out three days later on 6/6/17 by the staff nurse on duty, and reviewed by the former DON (Director of Nursing) on 6/7/17. The report indicated that a significant medication error had occurred and the Resident required transfer to the Hospital. The report also indicated that an unknown medication at 100 unit dose IM (intramuscularly), was given with no order and the Agency Nurse was quoted to say, I don't remember what I gave her. The previous DON's statement on the report indicated that the staffing agency was contacted and informed that the Facility would not be booking her to work at the Facility again.

Based on Record Review and staff interview, the Facility failed to ensure that for 1 Resident (#5), of a total sample of 26 Residents, that care and treatment was provided in accordance with Professional Standards of Practice. Resident #5 was reportedly injected with an unidentified substance by a licensed Agency Nurse, which necessitated the Resident being transferred for assessment and treatment at the Hospital Emergency Department for a significant change in medical condition. Record Review on 12/8/17, indicated that the Resident was admitted in 6/2016 with [DIAGNOSES REDACTED]. Record Review on 12/08/17 at 11:44 AM, indicated that on 6/3/17 at 8:30 A.M., an Agency Nurse made a significant medication error that was observed by a Facility staff nurse. The Agency Nurse was observed by a staff nurse injecting 100 units of an unknown substance into the Resident. The site of injection was not documented. The on-call Physician was contacted and the Resident was sent out to the Hospital emergency room for evaluation. According to the ER (emergency room ) report, the Resident's blood pressure rose dangerously high, which required the administration of multiple doses of antihypertensive, and diuretic medications. The Resident's blood pressures, and medications administered in the Hospital E.R., were as follows: Blood Pressures: -6/3/17, 10:56 A.M., 201/74 mm/Hg -6/3/17, 11:00 A.M., 210/67 mm/Hg -6/3/17, 11:58 A.M., 201/74 mm/Hg -6/3/17, 12:00 P.M., 223/99 mm/Hg -6/3/17, 12:14 P.M., 223/99 mm/Hg -6/3/17, 3:01 P.M., 145/77 mm/Hg -6/3/17, 3:03 P.M., 145/77 mm/Hg -6/3/17, 4:21 P.M., 166/54 mm/Hg Medications Administered: -11:58 A.M., [MEDICATION NAME] 5 mg -11:58 A.M., [MEDICATION NAME] 50 mg -12:14 P.M., [MEDICATION NAME] Hcl ([MEDICATION NAME]) 50 mg -2:54 P.M., [MEDICATION NAME] 20 mg -3:03 P.M., [MEDICATION NAME] Hcl 50 mg Per interview with the DON and Administrator on 12/8/17 at 10:25 A.M., both the DON and Administrator said that the Facility failed to conduct an investigation into what had occurred, and failed to determine what it was that the agency nurse injected into the Resident. The Facility's only documentation of the serious medication error, was a Medication Variance Report, filled out three days later on 6/6/17 by the staff nurse on duty, and reviewed by the former DON (Director of Nursing) on 6/7/17. The report indicated that a significant medication error had occurred which required the Resident's transfer to the Hospital. The report also indicated that an unknown medication at 100 unit dose IM (intramuscularly), was injected into the Resident with no order. The Agency Nurse was quoted to say, I don't remember what I gave her. The previous DON's statement on the Medication Variance Report indicated that the staffing agency was contacted and informed that the Facility would not be booking the Agency Nurse to work at the Facility in the future. Additionally, there was a notation on the report that indicated family unreachable. The Facility failed to inform the Resident's Responsible Party of the significant medication error and resulting hospitalization to treat the effects caused by the injection of an unknown medication.

Based on record review and staff interviews, the facility failed to allow 1 Resident (#62) out of 2 closed records, to return to the facility following a transfer to the hospital for evaluation, failed to document any information to support the basis for discharge despite having been cleared by hospital staff to return, and refused to allow the Resident to return citing that he/she verbally threatened a staff member. Findings include: On 11/29/17 at approximately 1:30 P.M., the survey team was alerted by the facility's Ombudsman, that Resident #62 was denied readmission by the facility after being sent out to the hospital for an evaluation. On 11/29/17 at 2:30 PM, the Director of Nurses (DON), facility Administrator and Corporate Nursing Consultant was interviewed regarding events which led up to the hospitalization of Resident #62. The DON said that on 11/27/17 at approximately 4:00 P.M., Resident #62 self propelled his/her wheelchair down the unit hallway, approached a nurse at a medication cart and the DON said that he/she threatened to kill the nurse. The DON said that she was made aware of Resident #62's verbal threat by the nurse the following morning at approximately 5:00 A.M. (more than 12 hours after the incident occurred). The DON said that the Resident's physician was notified, a Section 12 obtained, and the Resident was transferred to the hospital for evaluation. She said that the Resident was immediately put on one-to-one (staff sitting outside the door), and remained in his/her room for the entire night with the door closed, and did not exhibit any verbal or physical behavior. The DON said that the Resident had not previously exhibited any violent behavior, but verbal behavior such as yelling had increased lately. The DON was unable to identify or describe specific verbal behaviors exhibited by the Resident, and said that she would have to look through the medical record to find out. Resident #62 was admitted to the facility on a short term basis in 10/2017 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) with a reference date of 10/13/17, indicated that Resident #62 was cognitively intact, had stable mood, exhibited no behaviors, had frequent pain, and received intravenous (IV) medication. Hospital discharge documentation indicated that during the course of inpatient treatment, the resident underwent [REDACTED]. Additionally, he/she developed an infection (osteo[DIAGNOSES REDACTED]) and subsequently had a PICC line (peripherally inserted central catheter) placed, and began a six week course of intravenous (IV) antibiotic therapy. The plan was for the Resident to remain at the facility until his/her scheduled surgery in 11/29/2017 to treat a bone infection. Review of 10/2017 physician's orders [REDACTED]. - [MEDICATION NAME] (antibiotic) 250 ml (milliliters) intravenously every 8 hours - [MEDICATION NAME] 975 mg every 8 hours for pain - [MEDICATION NAME] 650 mg every 6 hours prn (as needed) for pain - [MEDICATION NAME] 20 mg (milligrams) every 4 hours prn for pain Review of documentation from the infectious disease physician indicated that IV antibiotic treatment was discontinued on 11/10/17. Further review of the medical record indicated that in the 8 days prior to the discontinuation of IV antibiotic treatment on 11/10/17, prn pain medication was administered on 10 occasions. In the 8 days following the discontinuation of IV treatment, the Resident reported pain more frequently and prn pain medication was administered on 19 occasions. Nursing note dated 11/18/17, indicated that at approximately 9:00 A.M., Resident #62 complained of right lower extremity pain at a level of 8 out of 10 and prn pain medications [MEDICATION NAME] and [MEDICATION NAME] were administered. A follow-up note indicated the medications were ineffective and the Resident continued to have pain. Further review of the nursing note indicated that Resident #62 yelled at the nurse that he/she had pain of 8/9 out of 10, felt increased pressure and decreased feeling in the right lower extremity where the cast was placed. The physician was notified and gave an order to send the Resident to the hospital for evaluation. The Resident returned to the facility the same day after hospital staff cut the sides of the cast to relieve the pressure. Further review of the medical record indicated that the Resident reported pain more frequently and was administered prn pain medication on 31 occasions from 11/19/17 through 11/28/17. Review of social service note dated 11/21/17. indicated that the facility social worker and DON met with Resident #62 to discuss his/her verbal aggression toward staff earlier in the day (not documented in the medical record). The Resident said that he/she was upset because a nurse came into his/her room to speak with his/her roommate and was speaking too loudly, disrupting his/her sleep. The social worker and DON explained that the facility may not be the most appropriate environment for him/her because the IV therapy had been discontinued and he/she was no longer working with rehab staff, and he/she may be more comfortable at home to wait for his/her upcoming surgery. The Resident declined discharge. Resident #62 was seen by the facility's psychiatric consultant on the following dates: -10/7/17: Initial evaluation, no behaviors identified -10/28/17: Resident stated staff not coming into his/her room to provide care, no agitation, no violence -11/4/17: No behaviors identified. -11/18/17: Resident yelling at nursing related to cast on foot, agitated -11/24/17: Resident reports staff is trying to get him/her out of facility, no behaviors identified. Review of a 11/28/17 nursing note written by the DON, documented that a nurse reported to her that Resident #62 said he/she was going to kill a nurse and Resident #62 didn't care if he/she went to jail, and the Resident verbalized racial slurs and was agitated the previous evening. Further review of the medical record indicated that Resident #62 was sent to the hospital on [DATE] via a Section 12 (authorization for temporary involuntary hospitalization ) following a behavioral (verbal) incident toward staff on 11/27/17. Review of the Section 12 document indicated only a physician's signature and date. There was no supporting evidence identified on the form to indicate symptoms of mental illness, and likelihood of serious harm as required. There was no evidence in the medical record that the facility ascertained, more than 12 hours after making a threat, that he/she still posed a threat to necessitate a Section 12. Resident #62's physician (MD#1) was interviewed on 12/4/17 at 11:00 A.M. He said that he was contacted by the emergency room physician regarding Resident #62's status. MD#1 said he was told by the hospital physician that Resident #62 was calm, not homicidal, not a threat, and doing well. MD#1 said that he told the hospital physician that although the Resident was stable and not a threat, the facility did not want the Resident to return because the staff were uncomfortable. During interview with the facility social worker on 12/6/17 at 12:45 P.M., she said that Resident #62 had become increasingly loud and yelling at staff over the past few weeks. She also said that the Resident spoke loud normally and often did not realize it. The social worker said that she heard about the Resident being sent to the hospital when she came into work the next day and was under the impression that the facility did not want to take him/her back. The social worker said that no discharge information was given to the Resident because they usually don't discharge Residents to the hospital. During interview with the facility Administrator and DON on 12/7/17 at 1:30 P.M., the DON said that Resident #62 had a strong racial bias against people who were not white. She also indicated that the nurse that the Resident threatened to kill, was not white. The DON said that the facility did not notify the hospital and nursing facility where Resident #62 was transferred from the emergency room , about Resident #62's strong racial bias against people who are not white, and would not say why there was potential danger to Residents and staff at her facility, but not the facility where Resident #62 was transferred. Review of the medical record failed to indicate that the care plan was updated to reflect the Resident's increase in behavioral symptoms and interventions to address them. The medical record included a Notice of Intent Not to Readmit Resident Following hospitalization or Other Medical Leave of Absence from the Facility with Less than 30 Days' Notice signed by the facility Administrator on 11/28/17. There was no evidence that Resident #62 received a copy of the form. Review of the medical record failed to indicate information to support the basis for discharge after being transferred to the hospital for evaluation, having been evaluated to be able to return to the facility, the facility's refusal to allow Resident #62 to return.

Based on record review, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being by failing to provide adequate pain management for 1 sampled Resident (#62) of 26 sampled Residents. Findings included: For Resident #62, the facility failed to insure that effective pain management was provided to Resident #62 who, following a fall resulting in multiple fractures and developed a bone infection, complained of increasing pain that interfered with movement, contributed to immobility and affected the resident's mood. Resident #62 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) with a reference date of 10/13/17, indicated that Resident #62 was cognitively intact, required assistance from staff for bed mobility and toileting, had frequent pain, received scheduled and as needed (prn) pain medication, and received intravenous (IV) medication. Hospital discharge documentation indicated that during the course of inpatient treatment, the resident underwent [REDACTED]. Additionally, he/she developed an infection (osteo[DIAGNOSES REDACTED]) and subsequently had a PICC line (peripherally inserted central catheter) placed, and began a six week course of intravenous (IV) antibiotic therapy. The plan was for the Resident to remain at the facility until his/her scheduled surgery on 11/29/2017 to treat a bone infection. Review of 10/2017 physician's orders [REDACTED]. - [MEDICATION NAME] (antibiotic) 250 ml (milliliters) intravenously every 8 hours - [MEDICATION NAME] 975 mg every 8 hours for pain - [MEDICATION NAME] 650 mg every 6 hours prn (as needed) for pain - [MEDICATION NAME] 20 mg (milligrams) every 4 hours prn for pain Review of documentation from the infectious disease physician indicated that IV antibiotic treatment was discontinued on 11/10/17. Further review of the medical record indicated that in the 8 days prior to the discontinuation of IV antibiotic treatment on 11/10/17, prn pain medication was administered on 10 occasions. In the 8 days following the discontinuation of IV treatment, the Resident reported pain more frequently and prn pain medication was administered on 19 occasions. Nursing note dated 11/18/17, indicated that at approximately 9:00 A.M., Resident #62 complained of right lower extremity pain at a level of 8 out of 10 and prn pain medications [MEDICATION NAME] and [MEDICATION NAME] were administered. The nurse instructed the Resident to elevate his/her leg and rest. A follow-up note indicated the medications were ineffective and the Resident continued to have pain. Further review of the nursing note indicated that Resident #62 yelled at the nurse that he/she had pain of 8/9 out of 10, felt increased pressure and decreased feeling in the right lower extremity where the cast was placed. The physician was notified and gave an order to send the Resident to the hospital for evaluation. The Resident returned to the facility the same day after hospital staff cut the sides of the cast to relieve the pressure. Further review of the medical record failed to include information to support that staff notified the physician that Resident #62 reported pain at a greater level of severity (8 out of 10), and more frequently (31 occasions in a 9 day period from 11/19/17 through 11/28/17), and there was no documentation in the medical record to indicate that the Resident's pain regime was evaluated for effectiveness. During interview with Resident #62's physician on 12/4/17 at 11:00 A.M., he said that he had met him/her a few times and remembered the Resident complaining about staff and the food. The physician said that he believed that Resident #62's pain was under control, and was unaware he/she utilized prn pain medication frequently.

Based on record review and interview, the facility failed to ensure for 1 Resident (#62), in a sample of two closed records, that Residents were allowed to return to the facility after being transferred to the hospital for evaluation of verbal behaviors. The Resident was alleged to have threatened a nurse 12 hours before transfer to the hospital, and did not immediately call the physician to report concerns. Findings include: Resident #62 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. During interview with the Ombudsman on 11/29/17 at approximately 1:45 P.M., she said that she had been contacted by a social worker at St. Anne's hospital's psychiatric unit on 11/28/17, and was told that Resident #62 was sent to the hospital on [DATE] after making a verbal threat to kill a nurse, had been evaluated in the psychiatric unit, and was deemed safe to return to the facility. However, the facility refused to accept the Resident back. The facility Administrator, Director of Nursing (DON), and Corporate Nurse were interviewed on 11/29/17 at 2:30 P.M. The DON said that Resident #62 threatened to kill a nurse at approximately 4:00 P.M. on 11/27/17 at approximately 4:00 P.M. She said that she was told about the verbal threat by the nurse the following morning when she arrived at the building (more than 12 hours after the verbal threat occurred). The DON was told by the nurse that Resident #62 propelled his/her wheelchair down the hallway, approached the nurse who was at the medication cart, and said (in Spanish) that he/she would kill a nurse and did not care if he/she had to go to jail. The Resident then went to his/her room, closed the door and remained in his/her room. The DON said that she immediately put the Resident on a 1:1 (one to one supervision) outside of his/her room (the Resident was not aware he/she had a 1:1 because the door remained closed). She said that the Resident did not exhibit any verbal or physical behaviors once he/she went to his/her room and closed the door. The DON said that although the Resident made no further threats, or exhibited unsafe behaviors, and did not come out of his/her room since the previous afternoon, she decided to have him/her sent to the hospital via a Section 12 (authorization for temporary involuntary hospitalization ). The closed record was reviewed and indicated that required transfer/discharge documentation was not in the medical record. Review of the medical record indicated that Resident #62 was sent to the hospital on [DATE] via a Section 12 following a behavioral (verbally threatened to kill a nurse) incident toward staff on 11/27/17. Review of the Section 12 document indicated that it was faxed to the facility at 9:40 A.M. (more than 17 hours after the incident occurred). The medical record included a Notice of Intent Not to Readmit Resident Following hospitalization or Other Medical Leave of Absence from the Facility with Less than 30 Days' Notice signed by the facility Administrator on 11/28/17. The reason for the decision to not readmit the Resident was identified as threats to harm staff. Further review of the medical record indicated there was no Physician order for [REDACTED]. Resident #62's physician was interviewed on 12/4/17 at 11:00 A.M. The physician said that he was contacted by facility staff on 11/28/17 (more than 12 hours after the verbal threat occurred) with a request for a Section 12 due to a verbal threat that was made by Resident #62 toward facility staff on 11/27/17. He said he signed a Section 12 document and faxed it to the facility, but did not give an order for [REDACTED].#62 was calm, not homicidal, not a threat, doing well and ready for discharge back to the facility. Resident #62's physician told the attending physician that the facility would not readmit the Resident to the facility because staff were uncomfortable, and suggested the Resident be sent to a facility in Rhode Island to wait for his/her scheduled surgery on 11/29/17. The Ombudsman was interviewed on 12/6/17 at 12:45 P.M. She said that she had spoken to the hospital social worker again on 11/29/17, and was told that Resident #62's surgery scheduled for 11/29/17, was canceled due to his/her hospitalization and discharge to the hospital. During interview with the facility Administrator and DON on 12/7/17 at 1:30 P.M., the DON said that facility staff knew since admission in 10/2017, that Resident #62 had a strong racial bias and hated people who were not white. The DON said that the nurse to whom he/she made the threat was not white. The DON said that Resident #62 had been transferred from the hospital to a sister facility and that she did not notify the hospital or the nursing facility, about Resident #62's strong racial bias and hatred for people who are not white. The DON was unable to explain why there was potential danger to Residents and staff at their facility, but not the facility where Resident #62 was transferred.

Based on observation, record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 Resident (Resident #1), from a total sample of 21 residents. For Resident #1, the facility failed to accurately assess, monitor and care plan to prevent fecal impaction with small bowel obstruction, which required a 12 day hospitalization . Findings include: Resident #1 was admitted to the facility in 9/2014 with [DIAGNOSES REDACTED]. Resident #1 was urgently transferred to the hospital in 9/2015 after complaining of left upper quadrant abdominal pain and vomiting fecal matter at the facility. Resident #1 was diagnosed with [REDACTED]. Review of the Annual Minimum Data Set (MDS) Resident Assessment (7/18/15) indicates the following: *a cognitive assessment score (BIMS) of 8/15 or moderately impaired *always continent of bowel and bladder and independent for toilet use Review of the Section K, Quarterly Nursing Assessments dated 7/9/15 and 4/13/15 (2 and 5 months prior to fecal impaction), indicated that the Resident required limited assistance in toilet use and was continent of bowel and urinary function. Bowel Pattern section indicated: Normal formed stool-rarely/never uses laxatives. Review of the Resident's care plans prior to hospitalization (9/2015) indicates no care plan for constipation (even though the resident had a history of [REDACTED]. A constipation care plan was initiated in 10/2015 following return from hospital admission. A care plan for behaviors related to perseveration on bowels (4/15/14) indicated interventions to include: administer medications as ordered, anticipate needs and psych consult as needed. The behavior care plan does not individualize interventions. Review of the Behavior/Intervention Monthly Flow Record for July, August and September 2015 indicates the following: July 2015: 1.) Paranoia: (# of episodes on day, evening and night shifts) indicates all 0s or no behaviors demonstrated. August 2015: 1.) Paranoia: all 3 shifts indicate 0s or no behaviors demonstrated. September 2015: 1.) Paranoia: all 3 shifts indicate 0s or no behaviors demonstrated with 11 from 27 days with recordings not completed at all (including the day before being transferred to the hospital). 2.) Repetitive Actions (newly added): 9/1 & 9/2/15 indicate yes on night shift with no behavior description, 9/6 indicates yes-intervention=give fluids and 9/11 indicates yes refer to nursing notes-9/11/15 nursing note indicates Resident was soiled with urine x2 and increased thirst with numerous requests for liquids (documentation does not indicate that the physician was not notified of this change in continence) Review of the Medication Administration Record [REDACTED]. twice/day for [MEDICAL CONDITION] disorder ([MEDICATION NAME] is an antipsychotic medication which can cause constipation, upset stomach and dry mouth) and Senna 17.2 mg. 1x/day (a laxative for constipation). The whenever necessary bowel (prn) medications ordered for 8/2015 included the following bowel, protocol if no bowel movement in 3 days: [MEDICATION NAME] suppository 10 mg, Fleet enema per rectum daily as needed and Magnesium [MEDICATION NAME] 10 ml every 6 hours by mouth for upset stomach. There were no prns administered for the months of 8/2015 and 9/2015. Review of the Laxative and Bowel Flow Sheets from 8/30/15-9/27/15 indicates that no laxatives or enemas were administered to the Resident. The bowel movement flow sheets were filled out incorrectly with m in the laxative and enema columns and therefore, unable to accurately assess bowel movements. There was no consistency description, such as loose or formed stool. The Surveyor interviewed staff nurse #1 throughout survey (8/12/16, 8/15/16 and 8/16/16). The staff nurse said that the CNAs relied on the Resident's self reporting of bowel movements and did not visualize the bowel movements for size or consistency. The Surveyor asked how the staff could assess the Resident's bowel status without accurate information and without performing abdominal assessments. The staff nurse did not respond. (According to Current Psychiatry, Volume 7, 2008,when evaluating a patient who complains of constipation, first determine what he or she means by constipation. Do not rely on frequency of bowel movements as the only criterion for diagnosis. Committee for Functional Gastrointestinal Disorders guidelines for [DIAGNOSES REDACTED]. Many patients who complain of constipation have daily, regular bowel movements that produce hard, difficult-to-pass stool or require straining or manual maneuvers. Take a careful history including: · stool frequency and quality · straining · sensation of blockage or incomplete evacuation Review of the Standard of Care form which, according to the Director of Nursing (DNS) is used as a reference tool during daily resident reviews and weekly updates with staff, indicated no for events and complete blanks for history of constipation, impaction/reason for impaction, on appropriate bowel regime. The Incontinence section indicates no for incontinence of bowel or bladder. Review of Nursing Progress Notes from 8/12/2015 to 9/27/15 (hospital admission) indicated the following behavior notes with no evidence of a follow-up abdominal assessment: 8/12/15 @ 01:00: Resident spending a great deal of time in his/her bathroom. Resident soiled the toilet and bathroom floor with feces, has not slept. Entry @ 05:16: awake all night, soiled the bathroom with feces and does not want roommate to use bathroom, verbally redirected without success. Entry @ 19:37: Family in to visit and notices an increase in behavior. 8/14/15 @ 03:57: not slept this evening and spent most of time in the bathroom. 8/15/15 @ 04:00: Resident continues with behaviors, frequently in the bathroom. 8/18/15 @03:54: In and out of the bathroom, sitting on the toilet for long periods of time and slept in short naps only during the night. 8/18/15 @ 18:54: new orders given to start [MEDICATION NAME] 25 mg by mouth daily (to treat depression and [MEDICAL CONDITION]-health care proxy and MD agreed) 8/19/15 @ 06:42: Resident noted to still be sitting on toilet and stated leave me alone. 8/22/15 @ 06:52: spent most of 11-7 shift on toilet and did not sleep and @ 19:25: spent majority of time in his/her bathroom during this shift 8/23/15 @ 14:41: noted to spend majority of time in bathroom today 8/24/15 @ 01:30: spending most of his time on the toilet with door open 9/10/15 @ 14:42: came to nursing station x3 asking for water, twice noted to be soiled with urine 9/11/15 @ 11:06: incontinent of large amounts of urine x2, asked for water twice 9/11/15 @ 18:08: refused supper and alternate, denies pain, increased thirst (family updated on behaviors) 9/12/15 @04:04: resistive to care and incontinent of urine this shift (attempting to get a urine specimen) 9/15/15 @ 19:09: on [MEDICATION NAME] for pneumonia and urinary tract infection-no behaviors 9/23/15 @ 04:54: slept poorly, frequent request for drinks this shift 9/27/15 @ 18:46: vomited and covered in large amount of black mucous like substance-reported that stomach ached-absent bowel sounds in lower quadrants-MD notified and sent to hospital with bowel obstruction and vomiting feces. On 8/15/16 at 9:15 A.M. the Surveyor interviewed the Nurse Practitioner (NP) by telephone. The NP said that the Resident was obsessed with his/her bowels and always complained of diarrhea or constipation. The Surveyor asked about her exam/visit on 7/17/16, which did not include an abdominal assessment. The NP said that the Resident was difficult to assess and that she didn't always conduct an abdominal exam. On 8/18/16 at 8:30 A.M. the hospital physician was interviewed by telephone. The physician said that the only way to truly assess for a potential obstruction is by abdominal exam. She said that days before a fecal impaction, the bowel sounds would be absent or very hypoactive with a very tender abdomen. The physician reviewed the hospital report again, (while on telephone), and said that the Resident presented to the emergency room with a very protuberant abdomen. The physician also said that the clinical presentation of fecal impaction with obstruction could include new incontinence of bowel and bladder (from the small bowel putting pressure on bladder and stool oozing around the impaction). The physician said that given the history, new incontinence, increased thirst and time spent in bathroom could have been red flags that something was brewing and a KUB could have been done in the facility. She also said that a bowel regimen should be individualized based on the resident's history, especially considering a previous history of fecal impaction (2010). On 8/18/16 at 10:45 A.M. the primary care physician was interviewed. The physician said that the Resident was never difficult to assess and never became combative or resistive to care (as the NP had said previously). The physician did say that Resident #1 was obsessed with his/her bowels. The Surveyor asked if this might be the case because of the Resident's previous history of constipation and fecal impaction (2010). The physician said that this was possible. The Surveyor asked about the physician's exam on 9/23/15 (4 days prior to the Resident's hospitalization ). The physician said if she wrote that the Resident's abdomen was soft, non-tender with active bowel sounds, then that is what she saw. The physician could not remember if she was notified of the Resident's change in behaviors (increased time in the bathroom) and new incontinence.

Based on observation, record review and interview, the facility failed to obtain timely urgent dental services for one Resident, (Resident #10), form a total sample of 21 residents. Findings include: Resident #10 was admitted to the nursing facility in 8/2015 with the following Diagnoses: [REDACTED]. Review of the medical record on 8/12/16 indicated that the Resident was assessed for pain as 0, or experiencing no pain and therefore, did not trigger for a pain care plan. Review of the Medication Administration Record [REDACTED]. Review of the physician's orders [REDACTED].#3 ordered every 4-6 hours as needed. The MAR indicated [REDACTED]. Review of the Nursing Progress Note dated 7/30/16 indicated that the Resident was complaining of a toothache because his/her filling had fallen out. The Resident was assessed by staff to have a swollen cheek. On 8/12/16 at 3:00 P.M., the Surveyor interviewed staff nurse #1. Staff nurse #1 said that Resident #10 had been complaining of a toothache for several days. She also said that the facility's dentist was unavailable covering other facilities and would not be available for months. The staff nurse said that she had just scheduled a dental appointment with a non-facility dentist for 8/13/16 (14 days after the Resident initially voiced complaints of tooth pain and had a visibly swollen cheek). The Surveyor interviewed the Resident on the afternoon of 8/15/16, outside his/her room. The Resident said that he/she was not doing so good and pointed to his/her left side of mouth and did not want to talk much. Review of the consultant dental report (dated 8/13/16) indicated that the Resident required 5 tooth extractions.

Based on observation, record review, and staff interview, the facility failed to investigate, document surveillance, and attempt to mitigate an outbreak of viral gastroenteritis in the facility. Between 12/23/11 and 1/22/12, a total of 21 residents, 3 staff and 1 visitor developed symptoms of gastrointestinal illness including 8 sampled residents, (#6, #8, #9, #24, #27, #29, #34, #37). The total sample included 39 residents. The facility failed to implement effective infection control policies and practices to prevent the spread of gastrointestinal illness. The findings include: 1. The facility failed to contain an outbreak of a gastrointestinal infection when first identified in the facility by failing to cohort residents, and identifying staff and visitors affected, in an effort to prevent the spread of the infection. The facility failed to identify and implement appropriate precautions to prevent cross contamination to other residents and staff. No residents with gastrointestinal (GI) symptoms were placed on Contact Precautions. Observations of improper precautionary measures included: staff observed in rooms of residents displaying symptoms without appropriate protective equipment, staff not following proper hand hygiene procedures and handling of infectious waste, and the lack of appropriate signage per the facility policy to alert staff and visitors to potential infection risks. 2. The facility failed to implement appropriate surveillance, investigation and monitoring measures to reduce the spread of infection. The facility failed to monitor residents and staff for symptoms of illness, identifying the location of those infected, and determining when previously infected residents and staff were no longer contagious. No resident who became ill between 12/23/11 and 1/8/12 was included on the Infection Control tracking list. On 1/18/12, review of the facility infection line list dated January 2012 revealed a list of 7 residents identified as "Residents with n/v (nausea, vomiting) diarrhea 24 hour virus." The Infection Control Coordinator was interviewed on 1/18/12 at 8:45 A.M. She reviewed the line listing with the surveyor and said that the seven residents listed, beginning 1/9/12 had symptoms that included nausea, vomiting and loose stools that resolved within 24 to 48 hours. The Infection Control Coordinator said that the line list reflected that six of the seven identified residents resided on the Borden Unit and developed symptoms over a nine-day period. The Infection Control Coordinator never identified the 24 hour GI virus as an outbreak of viral gastroenteritis infection. Per the facility's Infection Control policy for Norovirus, in the absence of stool culture for the confirmation of diagnoses, which was not done, a Norovirus outbreak was identified as: vomiting in more than half of the symptomatic cases; an average incubation period of 24 to 48 hours between exposure to the virus, and when symptoms are first apparent, and a duration of illness of 12 to 60 hours. The Infection Control Coordinator explained that the attending physician was made aware of the residents identified with the "GI illness on a case by case basis" and that the responsible family member was notified "as required." The Infection Control Coordinator was asked if employees had been sick with the gastrointestinal illness. She indicated that she did not handle employee sick calls but knew of 3 CNA's from the Borden Unit that had been out sick for a day and then returned to work the following day. The Infection Control Coordinator was asked if group activities and communal dining was limited. The Infection Control Coordinator replied "no." The Infection Control Coordinator said that was were no signs posted to alert visitors that the facility was experiencing an outbreak of a gastrointestinal illness. Additionally, she indicated that neither the local board of health or the Department of Public Health had been notified as required. The Infection Control Coordinator said that nursing management was aware of a "GI virus" in the facility. On 1/18/12 at 9:45 A.M., the Director of Nurses (DNS) was asked if there was an outbreak of gastrointestinal illness in the building. The DNS said that a "couple of cases" were reported. I. Containment: The facility failed to provide proper interventions to attempt to contain an outbreak of viral gastroenteritis in the facility from 12/23/11 through 1/22/12. The facility had no documented tracking of residents who developed symptoms of gastrointestinal illness from 12/23/11 through 1/8/12. When the facility identified that there were six residents on the Borden Unit who had developed symptoms of a gastrointestinal illness, beginning 1/9/12 and continuing through 1/17/12, they failed to follow their own policy to minimize resident movement within the facility. Interview with the Infection Control Coordinator on 1/18/12 at 8:45 A.M., confirmed that no containment interventions were initiated A. Contact Precautions/Personal Protective Equipment: The facility failed, from 12/23/11 until the time of surveyor inquiry on 1/18/11, to place affected residents on effective contact precautions to minimize the opportunity for transmission of the illness. Contact precautions are required due to the high incidence of direct and indirect transmission of gastrointestinal illness. The facility's policy requires cohorting or contact precautions, neither of which was done. According to the Massachusetts Department of Public Health, contact precautions are needed and should be maintained for up to 72 hours after the last symptom of illness, because the virus can still be transmitted. On 1/18/12 at 3:45 P.M, the Infection Control Coordinator said that residents affected by the gastrointestinal illness were to be on "contact precautions" which she said included wearing gloves when providing care and applying a gown "if the resident was visibly soiled." The Infection Control Coordinator identified no additional personal protective equipment (PPE) was needed. According to facility policy, the use of PPE included applying gowns and gloves upon entry to the room. The use of a procedure mask and eye protections is recommended particularly among those who are vomiting. Shared equipment is to be cleaned and disinfected between patient uses and heavily-soiled linens are to be handled carefully, without agitating them to avoid dispersal of virus. During the initial tour of the facility on 1/11/12 at 10 A.M., resident #8 was lying in bed and appeared weak. The Borden Unit manager reported that the resident had nausea, vomiting and diarrhea and that a gastrointestinal "bug" had affected some of the residents on the Borden Unit. Per observation at that time, there were no "precautions" set up to alert those caring for the resident that the resident had a potentially communicable disease. Staff were observed entering and exiting the room without any special consideration. B. Cohorting of Residents and Staff: Per interview with the Infection Control Coordinator on 1/18/12 at 8:45 A.M., the facility failed to consider the cohorting of exposed residents and staff to prevent the spread of infection to other residents and staff in the facility. Residents from all three units attended activities and meals in common areas with residents from other units without regard for the spread of the disease. Residents and staff recovering from the illness were not restricted from contact with non affected residents despite being potentially infectious for three days after symptom resolution. The facility failed to stop affected and non-affected residents from attending rehabilitation sessions in common areas. Following surveyor inquiry on 1/18/12, the facility planned to provide rehabilitation services at the resident's bedside instead of the main therapy room where it had previously been provided. The facility failed to consider which staff was caring for the sick residents and tailor the nursing assignments to minimize the opportunity for transmission consistent with the facility policy. The facility failed to track whether staff that floated unit to unit had been exposed to the illness and failed to consider stopping the practice of floating to minimize the opportunity for transmission between units. On 1/18/12, the facility reported to the surveyors that the practice of floating staff would be restricted to limit exposure. However, review of staffing assignments revealed that a nurse aide was assigned to work on three different units between 1/19/12 and 1/23/12. The Staffing Coordinator was interviewed on 1/24/12 at 11:30 A.M. said that she was not aware that she had to restrict floating until 1/23/12. C. Handwashing: The facility failed to ensure that staff was instructed on the importance of hand washing with soap and water, rather than a reliance on alcohol based gel, and failed to institute a more rigorous program of resident hand washing with soap and water. On 1/18/12 at 2:45 P.M. facility management, the Infection Control Coordinator and the nurse consultant presented a "GI Illness Management Plan" to the surveyors. The plan included that all staff would be educated regarding "strict handwashing." During this overview the facility said that proper handwashing included the use of hand gel. On 1/18/12 at 3:45 P.M.., the Infection Control Coordinator presented attendance rosters dated 1/18/12 that indicated that she had just educated 31 staff members on multiple topics including handwashing. No course material was attached and the facilitator was not listed. The Infection Control Coordinator told the surveyor the handwashing education included the use of hand gel. Per the Center for Disease Control and the Massachusetts Department of Public Health during a gastrointestinal illness outbreak, handwashing with soap and water was recommended. On 1/23/12 at 9:45 A.M. the nurse consultant said that facility policy indicated that during an outbreak, soap and water was the preferred method of hand hygiene. D. Environment cleaning: Per facility policy, the facility failed to ensure that staff responsible for cleaning infected areas were wearing proper personal protective equipment and were modifying cleaning assignments to minimize the opportunity for transmission of the illness. The facility failed to develop a comprehensive environmental disinfection program to minimize the opportunity for transmission of the illness. On 1/18/12 at 11:30 A.M. the Director of Environmental Services, who manages the contracted housekeeping service, said that he was not told of a gastrointestinal illness outbreak in the facility. The Director of Environmental Services said that no information regarding a gastrointestinal illness had been communicated during daily morning meetings which he regularly attends. The Director of Environmental Services said that he had increased cleaning of the common areas over the previous two weeks as a preventative measure because of the flu season. Following surveyor inquiry on 1/18/12, the facility began ensuring that housekeeping staff were wearing PPE in affected rooms and had a detailed cleaning schedule to minimize the spread of illness. E. Notification: 1. Visitors The facility failed to follow its policy to restrict non-essential visitors from affected areas of the facility during outbreaks of viral gastroenteritis. There was no process to ensure that visitors were screened and excluded from visiting if they had symptoms consistent with gastrointestinal illness. During interview on 1/18/12 at 8:45 A.M. the Infection Control Coordinator said that when a resident developed gastrointestinal illness, the responsible family member was contacted as required, to notify them about the illness. The Infection Control Nurse said that the facility could not prevent family members from visiting if they wanted to. The Infection Control Coordinator was unable to explain the facility's process for monitoring visitor compliance with infection control practices including hand hygiene and contact precautions. The Regional Ombudsman interviewed via telephone on 1/18/12 at 11:00 said that the facility Ombudsman was unaware that there was an outbreak of gastrointestinal illness in the facility. Following surveyor inquiry on 1/18/12, a sign was placed on the doors to the facility alerting visitors that residents in the building were "experiencing gastrointestinal disturbances." 2. Resident Notification: Per interview with facility management staff on 1/18/12 at 2:45 P.M., residents were not aware of a gastrointestinal illness outbreak in the facility. Residents were not told the importance of more frequent handwashing with soap and water. 3. Notification of other health care providers Health care facilities including hospitals and wound clinics accepting residents for transfer were not informed of resident illness or of the outbreak in the facility. F. The facility failed to develop containment strategies and failed to implement their own policy in an attempt to mitigate an outbreak of viral gastroenteritis resulted in 8 additional sampled residents becoming ill (#6, #8, #9, #24, #27, #29, #34, #37) of 21 residents who developed symptoms of gastroenteritis. Finding include: 1. Record review indicated that prior to Resident #8's gastrointestinal (G.I.) illness, there were 6 residents, all residing on the Borden unit, who had symptoms of gastrointestinal illness: Resident #34 on 12/23/11, Resident #6 on 1/3/12, non sampled resident (NS#1) on 1/4/12, Resident #34 on 1/9/12, non sampled resident (NS#2) on 1/10/12. Resident #37, non sampled resident (NS#3), and Resident #8 developed nausea, vomiting and diarrhea on 1/11/12. Resident #8 developed a G.I. illness and a change in condition that ultimately led to the resident's hospitalization . Resident #8 developed nausea, vomiting and diarrhea and was then hospitalized with pneumonia, urinary tract infection, dehydration and myocardial infarction. Resident #8, an aged, frail resident, had [DIAGNOSES REDACTED]. The resident's most recent initial Minimum Data Set Assessment (MDS) with a reference date of 11/14/11 indicated that the resident was cognitively impaired and needed extensive assistance from facility staff to complete the activities of daily living. Per review of the nurse's notes, on 1/11/12 at 7:48 A.M., the resident vomited 6 times and had 2 loose bowel movements. The resident's temperature was recorded at 102.9 degrees Fahrenheit (F.) The resident's physician ordered a clear liquid diet for 1/11/12, [MEDICATION NAME] A-D 2 mg by mouth every 4 hours as needed for loose bowel movements and [MEDICATION NAME] 25 mg suppository by rectum every 6 hours as needed for vomiting. The physician also ordered laboratory studies including a complete blood count (CBC) and basic metabolic panel (BMP). Results of the BMP drawn at 6 A.M. on 1/11/12 included Sodium 140 mmol/L (normal 135-144), blood urea nitrogen (BUN) 33 mg/dl (normal 5-25.) During the initial tour of the facility on 1/11/12 at 10 A.M., the resident was lying in bed and appeared weak. The Borden unit manager reported that the resident had nausea, vomiting and diarrhea and that a gastrointestinal "bug" had affected some of the residents on the Borden unit. Per observation at that time, there were no "precautions" set up to alert those caring for the resident that the resident had a potentially communicable disease. Staff were observed entering and exiting the room without using any personal protective equipment and soap/water hand hygiene. A care plan developed for Resident #8 for nausea and vomiting, " ?GI virus" was developed on 1/11/12. Goals were that the resident would have electrolyte lab values within normal limits, be free of signs and symptoms of dehydration and resume a normal diet. Interventions included reporting nausea and vomiting, activity as tolerated, anti-emetics as ordered, advance diet as tolerated, head of bed up and deep breathing to minimize vomiting and laboratory studies as ordered. Subsequent temperatures recorded in the nurse's notes for 1/11/12 included 102.7 F at 4 P.M., 101.4 F at 6:30 P.M. and 100.5 F at 11:58 P.M. During interview on 1/24/12 at 11:30 A.M., the facility nursing supervisor produced the resident's meal intake record to show monitoring of the resident's intakes during the spell of illness. Total intake for 1/11/12 was 265 cc's. Per the nurse's notes on 1/12/12, the resident was incontinent with a loose bowel movement at 6:30 A.M. and, despite the administration of [MEDICATION NAME], was again incontinent with a loose bowel movement at 7 A.M. The 11/14/11 MDS reported that the resident was always continent of stool. The temperature was 98 F. The nurse's notes reported that later on 1/12/12 at approximately 12:45 P.M., the resident had 4 loose bowel movements in a short period of time. Total intake for 1/12/12 was 600 cc's. Per the nurse's notes on 1/13/12, the resident complained of general discomfort and was administered Tylenol at 9:30 A.M. The resident also had 1 loose bowel movement. Total intake for 1/13/12 was 620 cc's. On 1/14/11 at 3:00 A.M. the nurse's notes reported that the resident had a health status change. The resident developed a congested cough, expiratory wheeze and drop in oxygen saturation to 85% (normal greater than 90%). The resident's lung sounds were diminished with crackles at the bases. Vital signs were blood pressure 97/53, pulse 77, respirations 24 and temperature 100.5 F. Oxygen was applied at 2 liters per minute and the resident's oxygen saturation improved to 95%. The physician and family were called and a decision was made to send the resident for emergency treatment. The resident arrived at the hospital emergency department at 4:35 A.M. on 1/14/12. Laboratory tests completed included an elevated sodium of 146 and an elevated B.U.N. of 50 - both indicative of dehydration. The resident's urinalysis reported positive [MEDICATION NAME], a large amount of leukocyte esterase and many bacteria - all indicative of urinary tract infection. The resident had an abnormal electrocardiogram and laboratory studies that included a critically elevated Troponin 1 1.84 ng/ml (range 0-0.3) and an elevated CKMB 12.3 ng/ml (0-5.0)- indicative for a myocardial infarction. A chest x-ray showed a right upper lobe infiltrate. The emergency room physician wrote: "? Aspiration". After discussion with family, the resident was sent back to the facility with orders to start antibiotics by mouth and receive supportive care. The resident was observed on 1/18/12 and 1/20/12 at the lunch meal. The resident appeared weak and was using supplemental oxygen. Nurse #3 reported that the resident's overall condition and appetite had declined since becoming ill and the subsequent hospitalization . 2. Record review indicated that following Resident #34's first episode of gastrointestinal illness on 12/23/11, there were 11 other residents on the Borden unit who had symptoms of gastrointestinal illness. Resident #6 on 1/3/12, Resident NS #1 on 1/4/12, Resident #9 and Resident #34 developed symptoms again on 1/9/12. On 1/10/12, Resident NS #2 developed symptoms, Resident #8, Resident NS #3 and Resident #37 developed symptoms on 1/11/12, non sampled resident NS #4 on 1/12/12, Resident NS #6 on 1/16/12, Resident NS #7 on 1/17/12. Resident #34 had a third episode of gastrointestinal illness on 1/22/12. The facility failed to implement containment strategies and failed to implement their own policy to minimize the spread of gastrointestinal illness. Resident #34 developed 3 separate episodes of G.I. illness: 12/23/11, 1/9/12, and 1/22/12. Resident #34 was admitted in late October 2011 with [DIAGNOSES REDACTED]. Record review on 1/24/12, revealed that according to the most recent MDS (Minimum Data Set), signed as being completed 11/2/11, the resident was assessed to experience altered mental status, as evidenced by a BIMS (Brief Interview for Mental Status) score of "4" out of a total of 15. Additionally, the MDS indicated that the resident was Portuguese-speaking, required extensive assistance with transfers, was totally dependent on staff for bed mobility, dressing, hygiene, and bathing, and experienced limitations in functional range of motion in both left and right lower extremities. The MDS also indicated that the resident was always incontinent of bladder and frequently incontinent of bowel. Record review on 1/24/12, revealed that on 12/23/11 at 8:33 A.M., the nurse documented that the resident had an occasional cough, expectorated thick yellow/green phlegm and yellow white sputum, and vomited a moderate amount of tan liquid after breakfast and lunch. The nurse practitioner was notified and ordered a chest x-ray, and a clear liquid diet until the vomiting resolved. A [MEDICATION NAME] (anti-nausea) suppository 25 mg. (milligrams) per rectum was ordered and given at 4:00 P.M. with good effect. Further record review on 1/24/12 documented no further episodes of vomiting following the episode on 12/23/11, until 1/9/12. On 1/9/12 at 2:45 A.M., the nurse noted that the resident had a loose bowel movement. The note indicated that while cleaning the resident's loose stool the resident began to vomit. The nurse administered a [MEDICATION NAME] suppository at 2:50 A.M. and noted good effect with no further vomiting. There was no evidence in the record that the physician was notified of the resident's gastrointestinal illness. Record review on 1/24/12, revealed that Resident #34, who had exhibited episodes of gastroenteritis on 12/23/11, 1/9/12 and 1/22/12, had not been identified on the facility's initial infection line listing. The facility failed to consider the resident a potential carrier of the gastrointestinal illness that had begun to spread throughout the facility. 3. Resident #24 was admitted to the facility's Talbot unit in November 2011 for short term rehabilitation. There were no residents identified on that unit with gastrointestinal symptoms at that time. According to the resident's initial Minimum Data Set, dated dated as completed on 11/28/11, Resident #24 was alert and oriented and required assistance with activities of daily living. Record review, on 1/20/12, of the nurse's note, dated 1/1/12 written at 1816 (6:16 P.M.), indicated that Resident #24's face was flush and complained of feeling nauseous with a temperature of 98.2 degrees Fahrenheit. Subsequently the note indicated that Resident #24 was unable to tolerate fluids and vomited clear liquid several times within a 5 hour period. The resident's temperature at that time was 100.0 degrees Fahrenheit. Shortly after being medicated with [MEDICATION NAME] (for nausea) and Tylenol (for the resident's temperature), the resident vomited clear liquid again. The nurse practitioner was notified and requested that Resident #24 be evaluated at the emergency room . Resident #24's daughter was notified of the resident's change in condition. The family member said to the nurse that "she recently had similar symptoms (vomiting, fever)". Resident #24 was transferred to emergency room at 1715 (5:15 P.M.). The nurse's note, dated 1/2/12 written at 3:28 A.M., indicated that a call was received from the hospital, at approximately 10:30 P.M, that Resident #24 would be returning to the facility with the [DIAGNOSES REDACTED].I. virus". The note indicated that the resident returned to the facility at 10:55 P.M. The resident returned with new orders for clear liquid then light diet times 24 hours each and an as needed order for the anti-nausea medication, [MEDICATION NAME]. Another nurse's note, dated 1/2/12 written at 10:03 A.M., indicated that the resident felt much better, that the resident tolerated the clear liquid diet for breakfast, and that the resident had a temperature of 99.3 degrees Fahrenheit. A nurse's note, dated 1/9/12, indicated that Resident #24 was discharged to an Assisted Living Facility on that date. The facility presented to the survey team their "G.I. Disturbance Resolution Log" on 1/23/12. This log identified residents with gastrointestinal symptom onset dates, ranging from 12/28/11 to 1/22/12. Resident #24 had symptoms of nausea and vomiting identified on 1/1/12 and a hospital [DIAGNOSES REDACTED].I.Virus" on 1/2/12. A nurse's note, dated 1/1/12, indicated that the resident's daughter had said that she had similar symptoms as Resident #24. Resident #24 was not included in the facility's identification log and there was no documented evidence that Resident #24's illness or that the resident's family comment regarding her own similar illness were considered by the facility in developing a containment program regarding the G.I. illness on the Talbot unit. Record review indicated that there were 3 residents who developed G.I. symptoms on the Talbot unit following Resident #24's incident on 1/1/12. Resident #27 on 1/4/12, Resident #28 on 1/6/12, and Resident #29 on 1/7/12. 4. Resident #29 had a [DIAGNOSES REDACTED]. According to the resident's initial Minimum Data Set, dated dated as completed on 1/18/12, Resident #29 was alert and oriented and required assistance with activities of daily living. Record review indicated that prior to Resident #29's gastrointestinal illness on 1/7/12, there were 3 residents on the Talbot unit who had symptoms of gastrointestinal illness. Resident #24 on 1/1/12, Resident #27 on 1/4/12, Resident #28 on 1/6/12. The facility failed to implement containment strategies and failed to implement their own policy to minimize the spread of gastrointestinal illness. Resident #29 developed a G.I. illness. Record review on 1/23/12, of a nurse's note, written at 15:10 (3:10 P.M.) indicated that on 1/7/12 Resident #29 vomited 2 times with no complaints of nausea. The nurse's note, dated 1/8/12 written at 4:37 A.M., indicated that the resident complained of nausea and vomited a small amount of yellow liquid 1 time at approximately 10 P.M. Review of the nurse practitioner's progress note, dated 1/9/12, indicated that the resident complained of nausea and vomiting since starting antibiotics, [MEDICATION NAME] and [MEDICATION NAME], in the hospital and reported mild diarrhea 2 days ago, which had been resolved. The nurse practitioner note posed the question of antibiotic use or viral gastrointestinal infection as possible causes for the resident's nausea. The nurse's note, dated 1/11/12 written at 19:34 (7:34 P.M.), indicated that the resident had a temperature of 98.4 degrees Fahrenheit and vomited a small amount shortly after taking morning medications. The note also indicated that the medication time was changed to decrease gastric irritation. The nurse's note, dated 1/13/12 written at 18:34 (6:34 P.M.), indicated that the resident received all morning medications without any nausea or vomiting, but at 3:45 P.M. vomited a small amount of bile and complained of feeling nauseous. The nurse practitioner was updated of the resident' status and subsequently gave a new order to discontinue the anti-nausea medication, [MEDICATION NAME] and start [MEDICATION NAME] suppository every 8 hours as needed. The physician's progress note, dated 1/13/12, indicated that the resident was examined and a "Health and Physical" was documented. There was no further assessment regarding the etiology (antibiotic use or viral gastrointestinal infection) as posed in the nurse practitioner's note of 1/9/12. The nurse's note, dated 1/15/12 written at 16:48 (4:48 P.M.), indicated that the resident had a temperature of 97.4 degrees Fahrenheit and that the resident's appetite remained poor and that the resident vomited a small amount of digested food at 11 A.M. The nurse's notes, dated 1/16/12, indicated that the resident had no instances of nausea and vomiting. The nurse's note, dated 1/17/12, indicated that Resident #29 was being transferred from the vascular surgeon's office to the hospital for further evaluation of the resident's continued complaints of leg pain and further treatment of [REDACTED]. 5. Resident #27 had [DIAGNOSES REDACTED]. On 12/15/11 the resident started chemotherapy. Resident #27 lived on the Talbot unit. Record review indicated that prior to Resident #27's gastrointestinal illness on 1/4/12. Resident #24, who also resided on the Talbot unit, had symptoms of gastrointestinal illness on 1/1/12. The facility failed to implement containment strategies and failed to implement their own policy to minimize the spread of gastrointestinal illness. Resident #27 developed a G.I. illness. A nurse's note, dated 1/4/12 at 7:24 P.M., reported that the resident vomited. Later, at 9:15 P.M., the nurse's note reported that the resident vomited a second time. A nurse's note, dated 1/5/12 at 11:16 A.M., reported that the resident was incontinent of stool (the resident was assessed as continent of stool). The resident also complained of nausea. Later that day, the nurse's notes reported that the resident refused breakfast and lunch. 6. Resident #6 was admitted to the facility on [DATE] following a medical leave of absence for the treatment of [REDACTED]. According to the resident's quarterly assessment, dated 1/2/12, the resident was alert and oriented and dependent on staff for activities of daily living. Record review indicated that prior to Resident #6's gastrointestinal illness, there was 1 resident on the Borden unit who had symptoms of gastrointestinal illness. Resident #34 on 12/23/11. Resident #6 developed G.I. symptoms on 1/3/12. The facility failed to implement containment strategies and failed to implement their own policy to minimize the spread of gastrointestinal illness. Resident #6 developed a G.I. illness. Record review on 1/13/12 of the nurse's note, dated 1/3/12 written at 16:27 (4:27 P.M.), indicated that the resident vomited large amounts of digested foods 2 times in the morning and had a temperature of 98.8 degrees Fahrenheit. A physician order [REDACTED]. The nurse's note, dated 1/4/12 written at 1850 (6:50 P.M.), indicated that the resident had no further nausea or vomiting, had a temperature of 98.4 degrees Fahrenheit, and took solid foods at lunch without difficulty. 7. Resident #9 was admitted with [DIAGNOSES REDACTED]. According to the most recent MDS (Minimum Data Set), signed as being completed 11/2/11, the resident required extensive assistance with bed mobility, transfers, dressing, hygiene, bathing, and required supervision with ambulation in the resident's room. The MDS noted that the resident was always incontinent of bowel and bladder. Record review indicated that prior to Resident #9's gastrointestinal illness on 1/9/12. There were 3 residents on the Borden unit who had symptoms of gastrointestinal illness. Resident #34 on 12/23/11, Resident #6 on 1/3/12, non sampled resident #1 on 1/4/12, and Resident #34 again on 1/9/12. The facility failed to implement containment strategies and failed to implement their own policy to minimize the spread of gastrointestinal illness. Resident #9 developed a G.I. illness. Record review on 1/11/12, revealed a nurses note written on 1/9/12 at 3:18 P.M. The note documented "Loose BM's times 2, vomited times 1 undigested food, no C/O pain or discomfort "+" (positive) bowel sounds all 4 quads (quadrants). The note indicated that the MD (physician) was aware, a clear liquid diet was ordered, and "notify the MD if vomiting continues". On 1/9/12 at 6:11 P.M., the nurse documented that the clear liquid diet was tolerated well and there was no further vomiting and no loose stools noted. On 1/10/12 at 4:05 P.M., the nurse's note indicated that there was no fur

Based on record review, observation and staff interview, the facility failed for 2 residents (#7 and #19) of a total sample of 39 residents, to ensure that each resident receive proper care and treatment of [REDACTED]. The findings included: 1. Resident #7 had [DIAGNOSES REDACTED]. The resident's most recent initial Minimum Data Set Assessment (MDS) with a reference date of 11/15/11 indicated that the resident was cognitively intact and needed the assistance of facility staff to complete the activities of daily living. The resident was admitted to the facility in November 2011 for the long term administration of intravenous antibiotics via a peripherally inserted central catheter (PICC) line. Per record review, a facility nurse documented that the PICC dressing was changed on 11/11/11. A baseline measurement reported that the external length of the catheter was 0 cm. The nurse failed to document whether the injection caps were changed as per policy with each dressing change. On 11/18/11, a scheduled weekly dressing change was not completed as per facility policy. No explanation was written. On 11/21/11, the dressing change was done. A facility nurse documented that the external length of the catheter was 5 cm. There was no indication that the facility nurse recognized that the catheter had potentially migrated out and made efforts to ensure proper placement of the central line in the superior vena cava. The nurse failed to call the physician to obtain an x-ray to verify placement of the intravenous line. During subsequent dressing changes on 11/28/11, 12/5/11, 12/19/11 and 12/24/11, facility nurses failed to document the external length of the catheter to assess for migration. On 12/25/11, the PICC was found to have migrated out 15 cm. A new PICC was placed on 12/26/11. The facility failed to obtain a baseline external measurement of the PICC line during the first dressing change of the new PICC on 12/27/11. During subsequent dressing changes on 12/29/11, 12/31/11, 1/1/12 and 1/8/12, nurses failed to document any measurement of the external catheter. Facility nurses failed to document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 1/12/12 the PICC was removed. Upon admission to the facility, the antibiotic [MEDICATION NAME] was ordered to be administered four times daily. Nurses failed to document that the medication was administered once on 11/11/11, twice on 11/12/11, once on 11/16/11, once on 11/29/11, and once on 12/5/11. 2. Resident #19 had [DIAGNOSES REDACTED]. The resident was newly admitted to the facility for the administration of intravenous antibiotics via a peripherally inserted central catheter (PICC) line. Per record review, the facility failed to obtain a baseline measurement of the external catheter to assess for migration of the line during the first dressing change on 1/15/12. According to the admission nursing assessment, the PICC had 2 lumens for administration. The facility had no method to account for which port was in use for the administration of the intravenous antibiotics and to ensure that any port not in use for more than 8 hours be flushed with 10 cc's of normal saline. For 2 of the 4 days available for review, facility nurses failed to document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Per observation of the intravenous tubing hanging in the room on 1/19/12 at 3:00 P.M., the tubing was not labeled and dated.

Based on record review, observation and staff interview, the facility failed for 1 resident (#8) of a total sample of 39 residents, to ensure that each resident receive proper care and treatment to maintain hydration. The findings included: 1. The facility failed to adequately monitor the resident's intake after the resident developed nausea, vomiting and diarrhea. The resident was then hospitalized with pneumonia, urinary tract infection, dehydration and [MEDICAL CONDITION] infarction. Resident #8 had [DIAGNOSES REDACTED]. The resident's most recent initial Minimum Data Set Assessment (MDS) with a reference date of 11/14/11 indicated that the resident was cognitively impaired and needed extensive assistance from facility staff to complete the activities of daily living. Per review of the nurses' notes, on 1/11/12 at 7:48 A.M., the resident vomited 6 times and had 2 loose bowel movements. The resident's temperature was recorded at 102.9 degrees Fahrenheit (F.) The resident's physician ordered a clear liquid diet for 1/11/12, [MEDICATION NAME] AD (anti-diarrheal) 2 mg by mouth every 4 hours as needed for loose bowel movements and [MEDICATION NAME] 25 mg suppository by rectum every 6 hours as needed for vomiting. The physician also ordered laboratory studies including a complete blood count (CBC) and basic metabolic panel (BMP). Results of the BMP drawn at 6 A.M. on 1/11/12 included Sodium 140 mmol/L (normal 135-144), blood urea nitrogen (BUN) 33 mg/dl (normal 5-25.) During the initial tour of the facility on 1/11/12 at 10 A.M., the resident was lying in bed and appeared weak. The Borden unit manager reported that the resident had nausea, vomiting and diarrhea and that a gastrointestinal "bug" had affected some of the residents on the Borden unit. A care plan for nausea and vomiting, "?[MEDICAL CONDITION]" was developed on 1/11/12. Goals were that the resident would have electrolyte lab values within normal limits, be free of signs and symptoms of dehydration and resume a normal diet. Interventions included reporting nausea and vomiting, activity as tolerated, anti-emetics as ordered, advance diet as tolerated, head of bed up and deep breathing to minimize vomiting and laboratory studies as ordered. Subsequent temperatures recorded in the nurses' notes for 1/11/12 included 102.7 F at 4 P.M., 101.4 F at 6:30 P.M. and 100.5 F at 11:58 P.M. During interview on 1/24/12 at 11:30 A.M., the facility nursing supervisor produced the resident's meal intake record to show monitoring of the resident's intakes during the spell of illness. Total intake for 1/11/12 was 265 cc's. Based on an approximate weight of 130 pounds from November 2011, the resident's daily fluid needs were approximately 1700 cc's per day. Per the nurses' notes on 1/12/12, the resident was incontinent with a loose bowel movement at 6:30 A.M. and, despite the administration of [MEDICATION NAME], was again incontinent with a loose bowel movement at 7 A.M. The 11/14/11 MDS reported that the resident was always continent of stool. The temperature was 98 F. The nurses' notes reported that later on 1/12/12 at approximately 12:45 P.M. the resident had 4 loose bowel movements in a short period of time. Total intake for 1/12/12 was 600 cc's. Per the nurses' notes on 1/13/12, the resident complained of general discomfort and was administered Tylenol at 9:30 A.M. The resident also had 1 loose bowel movement. Total intake for 1/13/12 was 620 cc's. On 1/14/11 at 3:00 A.M. the nurses' notes reported that the resident had a health status change. The resident developed a congested cough, expiratory wheeze and drop in oxygen saturation to 85% (normal is greater than 90%.) The resident's lung sounds were diminished with crackles at the bases. Vital signs were blood pressure 97/53, pulse 77, respirations 24 and temperature 100.5 F. Oxygen was applied at 2 liters per minute and the resident's oxygen saturation improved to 95%. The physician and family were called and a decision was made to send the resident for emergency treatment. The resident arrived at the hospital emergency department at 4:35 A.M. on 1/14/12. Laboratory tests completed included a urinalysis which reported positive [MEDICATION NAME], a large amount of leukocyte esterase and many bacteria- all indicative of urinary tract infection. The resident's sodium was elevated at 146 and the BUN had increased to 50- both indicative for dehydration. The resident had an abnormal electrocardiogram and laboratory studies that included a critically elevated Troponin 1 of 1.84 mg/ml (range 0-0.3) and an elevated CKMB 12.3 mg/ml (0-5.0)- indicative for a [MEDICAL CONDITION] infarction. A chest x-ray showed a right upper lobe infiltrate. The emergency room physician wrote "? Aspiration." After discussion with family, the resident was sent back to the facility with orders to start antibiotics by mouth and receive supportive care. The resident was observed on 1/19/12 at the lunch meal. The resident appeared weak and was using supplemental oxygen. Nurse#3 reported that the resident's overall condition and appetite had declined since the hospitalization .

Based on record review and staff interview, the facility failed to ensure that for 1 resident (#34) of a total sample of 39 residents, that the resident received adequate supervision, assistance devices and interventions to maintain a safe environment to prevent accidents and injury. Findings include: Between 11/1/11 and 1/17/12, Resident #34 had 7 falls while in the bedroom. The facility failed to recognize that the resident's falls all occurred in the resident's room and were mostly related to toileting needs. The failed to provide adequate supervision and implement effective interventions to maintain the resident's safety. Resident #34 was admitted in late October 2011 with [DIAGNOSES REDACTED]. Record review on 1/24/12, revealed that according to the most recent MDS (Minimum Data Set), signed as being completed 11/2/11, the resident was assessed to experience altered mental status, as evidenced by a BIMS (Brief Interview for Mental Status) score of "4" out of a total of 15. Additionally, the MDS indicated that the resident was Portuguese-speaking, required extensive assistance with transfers, was totally dependent on staff for bed mobility, dressing, hygiene, and bathing, and experienced limitations in functional range of motion in both left and right lower extremities. The MDS also indicated that the resident was always incontinent of bladder and frequently incontinent of bowel. Record review on 1/24/12, revealed that the resident was identified as being at high risk for falls on 11/1/11, related to poor comprehension, gait/balance problems, and non-compliance. The facility's plan of care to address the resident's high fall risk included the following interventions that were implemented on 11/1/11: -pt (patient) needs to be evaluated for, and supplied appropriate adaptive equipment or devices as needed -pt needs a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in a low position at night, side rails as ordered, handrails on walls, personal items within reach -pt needs to be in the "Falling Stars" program (designed by the facility to "establish a common method of communication to remind staff to monitor the resident for fall prevention.") 1. On 11/1/11 at 6:30 A.M., the resident had an unwitnessed fall in the bedroom. According to the falls investigation, the alarm sounded and LPN #1 responded "right away." LPN #1's statement verified that the resident was sitting on the floor with a spread under his/her feet, wearing slipper socks, the call bell within reach, and the bed in a low position. LPN #1 interviewed the resident regarding the cause of the fall. The resident did not know the cause. The resident did inform LPN #1 that at the time of the fall he/she wanted to go to the bathroom. There were no injuries documented. The Post-Fall Evaluation indicated that an alarm was in place at the time of the fall, and that it was effective, even though it failed to prevent the fall. Summary by the IDT (Interdisciplinary Team) indicated "Toilet pt (patient) before bed and as needed." Further review of the care plan on 1/24/12, documented no additional safety interventions following the fall of 11/1/11, to reduce the risk of further falls. 2. On 11/6/11 at 6:00 A.M. the resident experienced a second unwitnessed fall in his/her bedroom. According to the fall investigation, the resident was observed by a staff member sitting on the floor of the bedroom. The investigation indicated that the resident was not injured, and noted that the fall occurred due to an "unassisted transfer." The nurse's note indicated that the "resident had been toileted about an hour before." The nurse also documented that the resident stated she was "drunk." The facility failed to determine if the resident had an exacerbation of any medical condition, such as orthostatic hypotension or dizziness, that may have contributed to the resident feeling "drunk." The resident's blood pressure after the fall was 159/84. The Post Fall Evaluation failed to list what, if any, interventions were in place at the time of the fall. Interventions implemented after the fall included low bed-alarm. IDT Review and Summary indicated a recommendation for physical therapy. Review of the falls care plan on 1/24/12, added physical therapy. 3. On 11/10/11 at 11:30 P.M., the resident experienced his/her third unwitnessed fall in the bedroom. According to the fall investigation, a staff member heard an alarm and saw the resident's roommate standing in the doorway. The staff member then saw Resident #34 sitting on the floor facing the bed, and observed that the "floor from resident to bathroom wet." Additionally, the nurse documented that an incontinent brief was found in the bathroom floor. No injuries were noted and the investigation revealed that an alarm, low bed, and call bell were in place at the time. The investigation also indicated that the resident was toileted last at approximately 10:00 P.M. The IDT review and summary recommended physical therapy. Following the third fall since admission, the resident's plan of care was updated and included the following interventions: -pt needs activities that minimize the potential for falls while providing diversion and distraction (specify)- Per review, no specific regimen was completed by staff and, given the time of the resident's three falls (6 AM; 6:30 AM and 11:30 PM) it was unclear if this intervention was related to these three falls. -pt uses electronic alarm. Ensure the device is in place as needed -Anticipate and meet pt's needs -Assess risk for falls-complete the assessment that will identify pt's risk for falls i.e.: urine to rule out infection -Be sure the call light is in reach and encourage pt to use it for assistance as needed -Encourage pt to request assistance in ambulating -Ensure that pt is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair) -Follow facility fall protocol -Follow toileting regime/schedule (specify)- Per review, no specific regimen was completed by staff. -non-skid footwear -Provide resident/family teaching to include safety measures to reduce falls and what to do if a fall occurs -Remind pt and reinforce safety awareness: lock brakes on bed, chair, etc. before transferring. When rising from a lying position sit on side of bed for a few minutes before transferring -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter. -Remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary team) as to causes. -Use bed alarm when in bed. -Use chair alarm/pressure pad alarm when in chair/wheelchair -Wheelchair at side of bed, brakes locked for resident use at night to discourage furniture walking -Keep alarm on resident's left side secured to side rail, resident tends to get up on her right side -Resident to be toileted every two hours and prn (as needed) Further review of the revised falls care plan, and interventions added following the resident's third unwitnessed fall, revealed no additional measures to supervise the resident while the resident was alone in the bedroom. Review of the facility's fall investigations from all three unwitnessed falls, confirmed that each of the falls occurred while the resident was unsupervised in the bedroom. Additionally, at the time of two of the three falls, the resident required toileting. No additional toileting measures were utilized to address the resident's individualized toileting needs, beyond the standard schedule of every two hours. 4. On 12/17/11 at 7:10 P.M., the resident experienced his/her fourth unwitnessed fall since admission. Review of the facility's fall investigation noted that this fall resulted in significant injury. A statement from CNA #1, who had been working on the Borden Unit at the time of the resident's fall was reviewed. According to the statement, while leaving the room where she was attending to another resident, "I heard a loud bang" CNA #1 indicated that she arrived to the room and observed the nurse beside Resident #34, who was lying face forward on the floor near the end of the bed. CNA #1's statement did not indicate the status of the chair alarm that was supposed to be in place according to the revised falls care plan of 11/10/11. LPN #2's statement from the facility fall investigation was reviewed on 1/24/12. The statement indicated that when the nurse walked into Room #226 (two rooms down the corridor from Resident #34's room), she observed "Resident on floor head turned to R-(right) side, L-(left) arm under his/her, forehead was bleeding. He/She had a puddle of blood on the floor and covering the L-(left) side of his/her face/head." Further review of LPN #2's statement revealed that the resident was responsive and able to move all extremities, and "alarm box in place on W/C (wheelchair)." There was no evidence in the investigation that the alarm sounded to alert staff that the resident was rising from the wheelchair prior to the fall. The resident was transported to the hospital and treated for [REDACTED]. LPN #1 was interviewed on 1/24/12 at 3:00 P.M. regarding the resident's multiple unwitnessed falls, specifically the fall of 12/17/11 at 7:10 P.M. LPN #1 acknowledged that the resident continued to be at high risk for falls. She confirmed the resident's unsupervised fall with injury on 12/17/11 at 7:10 P.M., along with the three previous falls sustained by the resident. LPN #1 stated "he/she's so fast," and that the fall occurred during change of shift. LPN #1 also acknowledged that at the time of the fall on 12/17/11, the resident was able to propel his/her alarmed wheelchair from his/her room, to Room #226-B (two rooms away), stand up from the wheelchair unassisted, with no evidence of the alarm sounding, and fall face-first onto the floor without staff supervision. LPN #1 confirmed that the falls care plan, and interventions in place at the time of the fall, had not been effective in preventing falls/injury, and in maintaining the resident's safety. The nursing coordinator was interviewed on 1/24/12 at 2:50 P.M., regarding safety measures in place at the time of the fall. He acknowledged that an alarm was supposed to be in place, per review of the resident's care plan. However, he stated that the Post Fall Evaluation failed to document whether the alarm was functioning or not, at the time of the fall. Review of the Post Fall Evaluation for the 12/17/11 unwitnessed fall with injury listed the following factors: -Description of Fall- "pt found on floor of bedroom" -Intervention In Place At Time Of Fall- "alarms" -Location Of Patient Prior To The Fall- "room." -Activity At The Time of The Fall- "not applicable." -Predisposing Diseases- "dementia" -Conditions That May Contribute To Fall- "not applicable" -Footwear/Assistive Devices At Time of Fall- "not applicable" -Medications That May Contribute To Fall(s)- "not applicable" -Fall History- Fall(s) In The Last 60 Days?- "No" If Fall in last 60 days, List dates: No dates listed -Fall(s) In the last 90 days?- "Yes" If fall(s) In last 90 days, List dates: No dates listed -Patient's Statement (If Applicable)- "Resident unable to verbalize and/or recall contributory factors related to the fall." -Interventions After The Fall- "low bed, alarm." -Interdisciplinary Team Review and Summary- IDT Summary: (Review all information above and summarize findings related to fall and current safety interventions."P.T. (physical therapy) evaluation, "U/A (urinalysis), C/S (culture and sensitivity)" -IDT (Interdisciplinary Team) Review and Summary: Intervention Recommendations: (Choose All That Apply)- "Physical Therapy." Physical therapy was the only additional intervention listed to address the resident's continued risk for falls/injury, following the resident's fourth fall since admission. This fall resulted in the resident having to be transported to the emergency room where he/she received treatment for [REDACTED]. Further record review on 1/24/12, revealed that the facility failed to complete its Post Fall Evaluation for the 12/17/11 fall, according to its Falling Stars Policy. Consequently, as a result of this failure to follow its policy, interventions in place at the time of the fall, including staff supervision, safety alarm, toileting schedule, medication review, and other causative factors, were not evaluated for their utility and/or effectiveness. 5. On 12/18/11 at 6:00 A.M., the resident experienced the fifth unwitnessed fall since admission. Review of the fall investigation revealed that the resident was found sitting on the floor on the side of his/her bed. According to the investigation, the resident had been in bed immediately prior to the fall and did not sustain any injuries. The resident's activity at the time of the fall was "unknown." Interventions in place included alarm and low bed. The nurse's note, written on 12/18/11 at 8:01 A.M., indicated: "Resident non-compliant with calling for help." Predisposing diseases noted on the Post Fall Evaluation included "Dementia". Interventions following this fall of 12/18/11 included urinalysis, urine culture and sensitivity. The IDT Summary (Review all information above and summarize findings related to fall and current safety interventions) listed:"urine pending" and "psych eval" (psychiatric evaluation). IDT Review and Summary noted "physical therapy" as the only additional intervention listed following this fall. Review of the Post Fall Evaluation documented no plan for increased staff supervision following the resident's fifth fall since admission. The resident's falls care plan was updated on 12/19/11. It included a urinalysis, urine culture and sensitivity. However, the facility again, failed to re-evaluate all of the resident's safety interventions, and failed to put any interventions in place to prevent further falls/injury, and to maintain the resident's safety. 6. On 1/8/12 at 7:00 A.M., the resident experienced his/her sixth unwitnessed fall since admission. No injuries were documented on the fall investigation as a result of this fall. According to the fall investigation initiated by RN #1, the "patient's alarm sounded x 1, staff unable to get to patient's room before a loud noise heard from patient's room-patient sitting on floor leaning to left side." The Post Fall Evaluation noted that the resident had been in bed prior to the fall. Interventions in place at the time included alarm, call bell in place, and low bed. Predisposing diseases listed in the evaluation included dementia, osteoporosis, and general deconditioning. Conditions that may contribute to the fall were listed as, unsteady gait, history of fall(s), and non-compliance. The activity listed at the time of the fall was "unassisted ambulation" and "unassisted transfer." The Post Fall Evaluation documented that the resident stated in Portuguese, "I need the bathroom." According to the Post Fall Evaluation, "patient toileted, washed, and brought to nurse's station." Summary of the Interdisciplinary Team included "toilet q 2 h (every 2 hours) and PRN (as needed)", "unassisted transfer", and an Intervention Recommendation for "physical therapy." Following this fall, the facility, again, failed to re-evaluate all of the safety interventions in place at the time of the fall, failed to develop and implement effective strategies to prevent further falls, failed to provide increased supervision in the resident's room and failed to address the resident's toileting needs. 7. On 1/17/12 at 3:45 A.M., the resident experienced his/her seventh unwitnessed fall since admission. According to the fall investigation there were no injuries reported at the time of the fall. The investigation noted that the resident was found sitting on the floor in front of the bedside commode. According to CNA #2's statement, CNA #2 responded to the resident's alarm and noticed the resident sitting on the floor. Initially, the resident informed CNA #2 that he/she had put himself/herself on the floor. After assisting the resident to the bathroom, the resident told CNA #2 that he/she had fallen while trying to get to the bathroom unassisted. The Post Fall Evaluation listed interventions in place at the time of the fall as alarm, call bell in place, and low bed. Predisposing Diseases were listed as, osteoporosis, muscle weakness, transient cerebral ischemia, and [DIAGNOSES REDACTED]. The list did not include the resident's [DIAGNOSES REDACTED]. The Post Fall Evaluation included a list of Conditions That May Contribute to the Fall. They included unsteady gait, history of fall(s), non-compliance, and incontinence. Interventions listed on the Post Fall Evaluation included: alarm, low bed, and call light in place. Interview with the Administrator and corporate nurse consultant on 1/24/12 at 3:30 P.M., could provide no information concerning the provision of an effective plan to supervise the resident in the room or interventions implemented to address the resident's toileting needs which seemed related to some of the resident's falls.