Every finding on record at Vantage at Andover LLC

Based on observations and interviews, the facility failed to ensure resident rooms were maintained in good repair, clean and homelike on 2 of 3 resident care units.Findings include: On 8/19/25 & 8/21/24, following was observations were made on the first-floor unit in the following rooms:room [ROOM NUMBER]: The closet doors were missing and there was a scuffed metal frame around the doorway that appeared altered or broken with bent metal, chipped paint and cracked plaster along the wall. There was large discoloration located on two tiles visible from the hallway in the resident's closet that appeared to be water stains that were dark brown and spanned across two ceiling tiles. room [ROOM NUMBER]: The bathroom had one wet white blanket placed on the floor under the bathroom sink. There was water visible on the floor and wall. The surveyor turned the hot water faucet to the on position, water began to pour out of the bottom of the sink on to the floor and was observed spraying out from under the faucet handle on to the wall and floor. The surveyor turned on the cold-water faucet and no water came out of the faucet. There was no cold water accessible in the bathroom. -The ceiling in the bathroom has two large dark brown water stains that spanned across eight ceiling tiles. The tiles were discolored and appeared to be sagging from the ceiling. -The baseboard located in the bathroom was peeling off the wall and had light and dark brown discoloring throughout the baseboard. During an interview 8/19/25 at 8:31 A.M., Resident #28 said the bathroom sink started leaking over a week ago and said water was all over the floor and pouring out from under the sink. Resident #28 said there is no cold water and said staff have been bringing water from another room to provide care and wash their hands. Resident #28 said he/she notified the nursing staff and the maintenance director, but it has not been fixed. During an observation on 8/21/25 at 8:06 A.M., the surveyor observed one wet white blanket placed on the floor under the bathroom sink. There was water visible on the floor and wall. The surveyor turned the hot water faucet to the on position, water began to pour out of the bottom of the sink on to the floor and was observed spraying out from under the faucet handle on to the wall and floor. The surveyor turned on the cold-water faucet and no water came out of the faucet. There was no cold water accessible in the bathroom.During an interview on 8/21/25 at 8:08 A.M., Resident #28 said no one has been in to fix the sink and said the staff get frustrated because they can't wash their hands or get water for when he/she needs to be cleaned or changed.During an interview on 8/21/25 at 8:13 A.M., Certified Nursing Assistant (CNA) #1 said Resident #28's sink has been leaking for a while and said water pours out so staff placed a blanket under the since to catch the water. CNA #1 said staff bring in water from other rooms to provide care. CNA #1 said staff report issues to maintenance using the TELS system (online reporting system for maintenance issues) and said she did not report the issue but said she was told it was reported last week. During an interview on 8/21/25 at 8:20 A.M., Maintenance Staff #1 said he was not aware of water leaking in Resident #28's room and said he had been helping with issues because the maintenance director left last week. Maintenance Staff #1 reviewed the TELS system with the surveyor and said there were no reports of the leaking sink in the TELS system. During an interview on 8/21/25 at 8:47 A.M., Nurse #1 said she was not aware of the sink being broken and said she did notice there was a wet blanket on the floor in the bathroom this morning. Nurse #1 said she does not have access to the TELS system and said she would expect the leak to be reported. During an interview on 8/21/25 at 8:52 A.M., Unit Manger #1 said she was not aware of the leak in Resident #28's room and said she would expect staff to notify here right away and report it into the TELS system so it can be addressed. Unit Manager # 1 said everyone has access to the TELS reporting system. During an interview on 8/21/25 at 9:38 A.M., the Administrator said the leak should have been reported to maintenance when it first happened and again if staff noticed it was still leaking and if unable to access water in the room and said it should have been addressed.room [ROOM NUMBER]: The window had one large rip in the screen roughly the size of a softball. room [ROOM NUMBER]: The window had one large rip on the bottom of the screen approximately 10inches x 10inches. On 8/19/25 & 8/21/24, following was observations were made on the second-floor unit in the following rooms:room [ROOM NUMBER]: The wall located under the window had a large hole with cracked plaster that extended from the shelf under the window to the baseboard and was approximately 24inches x 18inches.-The interior wall located near the bed had chipped pain, scuff marks, and cracked areas that extend down the wall with exposed plaster near the call bell panel. -The bathroom sink had scuff marks, chipped laminate that was peeling off the wood located around the bathroom sink. room [ROOM NUMBER]: The window screen is ripped. During an interview on 8/19/25 at 7:48 A.M., Resident #67 said our screen is torn, they are all ripped so we couldn't open the windows because we are worried birds will fly in and said it has been this way since he/she was admitted this past January. The roommate Resident #20 interjected and said it has been ripped since at least October 2024, the roommate said both residents told the staff it's broken, and they keep saying it will be fixed but it hasn't gotten fixed. During an interview on 8/21/25 at 8:25 A.M., Maintenance Staff #1 said he is helping out with issues in the building because the maintenance director left last week and said he would expect staff to report building concerns and leaks in the TELS system so it can be tracked. During an interview on 8/21/225 at 8:39 A.M. the Director of Nursing said staff should report issues into the TELS system so things can be fixed and monitored. During an interview on 8/21/25 at 8:41A.M., the Administrator said she expects issues identified within the building to be reported by staff in the TELS system so it can be addressed and tracked. The Administrator said residents do not open windows and said she was aware of the ripped screens, but they were not fixed because residents should not be opening the windows. The Administrator said when it rains there are leaks in the building and said she identified issues last October that needed to be addressed but has not followed up on the issues and said she could not locate any information related to the areas identified. Throughout the survey the facility was unable to provide documentation that the areas of concern were being addressed. Review of the TELS system work orders failed to indicate concerns were documented or identified.

Based on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for four Residents (#12, #67, #95, and #96) out of 24 total sampled residents. Specifically,1.) For Resident #12, the facility failed to ensure nursing documented weekly blood sugar checks and administration of hydrocodone-acetaminophen (a narcotic pain medication).2.) For Resident #67, the facility failed to ensure nursing accurately documented that seizure pads were not applied to bilateral side rails when in bed.3.) For Resident #95, the facility failed to ensure dressing changes were accurately documented. 4.) For Resident #96, the facility failed to ensure dressing changes were accurately documented.Findings include:Review of the facility policy titled Charting and Documentation, dated July 2017, indicated but was not limited to: -The following information is to be documented in the resident medical record: Medications administered; Treatments or services performed. -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. -Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided, whether the resident refused the procedure/treatment. 1.) Resident #12 was admitted to the facility in June 2018 with diagnoses including diabetes and osteoarthritis. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/29/25, indicated Resident #12 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. During an interview on 8/19/25 at 2:33 P.M., Resident #12 said the nurses always check his/her blood sugars as ordered. Review of Resident #12's active physician's orders indicated: -Weekly Blood Sugar Checks, in the morning every Wed (Wednesday), initiated 4/17/24. -Hydrocodone-Acetaminophen Tablet 5-325 mg (milligram), give 1 tablet by mouth three times a day for pain, initiated 5/17/22. Review of Resident #12's Medication Administration Record (MAR), dated August 2025, indicated: -Weekly Blood Sugar Checks, in the morning every Wed (Wednesday), failed to indicate it was implemented as ordered at 6:00 A.M. on 8/6/25 and 6:00 A.M. on 8/13/25. -Hydrocodone-Acetaminophen Tablet 5-325 MG, failed to indicate it was administered as ordered at 6:00 A.M. on 8/6/25 and 6:00 A.M. on 8/13/25. Review of Resident #12's nursing progress note, dated 8/6/25 through 8/19/25, failed to indicate Resident #12's blood sugar was checked as ordered or any rationale for why it was not checked as ordered on 8/6/15 or 8/13/25. Review of these progress notes also failed to indicate the hydrocodone-acetaminophen 5-325 mg tablet was administered or rationale for why it was not documented as administered. During an interview on 8/20/25 at 9:53 A.M., Nurse #3 said he was the nurse responsible for Resident #12 on 8/6/25 at 6:00 A.M. and 8/13/25 at 6:00 A.M. Nurse #3 said he checked Resident #12's blood sugars on 8/6/25 and 8/13/25 but forgot to document it. Nurse #3 reviewed the controlled substance log with the surveyor which indicated a hydrocodone-acetaminophen 5-325 mg tablet was removed from controlled substance box on 8/6/25 at 6:00 A.M. and on 8/13/25 at 6:00 A.M. by Nurse #3 for Resident #12. Nurse #3 said he should have documented the blood sugar results and hydrocodone-acetaminophen administration in the medical record but did not. During an interview on 8/20/25 at 10:47 A.M., the Director of Nursing (DON) said Nurse #3 should have documented the weekly blood sugar check and the administration of the hydrocodone-acetaminophen tablet in the medical record before he left for the day on 8/6/25 and 8/13/25 but did not. 2.) Resident #67 was admitted to the facility in January 2025 with diagnoses including a seizure disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/24/25, indicated Resident #67 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. On 8/19/25 at 7:48 A.M., the surveyor observed Resident #67 in bed without any seizure pads on his/her bilateral side rails. There were seizure pads against the wall across the room. Resident #67 said he/she always refuses the seizure pads on his/her side rails because he/she hates them. On 8/19/25 at 11:02 A.M., 8/20/25 at 6:45 A.M., and 8/21/25 at 6:46 A.M., the surveyor observed Resident #67 in bed without any seizure pads on his/her bilateral side rails. There were seizure pads against the wall across the room. Review of Resident #67's physician's order, initiated 4/2/25, indicated: -Seizure pads to side rails when in bed, every shift for seizure precautions. Review of Resident #67's Treatment Administration Record (TAR), dated August 2025, indicated the order for seizure pads to side rails when in bed was documented as implemented on: -8/18/25 on night shift (11:00 P.M. - 7:00 A.M) -8/19/25 on day shift (7:00 A.M. - 3:00 P.M.) and night shift (11:00 P.M. - 7:00 A.M) -8/20/25 on day shift and night shift (11:00 P.M. - 7:00 A.M) During an interview on at 8/21/25 at 6:54 A.M., Certified Nurse Assistant (CNA) #2 said she works night shift and that Resident #67 should have seizure pads on his/her side rails when in bed. CNA #2 said Resident #67 did not have his/her seizure pads on his/her side rails during her shift because he/she always refuses them. CNA #2 said the nurses were aware that the Resident always refuses. During an interview on 8/21/25 at 7:20 A.M., Nurse #4 said she works day shift and that Resident #67 should have seizure pads on his/her side rails when in bed. Nurse #4 said Resident #67 often refuses seizure pads, but when she reapproaches, he/she often will accept them. Nurse #4 said nurses should not document the order for seizure pads to side rails when in bed as implemented if the Resident refused and should instead document the refusal in the medical record. During an interview on 8/21/25 at 7:37 A.M., Nurse #5 said she works night shift and that Resident #67 should have seizure pads on his/her side rails when in bed. Nurse #5 said Resident #67 doesn't use his/her seizure pads because he/she doesn't like them. Nurse #5 said she knew the seizure pads were not implemented on the night shift of 8/18/25 and 8/20/25 but she documented them as implemented, even though they weren't, because the Resident needs them. Review of Resident #67's nursing progress notes, dated 8/19/25 to 8/21/25, failed to indicate the any seizure pad refusal by the Resident. During an interview on 8/21/25 at 11:28 A.M., the Director of Nursing (DON) said Resident #67 should have had seizure pads on his/her side rails when in bed as ordered by the physician. The DON said if Resident #67 refused the seizure pads to his/her side rails when in bed the nurses should have documented it as refused or not implemented instead of as implemented. 3. Resident #95 was admitted to the facility in August 2024 with diagnoses including skin tears to the right forearm, skin cancer, and gout. Review of the Minimum Data Set assessment indicated it was not due. Review of the physician's note dated 8/13/25, indicated that resident #95 is alert and oriented to person, place and time. Review of the physician's orders, dated August 2025, indicated the following order: Right forearm skin tears; cleanse with wound cleanser, dry, apply xeroform (a petroleum impregnated gauze) and cover with DPD (dry protective dressing) every day shift. On 8/19/25 at approximately 8:10 A.M., the surveyor observed Resident #95 in bed with two dressings on the right upper arm, both dated 8/17/25. During an interview on 8/19/25 at approximately 8:10 A.M., Resident #95 said that the nurse didn't change the dressing yesterday. Review of the Treatment Administration Record (TAR) dated August 2025, indicted that on 8/18/25, the nurse documented that the dressings to the right forearm were changed as ordered. During an interview on 8/19/25 at 3:30 P.M., Nurse #2 said that he changed the dressing to the right forearm as ordered today. Nurse #2 then said that he did see that the date on the old dressing was dated 8/17/25. Nurse #2 then said that the nurse should have changed the dressing on 8/18/25 as the dressing is ordered to be changed daily. Nurse #2 then said that if the nurse did not change the dressing, then the medical record should not indicate that the dressing had been changed. During an interview on 8/19/25 at 4:09 P.M., the Director of Nursing (DON) said that dressing changes should be completed according to physician's orders. The DON then said that the medical record should accurately reflect the care provided to the Resident. 4. Resident #96 was admitted to the facility in August 2025 with diagnoses including heart disease, liver disease and cancer. Review of the Minimum Data Set assessment indicated it was not due at the time of survey. Review of the progress note dated 8/16/25, indicated that Resident #96 is alert and oriented to person, place and time. Review of the progress note dated 8/14/25, indicated that Resident #96 received a recent treatment to the right side of the face for skin cancer. Review of the physician's orders dated August 2025 indicated the following order: Right ear lesion and right temple: Iodosorb (an antibacterial gel) and DPD (dry protective dressing), change daily and PRN (as needed) every day shift. On 8/19/25 at 7:40 A.M., the surveyor observed Resident #96 in bed with a dressing dated 8/17/25 on the right temple area. Review of the Treatment Administration Record (TAR) dated August 2025, indicted that on 8/18/25, the nurse documented that the dressings to the right temple were changed as ordered. During an interview on 8/19/25 at 3:02 P.M., Nurse #2 said that the dressing should have been changed daily. Nurse #2 then said that he didn't notice the date on the old dressing before he removed it. Nurse #2 then said that if the nurse did not change the dressing, then the medical record should not indicate that the dressing had been changed. During an interview on 8/19/25 at 4:09 P.M., the Director of Nursing said that dressing changes should be changed according to physician orders. The DON then said that the medical record should accurately reflect the care provided to the Resident.

Based on observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on one of two nursing units. Findings include: Review of the facility policy titled HIPAA (Health Insurance Portability and Accountability Act), dated as revised 7/12/2012, indicated: It is the policy of the facility to limit access of confidential healthcare information to the minimum necessary - need to Know for the purpose of providing patient care. Individuals shall not access information for those in which they are not responsible for the provision of healthcare. On 8/21/25 at 8:01 A.M., the surveyor observed on the first-floor unit medication cart, a computer screen with an electronic health record that was open, and a document labeled Report Sheet, containing printed and handwritten patient information including full name, date of birth , diagnosis. The surveyor was able to read the PHI. The Nurse was not present at the cart, and the surveyor observed a resident and a housekeeping staff member in the area by the computer screen with visible patient information On 8/21/25 at 8:05 A.M., Nurse #1 returned to the medication cart, and said she should not have left the PHI visible and accessible on the medication cart. During an interview on 8/21/25 at 8:41 A.M., the Director of Nursing said nursing should ensure PHI is secure and not visible to those not authorized.

Based on record review and interview the facility failed to ensure for 1 Resident (#39), out of a total sample of 24 residents that an antianxiety medication administered PRN (as needed) was limited to 14 days, and that the prescriber documented in the clinical record the rationale for continued use and the duration of the use of the PRN antianxiety medication. Specifically, Resident #39 was administered PRN Ativan, (a medication used to treat anxiety signs and symptoms) without a duration for the use of the PRN Ativan. Findings include: Resident #39 was admitted to the facility in December 2023 with diagnoses that include but not limited to cerebral infarction (an occlusion of blood to the brain resulting in a stroke), adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #39 scored a 15 out of 15 on the Brief Interview of Mental Status exam indicating he/she as having intact cognition. Review of Resident #39's clinical record indicated the following physician's order: -Ativan Oral Tablet 0.5 Milligrams (MG) (Lorazepam) give 0.25 mg by mouth every 12 hours as needed for anxiety, order date 7/3/25. Review of the above physician's order failed to indicate a duration for the use of the PRN Ativan. Review of Medication Administration Record (MAR) dated July 2025 indicated the PRN Ativan was not administered to Resident #39. Review of the MAR dated August 2025 indicated the PRN Ativan was administered to Resident #39 on 8/6/25 0848 (8:48 A.M.), 8/7/25 0943 (9:43 A.M.), 8/10/25 0800 (8:00 A.M.), and 2015 (8:15 P.M.) for a total of 4 PRN doses since the initial order of 7/3/25. Review of Resident #39's clinical record indicated the following: -A note dated 7/3/25 written by the Nurse Practitioner (NP) Depression, unspecified depression type Nursing staff reports concerns of patient becoming depressed due to not being able to return home. Will start Ativan 0.25 mg twice daily as needed for anxiety/depression x 14 days. Although the NP note dated 7/3/25 indicated the PRN Ativan was for 14 days. Review of the order indicated it was entered without a stop date of 14 days and continued as PRN without a duration of use and end date. -A note dated 8/14/25 written by the NP, Depression unspecified depression type; Continue on Ativan 0.25 mg twice daily as needed. The NP note dated 8/14/25 indicated to continue with the PRN Ativan, however the order remained open ended and did not indicate the duration for the use of the PRN Ativan. -A note dated 8/6/25 type: Pharmacist note, -Lorazepam (Ativan) 0.25 q12h (every 12 hours) PRN (7/3/25) MD rec (medical doctor recommendation) stop date PRN Lorazepam. During an interview on 8/21/2025 at 9:43 A.M., Nurse #6 said Resident #39 has had an order for PRN Ativan for about a month or two. Nurse #6 said the target symptoms for Resident #39 is mood changes including crying, becoming agitated and frustrated with his/her situation. Nurse #6 said she has given Resident #39 the PRN Ativan. Nurse #6 said an order for psychotropic medication including Ativan should be for 2 weeks then after that it should have an end date. Nurse #6 reviewed Resident #39's order for the PRN Ativan with the surveyor and said the order was entered 7/3/25 and was indefinite. During an interview on 8/21/2025 at 10:10 A.M., Unit Manager #2 said Resident #39 was having increased anxiety related to his/her situation, and was recently started on Ativan as needed, and has responded well to the medication. Unit Manager #2 said we normally start with 14 day order for psychotropic medication and after that the MD or NP will review and see how a resident is doing and determine the duration for use of the PRN medication. Unit Manager #2 said the NP is here often and that the order written did not have a duration date and should have. During an interview on 8/21/2025 at 11:30 A.M., the Director of Nursing said Resident #39 was having increased anxiety and did not initially consent to the PRN Ativan medication and once he/she consented, the medication was used. The DON said the NP should have addressed the pharmacist recommendation to have an end date for the PRN Ativan. The DON then said the order should have a duration for the use of the PRN Ativan and that the NP should have a note regarding the duration of use and the order should not be written without end date.

Based on observation, record review and interview the facility failed to implement the plan of care for two Residents (#95 and #96) out of a total sample of 24 residents. Specifically: For Resident #95 the facility failed to change a dressing to the forearm as ordered.For Resident #96 the facility failed to change a dressing to the right temple as ordered.Findings include:Review of the facility policy titled Wound Care Policy dated as revised 11/5/24, failed to indicate that physician ordered dressing changes are to be completed as ordered. 1. Resident #95 was admitted to the facility in August 2024 with diagnoses including skin tears to the right forearm, skin cancer, and gout. Review of the Minimum Data Set assessment indicated it was not due. Review of the physician's note dated 8/13/25, indicated that resident #95 is alert and oriented to person, place and time. Review of the physician's orders, dated August 2025, indicated the following order: Right forearm skin tears; cleanse with wound cleanser, dry, apply xeroform (a petroleum impregnated gauze) and cover with DPD (dry protective dressing) every day shift. On 8/19/25 at approximately 8:10 A.M., the surveyor observed Resident #95 in bed with two dressings on the right upper arm, both dated 8/17/25. During an interview on 8/19/25 at approximately 8:10 A.M., Resident #95 said that the nurse didn't change the dressing yesterday. During an interview on 8/19/25 at 3:30 P.M., Nurse #2 said that he changed the dressing to the right forearm as ordered today. Nurse #2 then said that he did see that the date on the old dressing was dated 8/17/25. Nurse #2 then said that the nurse should have changed the dressing on 8/18/25 as the dressing is ordered to be changed daily. During an interview on 8/19/25 at 4:09 P.M., the Director of Nursing said that dressing changes should be completed according to physician's orders. 2. Resident #96 was admitted to the facility in August 2025 with diagnoses including heart disease, liver disease and cancer. Review of the Minimum Data Set assessment indicated it was not due. Review of the progress note dated 8/16/25, indicated that Resident #96 is alert and oriented to person, place and time. Review of the progress note dated 8/14/25, indicated that Resident #96 received a recent treatment to the right side of the face for skin cancer. Review of the physician's orders dated August 2025 indicated the following order: Right ear lesion and right temple: Iodosorb (an antibacterial gel) and DPD (dry protective dressing), change daily and PRN (as needed) every day shift. On 8/19/25 at 7:40 A.M., the surveyor observed Resident #96 in bed with a dressing dated 8/17/25 on the right temple area. During an interview on 8/19/25 at 3:02 P.M., Nurse #2 said that the dressing should have been changed daily. Nurse #2 then said that he didn't notice the date on the old dressing before he removed it. During an interview on 8/19/25 at 4:09 P.M., the Director of Nursing said that dressing changes should be changed according to physician orders.

Based on observation, interviews, and record review, the facility failed to ensure one Resident (#71), out of 24 total sampled residents, received adequate supervision and assistance devices to prevent accidents. Specifically, for Resident #71, who had multiple recent falls, the facility failed to ensure staff implemented fall interventions, including the use of a baby monitor when in bed and ensuring his/her call bell was within reach.Findings include:Review of the facility policy titled Procedure for Falls, undated, indicated:-Update Kardex (a summary of a patient's plan of care), care plan and communicate this information.-If the intervention is not working discontinue and find another solution.Resident #71 was admitted to the facility in November 2024 with diagnoses including dementia.Review of the most recent Minimum Data Set (MDS) assessment, dated 7/31/25, indicated Resident #71 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15. This MDS also indicated Resident #71 had 3 or more falls in the past quarter.Review of Resident #71's nursing and physician progress notes, dated 4/3/25 to 7/26/25, indicated Resident #71 had multiple recent falls including a fall on 4/3/25 resulting in a humerus fracture, 6/25/25 resulting in scalp sutures, 7/21/25 resulting in scalp sutures, and another fall on 7/26/25.Review of Resident #71's active plan of care related to falls, revised 8/8/25, indicated:-Be sure the call light is within reach and encourage Resident #71 to use it for assistance as needed. Needs prompt response to all requests for assistance.-Baby monitor when in bed, staff in dayroom when patient is out of bed.On 8/19/25 at 7:59 A.M., the surveyor observed Resident #71 in bed without any staff within view of the Resident. There was a call bell on the floor and a hand bell on the windowsill not within reach of the Resident. There was a baby monitor on the roommate's side of the room facing away from Resident #71.On 8/20/25 at 6:54 A.M., the surveyor observed Resident #71 in bed without any staff within view of the Resident. There was a call bell on the floor and a hand bell on the windowsill not within reach of the Resident. There was a baby monitor camera on the roommate's side of the room facing away from Resident #71.On 8/20/25 at 6:57 A.M., the surveyor observed the baby video monitor at the nurse's station which showed video feed of the Resident's bathroom, without any portion of the Resident, who was in bed at the time and without any staff in the room.On 8/20/25 at 8:34 A.M., the surveyor observed Resident #71 in bed without any staff within view of the Resident. There was a call bell on the floor and a hand bell on the windowsill not within reach of the Resident. There was a baby monitor camera on the roommate's side of the room facing away from Resident #71.On 8/21/25 at 6:44 A.M., the surveyor observed Resident #71 in bed without any staff within view of the Resident. There was a call bell on the floor and a hand bell on the windowsill not within reach of the Resident. There was a baby monitor camera on the roommate's side of the room facing away from Resident #71. On 8/21/25 at 6:47 A.M., the surveyor observed the baby video monitor at the nurse's station which was not powered on and had no video feed of the Resident's room. Resident #71 was in bed at this time without any staff in the room.During an interview on 8/20/25 at 12:20 P.M., Unit Manager #2 and Nurse #4 said staff use a baby monitor to supervise Resident #71 in his/her room. Unit Manager #2 and Nurse #4 said there is one baby monitor system used to monitor both Resident #71 and his/her roommate, and it should be directed to capture both Residents when they are in their room.During an interview on 8/21/25 at 6:45 A.M., Certified Nurse Assistant (CNA) #2 said she uses the kardex to obtain specific care instructions for each resident on her assignment. CNA #2 said all interventions listed on the kardex should be implemented, and if they were unable to be implemented the CNA should alert the nurse. CNA #2 and the surveyor reviewed Resident #71's kardex, which indicated the following active interventions: Be sure the call light is within reach and encourage Resident #71 to use it for assistance as needed and Baby monitor when in bed, staff in dayroom when patient is out of bed. CNA #2 said Resident #71 should have a baby monitor always directed at him/her when he/she is in bed when staff is not present in the room. CNA #2 said the staff does not give Resident #71 a call bell because he/she would press it a lot of times. CNA #2 and the surveyor went into Resident #71's room and CNA #2 said both the call bell and the hand bell was out of reach because staff does frequent checks instead.During an interview on 8/21/25 at 7:20 A.M., Nurse #4 said CNAs are expected to get resident care information from the kardex. Nurse #4 said all interventions should be implemented. Nurse #4 said if the intervention is refused or ineffective the Nurse should be notified, and it should be documented or the plan of care revised as necessary. Nurse #4 said Resident #71 should have a baby camera directed at him/her when he/she is in his/her room, except when staff is in the room providing care. Nurse #4 said Resident #71 should have a call bell within reach if it is an intervention on his/her care plan or kardex.During an interview on 8/21/25 at 7:37 A.M., Nurse #5 said she does not use the baby monitor for Resident #71 because she felt it was an ineffective intervention and said this was why the baby monitor was not powered on at the time. Nurse #5 said she does frequent checks on the Resident instead. Nurse #5 said Resident #71 should have a call bell within reach if it is an intervention on his/her care plan or kardex and was unaware staff were not giving Resident #71 the call bell. Nurse #5 said if an intervention is ineffective the plan of care should be revised but it was not.Review of Resident #71's nursing progress note, dated 8/19/25 to 8/21/25, failed to indicate any rationale for call bell not being within reach and for baby monitor not being utilized. During an interview on 8/21/25 at 11:28 A.M., the Director of Nursing (DON) said CNAs and nurses should implement all interventions on the care plan and kardex, document refusal, or revise the plan of care for ineffective interventions. The DON said the baby monitor should have been directed at Resident #71 if unattended in bed and turned on if that was intervention. The DON said Resident #71's call bell should have been within reach if that had been an intervention. The DON further said that if any intervention is not appropriate it should have been documented as to why it was not done and/or plan of care should have been revised if the intervention was ineffective.

Based on observations, interviews, and record review, the facility failed to provide care and maintenance of a peripherally inserted Intravenous catheter (IV), consistent with professional standards of practice for one Resident (#94), out of a total sample of 24 residents. Specifically, for Resident #94, the facility failed to monitor a peripherally inserted Intravenous IV catheter site and failed to develop a plan of care for the IV.Findings include:Resident #94 was admitted to the facility in August 2025 with diagnoses including acute kidney failure, fracture of the right humerus (upper arm) and heart disease. Review of the Minimum Data Set assessment indicated that it was not due. Review of the progress note dated 8/18/25, indicated that resident #94 is alert and oriented x3 (to person, place and time). On 8/19/25, at 8:01 A.M. the surveyors observed Resident #94 with a peripherally inserted intravenous (IV) line in the left antecubital (inner elbow) space. The surveyors also observed a clear dressing over the site without a date. Review of the physician's orders indicated an order dated 8/14/25 to start a peripheral IV line and administer normal saline at 50 milliliters per hour for one liter. Review of the physician's orders dated August 2025 failed to indicate an order to monitor the IV site or how to care for the IV site. Review of the care plan dated 8/17/25, failed to indicate a focus to monitor the IV site or how to care for the IV site. During an interview on 8/19/25 at 3:30 P.M., Nurse #2 said that he was not able to locate an order for the monitoring of or for the care of the IV site in the medical record. Nurse #2 then said that the IV site should be monitored every shift for signs/symptoms of infiltration and infection. During an interview on 8/19/25 at 3:33 P.M., Resident #94 said that the IV was inserted in the facility last week. During an interview on 8/19/25 at 4:09 P.M., the Director of Nursing said that all IV sites should be monitored each shift for signs/symptoms of infiltration and infection. The DON said that the medical record should indicate monitoring of the IV site.

Based on observations, and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure nursing staff secured medications in the medication cart prior to leaving the cart unattended on the first-floor unit. Findings include:Review of the facility policy titled Storage of Medications, dated as revised August 2018, indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 8/21/25 at 8:01 A.M., the surveyor observed a medication cart unlocked and unsupervised on the first-floor unit. The surveyor observed one bottle of nystatin powder (antifungal powder to treat skin infections) and one container of clotrimazole ointment (antifungal medication to treat skin infections) on top of the medication cart. The surveyor observed a resident and a housekeeping staff member in the area by the unlocked medication cart. During an interview on 8/21/25 at 9:05 A.M., Nurse #1 she should not have left the mediations on top of the medication cart and said the medication cart should have been locked prior to walking away from the cart when she was in a Residents room. During an interview on 8/21/25 at 8:39 A.M., the Director of Nurses (DON) said she expects nursing staff to lock the medication carts and not to keep medications stored on top of the medication carts when they are not using or accessing the carts. The DON said the medications must be stored and locked appropriately when not in use.

Based on observation, record review and interview the facility failed to ensure proper food handling practices to prevent cross contamination during the meal distribution service in the kitchen. Findings include: Review of the facility's policy titled Handwashing-Glove, manual Dietary Services, dated 9/14/20 indicated the following: Purpose Guidelines for hand washing and glove use to promote safe and sanitary conditions throughout the department. Hand washing procedure- 1. Hand washing is a priority for infection control. 2. Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food substances. raw chicken to fresh fruit, following contact with any unsanitary surface i.e. touching hair sneezing opening door etc. Gloves 1 Gloves will be worn/changed when: a) handling raw meats poultry, and fish/seafood. b) handling ready-to-eat foods. C) transitioning from one task to another including raw to ready-to eat food prep, leaving the work area and returning, using rest room and returning, potentially touching a contaminated surface and returning to work duties. 2) When gloves are used, hand washing must occur per above procedures prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed, see above. Gloves may be used for one task only. During the lunch meal distribution in the kitchen on 8/7/24 at 11:41 A.M., the following was observed: After recording the temperature of the food [NAME] #1 removed her gloves from both hands and, without hand hygiene, placed new gloves on both hands and proceeded to gather utensils for the food. [NAME] #1 touched the top of the cover to the pan on the back stove, potentially contaminating the gloves, then using her gloved hands, directly removed green salad mix and placed it on a plate. -At 12:00 P.M., [NAME] #1 used her gloved hands to pick up salad greens and placed them directly on the plate. -At 12:08 P.M., [NAME] #1 used her gloved hands to pick up salad greens and place directly on the plate. [NAME] #1 then touched the pan cover on the back oven with her gloved hands. -At 12:17 P.M. [NAME] #1 placed her gloved hand inside a bag of rolls and removed a roll and placed it on a plate. -At 12:19 P.M., [NAME] #1 used her gloved hands to place salad greens on a plate then used the same gloved hand to reach into a bag of rolls and removed a roll and placed it directly on the plate. During an interview on 8/7/24 at 2:13 P.M., the surveyor told the Food Service Director (FSD) the observation that were made during the meal distribution. The FSD said hand washing should occur before putting on gloves and food should not be touched directly to prevent cross contamination.

Based on observation, record review and interview the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded to reflect the status of one Resident (#70) out of a total sample of 19 residents. Specifically, two comprehensive MDS assessments failed to code Resident #70 with obvious or likely carious or broken natural teeth. Findings include: Resident #70 was admitted to the facility in November 2023 with diagnoses including chronic obstructive pulmonary disease, transient cerebral ischemic attack (stroke), anxiety and mood disorder. Review of the most recent MDS, dated [DATE], indicated Resident #70 scored a 13 out of 15 on the Brief Interview for Mental Status exam, indicating he/she is cognitively intact. During an observation and interview on 8/6/24 at 8:49 A.M., Resident #70 was observed to have missing lower teeth and some partial teeth. Resident #70 said his/her bottom teeth have been broken and missing since he/she came here. Review of Resident #70's medical record indicated the following: -A nursing assessment dated [DATE] indicated nursing staff assessed Resident #70 as having broken or carious (decayed) teeth. -An oral assessment dated [DATE] indicated nursing staff assessed Resident #70 with the presence of broken/missing teeth. Review of the MDS comprehensive assessments, dated 11/15/23 and 7/3/24, at Section L, oral/dental status, indicated Resident #70 as not having obvious or likely cavity or broken natural teeth. The two MDS assessments conflict with the nursing assessments of Resident #70's oral/dental status. During an interview on 8/7/24 at 4:09 P.M., the MDS nurse said Resident #70 is on a soft diet, is assisted with oral hygiene and does not have pain. The MDS nurse said the MDSs dated 11/11/23 and 7/3/24 do not match the nursing oral assessment for Resident #70 and need to be modified to reflect Resident #70's status.

Based on record review and interview the facility failed to ensure for one Resident (#15), out of a total sample of 19 residents, was referred for a Preadmission Screening and Resident Review (PASARR) evaluation (an evaluation to determine if a resident needs specialized services to address his/her Serious Mental Illness (SMI) once it was identified the Resident had a new diagnosis of schizoaffective disorder. Findings include: Review of the MassHealth Nursing Facility Bulletin 186, dated June 2024 indicated the following: Definition: Level I Screening- A preliminary screening of all nursing facility applicants, regardless of payer source, conducted prior to their admission to a nursing facility, as required by federal PASARR regulations at 42 CFR 483.100 et seq. using the Level 1 Screening Form. A level 1 Screening identifies whether an applicant has, or is suspected of having, ID (intellectual Disability), DD (Developmental Disability), and/or SMI (Serious Mental Illness). C. Postadmission Level II Evaluations for Individuals with SMI. 1. A nursing facility must ensure an individual who has or is suspected of having an SMI is referred to DMH (Department of Mental Health) PASARR, accordance with Section 3. A for a post-admission Level II Evaluation (I.e. Resident Review) in the following instances: b. When an individual who resides in a nursing facility has experienced a significant change or the individual is newly identified as having a condition that may impact the individuals PASARR disability status, the appropriateness of the individual's nursing facility placement, or the individual's need for specialized services and/or Behavioral Health Services. Resident #15 was admitted to the facility in February 2020 with diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, chronic pain syndrome and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 scored a 9 out of 15 on the Brief Interview for Mental Status exam, indicating he/she had moderately intact cognition. Review of Resident #15's medical record indicated the following: -A Physician's order note dated 4/5/2022, NP (Nurse Practitioner) in today-new order to add dx (diagnosis) Schizoaffective disorder. Medical diagnosis list updated. The diagnosis of Schizoaffective disorder was added after Resident #15 was admitted to the facility. -A Social Services Note, dated 4/5/2022, note text: SW (social worker) offered supportive check-in to resident today. He/She presented with baseline paranoia but was redirectable with supportive discussion. He/she expressed concern that he/she may experience auditory hallucinations recently and confirmed plan to follow-up with Psych NP (Nurse Practitioner). SW will continue to follow. Review of documents provided by the facility Social Worker indicated a Level 1 PASRR dated 2/10/20 was incomplete. A second Level PASRR dated 12/3/20 indicated the Serious Mental Illness Screening indicated Resident #15 had a negative SMI screen. Review of the MDS dated [DATE] at Section I documented Resident #15 with psychotic disorder, other than schizophrenia. Review of the MDS dated [DATE] at Section I documented Resident #15 with Schizophrenia (e.g. schizoaffective, schizophreniform) Review of the clinical record failed to indicate a referral for a PASRR was completed with the onset of the diagnosis of Schizoaffective disorder. During an interview on 8/07/24 at 10:10 A.M. Social Worker (SW) #1 said a PASRR referral is triggered if a resident presents after admission with a change due to mental illness, has a new diagnosis that may impact them and create limitations. During a subsequent interview on 8/07/24 at 11:20 A.M., SW #1 said the PASRR dated 12/3/20 was negative for SMI. SW #1 said that Resident #15 is seen by the facility's psychological services provider for the diagnosis of schizoaffective disorder and symptoms of paranoia and delusions. SW #1 said they (she and SW #2) are working on a submitting a PASRR for Resident #15

Based on observation and interview, the facility failed to provide a homelike environment in two resident rooms on the second floor. Specifically, the facility failed to 1. repair a broken overhead light and 2. failed to maintain hot water temperatures in a resident bathroom. Findings include: 1. During a family interview on 8/7/24 at 10:49 A.M., the family member said that the overhead bed light in room [ROOM NUMBER] was not working and that she has notified staff before. During an observation on 8/7/24 at 12:02 P.M., the surveyor attempted to turn on one of the overhead bed lights in room [ROOM NUMBER]. The light did not work. 2. During an interview on 8/6/24 at 8:15 A.M., one Resident said that his/her bathroom water was lukewarm and not getting hot. The Resident said that this has been an issue that the hot water has not been working for some time and he/she has notified staff. During an observation on 8/8/24 at 8:01 A.M., the surveyor obtained a hot water temperature of 68 degrees Fahrenheit from the sink in room [ROOM NUMBER]. During an interview on 8/8/24 at 8:15 A.M., the Maintenance Director was made aware of the broken light and the hot water temperature. The Maintenance Director said that staff are responsible for reporting broken equipment into their online reporting system and that he would input the repairs into the system and look at both issues. The Maintenance Director said he was not aware of the two issues.

Based on observation, record review and interview the facility failed to ensure for one Resident (#39), out of a total sample of 19 residents, that newly identified skin injuries, including an open skin area, was reported to the physician or the nurse practitioner, that the open area was measured, and that a treatment order was obtained to treat the open area. Findings include: Review of facility's policy titled: Wound Documentation effective 3/11/13 indicated Goal: To ensure appropriate wound documentation is recorded in the patient/resident medical record. Policy: 1. The facility will document notification of the physician, patient/resident and /or responsible party at the onset of a new wound or the deterioration of an existing wound. Procedure: 2. At the onset of a new wound, the nurse will initiate a weekly flow sheet (pressure or non-pressure) for each new wound. Policy titled Wound NTASureiment (sic) dated 3/11/13 indicate the patient/resident plan of care will be developed at the onset of each wound and will be revised as necessary. Policy: the facility will obtain measurements at the onset of a new wound. Resident #39 was admitted to the facility in February 2022 and has diagnoses that include, but are not limited to, venous insufficiency, adult failure to thrive, dementia, and moderate protein calorie malnutrition. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a score of 14 out of 15 on the Brief Interview for Mental Status exam indicating Resident #39 as cognitively intact and requires dependence on staff for bathing, toileting and dressing. Further review of the MDS indicated Resident #39 was at risk for developing pressure ulcers. Review of Resident #39's medical record indicated the following: -A care plan dated as initiated 2/10/2022, Resident has potential for skin breakdown r/t (related to) impaired mobility, has low weight, incontinence, has contractures to LE (lower extremities). Interventions included *Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration, etc. to MD (medical doctor) -A Norton Scale for Predicting Pressure Ulcer Risk dated 3/20/24 and 6/12/24 with scores of 10, which indicates a high risk for developing pressure ulcer. -A physician's order, weekly skin assessment due Friday on 7-3 shift, dated 2/10/24. Review of the weekly skin check dated 7/12/24 indicated Resident #39 had a right trochanter (hip) open area and the left trochanter (hip) redness. The document had the following questions: 3. If new areas noted what interventions were implemented? 4. Was the wound team notified? Both questions were left blank. Review of the nursing progress notes failed to indicate the areas on Resident #39's right and left hip were reported to the physician, were measured, or that a treatment was implemented. During an interview on 8/8/24 at 8:34 A.M. and 9:39 A.M., Unit Manager (UM) #1 said if a resident is identified with any skin injuries including pressure injury, the nurse notifies the physician and gets orders for a treatment. UM #1 said they also will consult with the wound doctor and investigate the cause of the skin injury. UM #1 said he would also be notified on an open area. During an interview on 8/8/24 at approximately 9:50 A.M., the Assistant Director of Nursing (ADON) said when a nurse identifies a new skin injury or pressure area the nurse calls the doctor to get a treatment order, fills out an incident report packet, and she gets notified. The ADON said this was not done in the case of Resident #39. Review of the medical record failed to indicate the MD/NP was notified of Resident #39's right trochanter (hip) open area and the left trochanter (hip) redness when it was identified on 7/12/24.

Based on observation, record review and interview the facility failed to implement the use of a hand splint in accordance with the rehabilitation plan of care for one Resident (#70), out of a total sample of 19 residents. Findings include: Review of the facility's policy with the subject Splints/Orthotics, dated February 2022, indicated Therapy will issue appropriate positioning splints/orthotic determined by patient needs. Purpose Splints or orthotic devices are those which are given to maintain range of motion, enable proper joint alignment, promote good skin integrity and hygiene, enhance functional ability and prevent further deformity. These include but are not limited to: splint, palm protectors, elbow and knee braces, ankle/foot orthotics etc. Procedure: 1: Order for OT (occupational therapy) or PT (physical therapy) evaluation and treatment will be obtained, and evaluation completed to determine the proper positioning device. 2: Splints or orthotics will be issued by an OT/PT or MD (medical doctor) and PT/OT will complete assessment and treatment to ensure proper plan of care is established. 3: Nursing staff will be in-serviced on proper application, wearing schedule, care and precautions related to the device being issued. The charge nurse will provide additional in-service to staff as needed. 4: The charge nurse will put the splint schedule on the CNA (certified nursing assistant) cardex and flow sheet. 5: The splint schedule will be put on the nursing cardex and monitored each day by nursing. 6: the splint schedule will be included on the resident plan of care. 7: If there is a problem with a device, the charge nurse or rehab department should notify of the specific problem. A screen form will be initiated by nursing and sent to the rehab department for follow up. Resident #70 was admitted to the facility in November 2023. Resident #70 has diagnoses that include, but are not limited to chronic obstructive pulmonary disease, transient cerebral ischemic attack, mood disorder, traumatic subarachnoid hemorrhage without loss of consciousness and hemiplegia unspecified affecting left nondominant side. Review of the most recent Minimum Data Set assessment dated [DATE] indicated Resident #70 scored a 13 out of 15 on the Brief Interview for Mental Status exam, indicating he/she is cognitively intact. Further, the MDS indicated Resident #70 was dependent on staff for toileting, bathing and dressing. During an observation and interview on 8/6/24 at 8:49 A.M., Resident #70 was observed with his/her left arm and hand resting on a pillow. Resident #70 said he/she has a left-hand splint with Velcro and that some staff get frustrated putting on the left-hand splint. During an interview and observation on 8/6/24 at 4:44 P.M., Resident #70 was observed resting in bed. Resident #70's left arm/hand was resting on a pillow/wedge. A hand splint was on his/her bedside table. A sign above Resident #70's bed indicated hand splint on at evening and off in A.M. Review of Resident #70's medical record indicated the following: *No physician's order for the donning or doffing or schedule for the use of a left-hand splint. *The Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated for 6/2024, 7/2024 and 8/2024 did not indicate the use of a left-hand splint, including a donning and doffing schedule. *The Kardex (a document which details a summary of a resident's care needs) failed to indicate the use of a left-hand splint, or a schedule for the use of the splint. *The Care Plans dated prior to 8/8/24 did not indicate the use of a left-hand splint. During an interview on 8/7/24 at 8:50 A.M., the Assistant Director of Rehabilitation (ADOR) said Resident #70 uses a left-hand splint at night and is currently being trialed for left-hand splint use during the day and remains on skilled occupational therapy services. During further interview on 8/7/24 at 8:56 A.M., the ADOR said Resident #70 had a change of status in May and that Resident #70's left side including his/her upper extremity was impaired. The ADOR reviewed Resident #70's medical record and said there was no physician's order for the left-hand splint. The ADOR said an order is typically entered for the use of a device and that she was not sure if nursing staff document the donning or doffing of the left-hand splint. Review of the document the ADOR provided, titled Care Plan Updates, dated 6/26/24 and signed by the therapist and nurse, indicated the following: -A splint will be applied to L (left) Hand at bedtime and remove during A.M. care. Sleeping Splint. The education provided indicated: *please place isotoner glove on left hand at noc (night), followed by L hand splint. Remove both with A.M. care. The document was signed by five CNA (certified nursing assistant) staff. Review of the Occupational Therapy OT Recert Progress Report and Updated Therapy Plan, with a certification period of 7/23/24-8/23/24 indicated Goal #6.0-continue Pt/caregiver will demonstrate 100% competency of proper donning/doffing splint, splinting PM schedule, and skin checks in order to maintain joint/skin integrity to improve QoL (Quality of Life) During an interview on 8/7/24 at 3:20 P.M., CNA #1 said Resident #70 wears a leg and hand splint at night and that he was educated on how to put it on and that he only works to 7:00 P.M. CNA #1 said when he comes back to work the next morning the hand splint is sometimes off. CNA #1 said he did not know where the use of the splint is documented. During an interview on 8/7/24 at 3:24 P.M., Nurse #1 said Resident #70 has worked with OT and PT and has made some gains after he/she suffered a stroke. Nurse #1 said devices used are put in as physician orders, the CNAs put on the device and the nursing staff document the use on the TAR. Nurse #1 said there was no order that she could see for the use of a left-hand splint for night use. During an interview on 8/7/24 at 3:33 P.M., Unit Manager #1 said Resident #70 was to use a left-hand splint at night and that it never got on the orders and therefore there was no documentation to ensure it was being completed. During an interview on 8/7/24 3:49 P.M. Occupational therapist #2 said that she began treating Resident #70 a few weeks ago when the other treating OT left. OT #2 said she has treated the Resident three for four times. OT #2 said she is trialing the use of a day splint, that there were occasions that the Resident removed the splint him/herself. OT#2 said she did not discontinue the night splint during the trials because he/she did not want the Resident to have nothing and would benefit from using the splint. OT #2 said CNA staff can don and doff the splint once there is an order and education is provided. OT #2 said the Resident said that staff do not always put on the splint.

Based on observation, record review, and interview, the facility failed to ensure the catheter bag for one Resident (#14) was off the floor to prevent potential contamination, out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Foley Catheter Care, Date May 1, 2022, reviewed 2023 indicated the following: - A foley catheter is a closed urinary drainage system consisting of a Foley catheter with a balloon at the distal end to secure it in place inside of the bladder. - The Foley catheter is attached to a collection bag making it a closed system. The system should not be broken unless there is a specific reason such as changing the collection bag. - The following policy provides guidance related to MD orders necessary for the care and maintenance of a Foley Catheter. The MD may write additional orders if there is a specific resident need. Policy: It is the policy of this facility to maintain MD orders for the care and maintenance of a foley catheter. The MD orders will include: 1. When the foley is to be inserted. 2. The size of the foley lumen. 3. The size of the foley balloon. 4. Catheter care once each shift including: Checking the foley for patency * Checking the foley position * Checking the condition of the urine noting presence of sediment and urine color. * Perineal care * Wash perineum with warm soapy water, rinse well and dry well. 5. MD order will indicate if the foley may be irrigated with 50cc of normal saline if there are signs of blockage. * This would include be increase in sediment and decrease in urine being collected. 6. MD order will indicate if the foley may be changed if a clog is not relieved with irrigation. 7. MD order will indicate when to change the collection bag. * Note: there is no specific timeframe for changing the collection bag. It should be changed when it has become soiled inside with sediment or outside from another source. 8. Foley collection bags should be emptied once each shift. The amount emptied should be recorded in the resident's clinical record. Resident #14 was admitted to the facility in November 2020 with diagnoses that include but are not limited to hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, benign prostatic hyperplasia with lower urinary tract symptoms. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #14 scored a 15 out of 15 on the Brief Interview for Mental Status which indicates he/she is cognitively intact, require substantial/maximal assistance from staff for dressing, is dependent for toileting and did have behaviors. Further the MDS indicated Resident #14 has an indwelling catheter for urinary output. During the survey the following observations were made by the surveyor. On 8/06/24 at 9:04 A.M. Resident #14's was in his/her bed. The urinary drainage bag was on the floor on his/her right side of the bed. The drainage bag was opaque, not covered, and was bulged. Resident #14 said staff empty around it 5 in the morning and that he/she did not place it on the floor and could not physically place it on the floor. On 8/6/24 at 9:56 A.M., Resident #14 was in his/her bed and the urinary drainage bag was on the floor. On 8/7/24 at 8:19 A.M., Resident #14 was in bed. The bottom of the urinary drainage bag was resting on the floor. On 8/08/24 at 6:51 A.M., Resident #14 was in bed. The urinary drainage bag was on the floor on the right side of his/her bed. At this time Certified Nursing Assistant (CNA) #2 came in the room and observed the urinary drainage bag on the floor and said the bag should not be on the floor and should be hung higher on the side of the bed. CNA #2 said the bag may have moved when the bed was moved. During an interview on 8/08/24 at 8:47 A.M., Unit Manager (UM) #1 said the urinary collection bag should not be on the floor, that the Resident does use the bed control and moves his/her bed and that could be why the urinary collection bag was on the floor. UM #1 staff should monitor the position of the urinary collection bag.

Based on observation and interview, the facility failed to serve food that is palatable and at a safe and appetizing temperature. Findings include: Review of the facility's policy titled, Palatability dated effective 6/29/20 indicated Purpose: -Ensure food has an appetizing aroma and appearance. -Food is served at a preferable temperature (hot foods served hot and cold foods served cold). During the resident group meeting on 8/7/24 at 10:02 A.M., 4 out of 6 participating residents said that the food served is always cold and bland. During a test tray conducted on 8/7/24 at 12:12 P.M., the following was observed: - The milk temperature was 50 degrees Fahrenheit. - The sweet potato was 100 degrees Fahrenheit and tasted lukewarm, and was sitting in water on the plate. - The ham was 90 degrees Fahrenheit, tasted lukewarm, and was sitting in water. - The zucchini squash was 100 degrees Fahrenheit and was very soft, not strained, and in liquid. 46339 A test tray was completed on 8/7/24 at 1:00 P.M., of the 1st floor unit the following temperatures were recorded: -Ham was 115 degrees Fahrenheit and tasted lukewarm and watery. -Sweet potato was 130 degrees Fahrenheit and tasted watery. -Zucchini was 127 degrees Fahrenheit and tasted bland and watery. -Yogurt was 53 degrees Fahrenheit. -Chocolate cake was 74 degree Fahrenheit. During an interview on 8/7/24 at 4:37 P.M., the findings of the test trays was shared with the Food Service Director.

Based on record review and interview the facility failed to obtain consent for the use of a psychotropic medication for 1 Resident (#66) out of a total sample of 18 residents. Findings Include: Resident #66 was admitted to the facility in April 2023 with diagnoses including dementia, acute embolism and adult failure to thrive. Review of Resident #66's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairment. Review of Resident #66's June 2023 Physician Orders, indicated the following: - Lorazepam (a medication used to treat anxiety) 2 mg/ml, Give 0.25 milliliters (ml) by mouth at bedtime for anxiety. Review of Resident #66's June 2023 Medication Administration Record (MAR) indicated he/she received Lorazepam 0.25 ml daily at bedtime from 6/8/23 to 6/20/23. Review of Resident #66's medical record failed to indicate a consent was obtained for his/her Lorazepam. During an interview on 6/21/23 at 7:46 A.M., Unit Manager # 1 said that when a resident has an order for Lorazepam, consent is needed.

Based on record review, interview and observation, the facility failed to implement 1 Resident's (#60) oxygen plan of care out of a total of 18 sampled residents. Findings Include: Resident #60 was admitted to the facility in May 2023 with diagnoses including dysphagia, polymyalgia rheumatica and spinal stenosis. Review of the facility policy titled Oxygen Administration, dated 12/22, indicated All tubing will be changed at least weekly, more often if soiling with secretions occurs. Review of Resident #60's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she was cognitively intact. During an observation on 6/20/23 at 8:50 A.M., the surveyor observed Resident #60 in bed with oxygen running via nasal cannula, the oxygen tubing was not dated. During an observation on 6/20/23 at 12:22 P.M., the surveyor observed Resident #60 in bed with oxygen running via nasal cannula, the oxygen tubing was not dated. During an observation on 6/21/23 from 7:38 A.M. to 7:42 A.M., the surveyor observed Resident #60 in bed with oxygen running via nasal cannula, the oxygen tubing was not dated. Review of Resident #60's oxygen therapy care plan, dated 5/5/23, indicated Please change nasal cannula tubing, nasal cannula, (face mask) weekly and as needed. Review of Resident #60's June 2023 Physician Orders, indicated Change Oxygen tubing weekly on Fridays, 11a-7p (11:00 A.M. to 7:00 P.M.) shift and PRN (as needed). The orders further indicated Oxygen at 2 LPM (liters per minute) via NC (nasal cannula) continuously for SOB (shortness of breath). During an interview and observation on 6/21/23 at 8:08 A.M., Nurse #1 said that Resident #60's oxygen tubing was not labeled and said it should be changed weekly. During an interview on 6/21/23 at 8:15 A.M. Unit Manager #1 said the expectation is for nursing to change the oxygen tubing weekly and to date the oxygen tubing.

Based on policy review, observation and interview the facility failed to provide assistance with Activities of Daily Living (ADLs) for 2 Residents (#7, and #66) out of a total sample of 18 residents. Findings Include: Review of the facility policy titled, Activities of Daily Living (ADL), dated 12/2022, indicated A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will provide care and services for the following activities of daily living: d. Dining- eating, including meals and snacks 1. Resident #7 was admitted to the facility in May 2023 with diagnoses including end stage renal disease, severe protein-calorie malnutrition, and renal dialysis. Review of Resident #7's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 14 out a possible 15 on the Brief Interview for Mental Status, which indicated he/she was cognitively intact. The MDS further indicated he/she required limited assistance on one staff person for eating. During an observation on 6/20/23 from 8:19 A.M. to 8:23 A.M., Resident #7 was in bed with their breakfast tray, uncovered and untouched, falling asleep at times. No staff were present in the room. During an observation on 6/20/23 from 12:12 P.M. to 12:17 P.M., Resident #7 was in bed with their lunch tray uncovered and untouched, not initiating eating. No staff were present in the room. During an observation on 6/21/23 from 8:15 A.M. to 8:22 P.M., Resident #7 was in bed, falling asleep, with their breakfast tray in front of him/her, uncovered and untouched. No staff were present in the room. Review of Resident #7's Activity of Daily Living (ADL) care plan, dated 6/9/23, indicated EATING: he/she requires direct supervision in a group setting during meals provide set up assist. Review of Resident #7's Certified Nurse Aide (CNA) Kardex, dated 6/20/23, indicated EATING: he/she requires direct supervision in a group setting during meals provide set up assist. During an interview on 6/21/23 at 8:16 A.M., Unit Manager #1 said that Resident #7 does need to be in a supervised setting during meal time. Unit Manager #1 said that staff usually sit with him/her as the Resident likes to eat in bed. 2. Resident #66 was admitted to the facility in April 2023 with diagnoses including dementia, acute embolism and adult failure to thrive. Review of Resident #66's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairment. The MDS further indicated he/she required an extensive assist of one staff person for eating. During an observation on 6/20/23 from 8:12 A.M. to 8:14 A.M., the surveyor observed Resident #66 not touching their breakfast, playing with it at times dropping eggs, no staff were present. During an observation on 6/20/23 from 12:10 P.M. to 12:17 P.M., the surveyor observed Resident #66 in the dining room he/she was struggling to bring food to his/her mouth, no staff were present. During an observation on 6/21/23 from 8:05 A.M. to 8:10 A.M., the surveyor observed Resident #66 in bed with his/her breakfast tray falling asleep at times, no staff were present in the room. Review of Resident #66's Activity of Daily Living (ADL), dated 5/4/23, indicated Eating: assist/totally dependent with meals. Review of Resident #66's Certified Nurse Aide (CNA) Kardex, dated 6/20/23, indicated Eating: assist/totally dependent with meals. During an interview on 6/21/23 at 8:16 A.M., Unit Manager #1 said she reviewed Resident #66's care plan and it does indicate that he/she needs assistance with meals. The Unit Manager said that the CNA's are to look at the CNA Kardex to see what each resident requires for assistance.

Based on observation, record review and interview the facility failed to ensure 1.) an air mattress was on the correct setting for 1 Resident (#60) who had actual skin breakdown 2.) heels were offloaded as ordered for 1 Resident (#273) who had actual skin breakdown to the right heel out of a total sample of 18 Residents. Findings Include: 1. Resident #60 was admitted to the facility in May 2023 with diagnoses including dysphagia, polymyalgia rheumatica and spinal stenosis. Review of the facility policy titled, Specialty Mattress Procedure, not dated, indicated The residents' weight will be obtained as necessary for settings. Review of Resident #60's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she was cognitively intact. During an observation on 6/20/23 at 8:50 A.M., the surveyor observed Resident #60 lying in bed on an air mattress, the air mattress pump was set to 250 pounds (lbs). The air mattress pump had a label to set the air mattress to 150 lbs. During an observation on 6/20/23 at 12:22 P.M., the surveyor observed Resident #60 lying in bed on an air mattress, the air mattress pump was set to 250 pounds (lbs). The air mattress pump had a label to set the air mattress to 150 lbs. During an observation on 6/21/23 from 7:42 A.M. to 8:08 A.M., the surveyor observed Resident #60 lying in bed on an air mattress, the air mattress pump was set to 250 pounds (lbs). The air mattress pump had a label to set the air mattress to 150 lbs. Review of Resident #60's Physician Orders, indicated Air mattress to bed set at 150 lbs, every shift for prevention. Review of Resident #60's skin care plan, dated 6/4/23, indicated pressure-relieving/reducing device mattress in bed. Review of Resident #60's weight dated 6/5/2023 indicated his/her weight was 132.5 lbs. Review of Resident #60's skin assessment, dated 6/21/23, indicated he/she had a stage 2 on his/her sacrum. During an interview and observation on 6/21/23 at 8:08 A.M., Nurse #1 said Resident #60's doctors order says to set his/her air mattress to 150 lbs. Nurse #1 said that the air mattress is currently set to 250 lbs which would cause more pressure to the Resident as he/she has a pressure wound. During an interview on 6/21/23 at 8:15 A.M. Unit Manager #1 said Resident #60's air mattress should be set by the doctor's order which reflects the weight of the resident to prevent skin breakdown. 2. Resident #273 was admitted to the facility in June 2023 with diagnoses including chronic kidney disease, heart failure, dysphagia and acute respiratory failure with hypoxia. Review of Resident #273's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored 11 out of possible score of 15 on the Brief Interview for Mental Status. Further review of the MDS indicated he/she required an extensive assist of two staff members for bed mobility and indicated he/she does not reject care. During an observation on 6/20/23 from 7:35 A.M. to 8:22 A.M., the surveyor observed Resident #273 lying in bed with his/her heals on the mattress. The surveyor also observed his/her Prevalon boots on the chair. During an observation on 6/21/23 from 7:37 A.M. to 8:09 A.M., the surveyor observed Resident #273 lying in bed with his/her heals on the mattress. The surveyor also observed his/her Prevalon boots on the chair. During an observation and interview on 6/21/23 at 8:15 A.M., Unit Manager #1 said that Resident #273 should have his/her heels off loaded as ordered and said his/her boots should be on as he/she has wounds on his/her heel. The Unit Manager said the nurses as to check on these things every time they go into the room. During an interview on 6/21/23 at 8:17 A.M., Resident #273 said that staff do not offer to off load his/her heels and said that his/her heels do hurt at times. Review of Resident #273's Physician Orders, indicated Prevalon boots at all times except walking with rehab and bathing, every shift for prevention. Not with rehab/walking/or bathing. The orders further indicated an order for Elevate feet on pillows when in bed to prevent pressure to heels, every shift. Review of Resident #273's wound doctor's note, dated 6/15/23, indicated Wound: Unstageable necrosis pressure ulcer (full thickness wound) of the right plantar heel.

Based on observation, interview and record review, the Facility staff failed to ensure that 1 Resident (#66) out of a total sample of 18 Residents received adequate supervision and assistance to prevent an accident resulting in a laceration requiring sutures. Findings include: Resident #66 was admitted to the Facility in 5/2018 after a fall resulting in a cervical (neck) fracture. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], and the Quarterly MDS, dated [DATE], indicated that Resident #66 had a severe cognitive impairment, scoring a 0 out of 15 on the Brief Interview for Mental Status (BIMS), and needed extensive assistance from staff, requiring a two person physical assist for bed mobility, transfers, locomotion and activities of daily living. Review of the ADL care plan dated 8/31/18 indicated that Resident #66 required the assistance of 2 for transfer to wheelchair and required assistance of 2 for activities of daily living and bed mobility. Review of the Certified Nursing Assistant (CNA) Care Card indicated that as of 5/14/18 Resident #66 required the assistance of 2 for transfers. Review of the clinical record indicated that on 7/22/18 at approximately 7:00 P.M., CNA #6 had discovered a large skin tear on the right outer lateral aspect of Resident #66's leg. Resident #66 said that when he/she was being pushed in the wheelchair by staff, they had accidentally hit his/her leg on something. Resident #66 scored a 0 out of 15 on the BIMS indicating a severe cognitive impairment. Resident #66 was transferred to the hospital emergency room for evaluation. CNA #6 was not available for interview. Review of her statement at the time of the incident indicated that at approximately 7:00 P.M. she transferred Resident #66 with a gait belt from the wheelchair into bed and not with an assist of 2 per the plan of care. After the transfer CNA #6 removed the residents clothing and discovered a large skin tear on the right outer calf and notified the nurse. Review of statements from staff that were working prior to the incident indicated that the skin tear was not present prior to CNA #6 transferring Resident #66 from the wheelchair into bed. Review of the emergency room evaluation indicated that Resident #66 had deep sutures in the subcutaneous (under the skin) tissue and then the skin closed with steristrips (tape that acts as stitches). During an interview with the Administrator on 10/18/18 at 7:15 A.M., she said that the shape and location of the wound appeared as if it could have happened if Resident #66's leg had come in contact with the wheelchair footrest. She said there were no staff statements to back up the theory so the Facility was unable to determine the cause of the wound. During an interview with the Director of Nurses (DNS) on 10/18/18 at 1:15 P.M., she said she was not employed at the Facility at the time of the incident, but upon review of the incident file it appeared that the plan of care for Resident #66 was not followed.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure staff followed Resident #1's plan of care related to safety, when staff failed to implement safety interventions to avoid accidents and injuries, when on 9/5/17, Certified Nurse Aides (CNA's) physically transferred Resident #1, did not use the Hoyer (mechanical) lift per the plan of care, and as result Resident #1 sustained fractures to his/her right ankle and left knee. Findings include: The Facility Policy titled, Event/Incident Report, dated June 2011, indicated it is the policy to provide an environment that is free from hazards over which the center has control. The intent of this policy is that the center identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents. On admission the Licensed Nurse completes an evaluation of the resident and the environment to identify risk factors and develops an Interim Care Plan. Interdisciplinary Team (IDT), based upon the identified potential risk factors develops and implements an individualized plan of care. The IDT evaluates, monitors and revises the individualized plan of care as necessary. The Facility Policy titled, Hoyer Mechanical Lift, dated July 2013, indicated all resident care will be provided in a safe, appropriate and timely manner in accordance with the individual's plan of care. All residents will be assessed with [REDACTED]. This policy is intended to provide appropriate care for each resident and maintain a safe work environment. Residents identified as Totally Dependent or Extensive Assistance, for example, will be transferred by means of lift equipment and/or resident assist devices instead of by manual lift. The Certified Nursing Assistant Care (CNA) Card, dated 5/15/2017, indicated Resident #1 was dependent for transfers and required a Hoyer (mechanical) lift for transfers. The Therapy Screen Form, dated 6/7/2017, indicated Resident #1 rarely got out of bed, was dependent and required a Hoyer lift for transfers. The Annual Minimum Data Set (MDS) Assessment, dated 6/8/2017, indicated Resident #1 was cognitively impaired and dependent for bathing, grooming and transfers. The Falls Care Plan included the intervention, dated 6/19/17, that Resident #1 required a Hoyer (mechanical) lift for transfers. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Plan included the intervention, dated 6/20/17, that Resident #1 required a Hoyer (mechanical) lift for transfers. The Hospital emergency room Admissions Report, dated 9/5/17, indicated Resident #1 appeared to be in distress due to pain and presented (from the Facility) with obvious deformities to the right ankle and left lower leg and diagnosed with [REDACTED]. A Hospital Orthopedic Consultation, dated 9/6/17, indicated Resident #1 was diagnosed with [REDACTED]. (fractured bone does not heal properly), nonunion (permanent failure of bone healing) and delayed union (fracture takes longer than usual to heal). The Facility Investigation Report, dated 9/8/2017, indicated Resident #1 complained of pain and presented with lower extremity swelling on 9/5/2017, was diagnosed with [REDACTED]. The Facility Investigation Report indicated Resident #1 was physically transferred using a stand-pivot transfer and not a mechanical (Hoyer) lift. This was not consistent with Resident #1's Activities of Daily Living (ADL) Functional/Rehabilitation Potential and Falls Care Plans. The Surveyor interviewed The Assistant Director of Nursing (ADON) at 9:05 A.M. on 10/5/2017, the Unit Manager 10:38 A.M. on 10/5/2017 and 1:08 P.M. on 10/5/2017, CNA #8 at 1:37 P.M. on 10/6/2017 and CNA #9 at 1:46 P.M. on 10/6/2017. The ADON, Unit Manager, CNA #8 and CNA #9 said Resident #1 was physically transferred out of bed, on the morning of 9/5/17, and a Hoyer Lift was not used. This was not consistent with the Facility Policy titled, Event/Incident Report, dated June 2011 and the Facility Policy titled, Hoyer Mechanical Lift, dated July 2013. The Surveyor interviewed the Unit Manager 10:38 A.M. on 10/5/2017 and 1:08 P.M. on 10/5/2017, CNA #2 at 9:31 A.M. on 10/5/2017 and CNA #6 at 2:56 P.M. on 10/5/2017 and CNA #7 at 3:20 P.M. on 10/5/2017. the Unit Manager, CNA #2, CNA #6 and CNA #7 said Resident #1 was physically transferred back into bed after lunch on 9/5/2017 and a Hoyer Lift was not utilized. This was not consistent with the Facility Policy titled, Event/Incident Report, dated June 2011 and the Facility Policy titled, Hoyer Mechanical Lift, dated July 2013.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to utilize assistive devices to ensure a safe transfer and prevent Resident #1 from sustaining serious injuries to his/her right and left lower extremities. Resident #1 was assessed and care planned as requiring a Hoyer (mechanical) lift for all transfers. On 9/5/2017 at approximately 6:00 A.M., staff transferred Resident #1 out of bed to wheelchair via a 2-person physical assist and did not use a Hoyer lift for the transfer. On 9/5/2017 at approximately 1:00 P.M., Resident #1 exhibited symptoms of pain and staff transferred Resident #1 out of the wheelchair and into bed via a 3-person physical assist and did not use a Hoyer (mechanical) lift for the transfer. On 9/5/2017, at approximately 7:20 P.M., x-rays indicated Resident #1 was diagnosed with [REDACTED]. Findings include: The Facility Policy titled, Event/Incident Report, dated June , indicated it is the policy to provide an environment that is free from hazards over which the center has control. The intent of this policy is that the center identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents. On admission the Licensed Nurse completes an evaluation of the resident and the environment to identify risk factors and develops an Interim Care Plan. Interdisciplinary Team (IDT), based upon the identified potential risk factors develops and implements an individualized plan of care. The IDT evaluates, monitors and revises the individualized plan of care as necessary. The Facility Policy titled, Hoyer Mechanical Lift, dated July 2013, indicated all resident care will be provided in a safe, appropriate and timely manner in accordance with the individual's plan of care. All residents will be assessed with [REDACTED]. This policy is intended to provide appropriate care for each resident and maintain a safe work environment. Residents identified as Totally Dependent or Extensive Assistance, for example, will be transferred by means of lift equipment and/or resident assist devices instead of by manual lift. The Annual Minimum Data Set (MDS) Assessment, dated 6/8/2017, indicated Resident #1 was cognitively impaired and dependent for bathing, grooming and transfers. The Certified Nursing Assistant Care (CNA) Card, dated 5/15/2017, indicated Resident #1 was dependent for transfers and required a Hoyer (mechanical) lift for transfers. The Therapy Screen Form, dated 6/7/2017, indicated Resident #1 rarely got out of bed, was dependent and required a Hoyer lift for transfers. The Falls Care Plan included the intervention, dated 6/19/17, that Resident #1 required a Hoyer (mechanical) lift for transfers. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Plan included the intervention, dated 6/20/17, that Resident #1 required a Hoyer (mechanical) lift for transfers. The Hospital emergency room Admissions Report, dated 9/5/17, indicated Resident #1 appeared to be in distress due to pain and presented (from the Facility) with obvious deformities to the right ankle and left lower leg and diagnosed with [REDACTED]. A Hospital Orthopedic Consultation, dated 9/6/17, indicated Resident #1 was diagnosed with [REDACTED]. (fractured bone does not heal properly), nonunion (permanent failure of bone healing) and delayed union (fracture takes longer than usual to heal). The Facility Investigation Report, dated 9/8/2017 indicated Resident #1 complained of pain and presented with lower extremity swelling on 9/5/2017, was diagnosed with [REDACTED]. The Facility Investigation Report indicated Resident #1 was physically transferred using a stand-pivot transfer and not a mechanical (Hoyer) lift. This was not consistent with Resident #1's Care Plan and not consistent with the Facility Policies titled, Event/Incident Report, dated June 2011 and Hoyer Mechanical Lift, dated July 2013. The Surveyor interviewed The Assistant Director of Nursing at 9:05 A.M. on 10/5 /2017. The ADON said he was informed of Resident #1's lower extremity swelling on 9/5/2017 and he assessed Resident #1. The ADON said Resident #1 was diagnosed with [REDACTED]. The ADON said Resident #1 was physically transferred by two CNA's out of bed using a stand-pivot transfer, not via the Hoyer (mechanical) Lift, in the morning on 9/5/2017. The Surveyor interviewed CNA #2 at 9:31 A.M. on 10/5/2017, CNA #6 at 2:56 P.M. on 10/5/2017 and CNA #7 at 3:20 P.M. on 10/5/2017. CNA #2, CNA #6 and CNA #7 said they physically transferred Resident #1, using a three person physical assist, out of the wheelchair and back into bed after lunch on 9/5/2017. CNA #2, CNA #6 and CNA #7 said they knew Resident #1 required a Hoyer Lift for transfers and did not use a Hoyer Lift because they were not able to get the Hoyer pad underneath Resident #1. This was not consistent with the Facility Policy titled, Event/Incident Report, dated June 2011 and the Facility Policy titled, Hoyer Mechanical Lift, dated July 2013. CNA #7 said the Unit Manager indicated it was okay to physically transfer Resident #1 without the Hoyer Lift. CNA #2 and CNA #6 said Resident #1 appeared to be in pain and his/her knee and lower extremities appeared swollen prior to the transfer and the Unit Manager was informed. The Surveyor interviewed the Unit Manager 10:38 A.M. on 10/5/2017 and 1:08 P.M. on 10/5/2017. The Unit Manager said she worked the morning shift on 9/5/2017 and Resident #1 was out of bed, appeared to be uncomfortable, and was sitting in the dining room when she arrived on the unit that morning. The Unit Manager said Resident #1 received his/her scheduled dose of Tramadol (narcotic medication used to treat pain) that morning and appeared to be comfortable until after lunch. The Unit Manager said she instructed CNA #2, CNA #6 and CNA #7 to physically transfer Resident #1, without the Hoyer Lift, back into bed after lunch because she was informed they could not get the Hoyer Lift pad underneath Resident #1. This was not consistent with the Facility Policy titled, Event/Incident Report, dated June 2011 and the Facility Policy titled, Hoyer Mechanical Lift, dated July 2013. The Unit Manager said she was informed by the CNA's, after Resident #1 was back in bed, that Resident #1's knee was swollen, she assessed Resident #1 at that time, informed the Physician and obtained x-rays. The Unit Manager said Resident #1 was diagnosed with [REDACTED]. The Unit Manager said she was informed Resident #1 had been transferred using a stand-pivot transfer, not a Hoyer Lift, in the morning on 9/5/2017. The Unit Manager said Resident #1 had brittle bones. The Unit Manager said Resident #1 had no recent falls, accidents or incidents. The Surveyor interviewed Occupational Therapist (OT) #1 at 1:38 P.M. on 10/5/2017 and Physical Therapist (PT) #1 at 1:45 P.M. on 105/2017. OT #1 and PT #1 said if Resident #1 had been assessed and care planned for a Hoyer Lift transfer then it would not be safe to utilize a stand-pivot transfer or any other type of transfer. OT #1 and PT #1 said residents should be re-assessed before deviating from the care plan and initiating another type of transfer for the safety of staff and residents. The Surveyor interviewed Nurse #2 at 2:20 P.M. on 10/5/2017. Nurse #2 said she was assigned to care for Resident #1 on 9/4/2017, 11:00-7:00 A.M. shift. Nurse #2 said her shift went well and she was not informed of any incidents involving any residents. Nurse #2 said she did not know how the CNA's transferred Resident #1 out of bed in the morning on 9/5/2017. Nurse #2 said if Resident #1's Care Plan indicated he/she required a Hoyer lift transfer then a Hoyer Lift transfer should have been utilized to ensure a safe transfer for Resident #1. The Surveyor interviewed CNA #8 at 1:37 P.M. on 10/6/2017. CNA #8 said she worked for a Staffing Agency and was assigned to work at the Facility on 9/4/2017, 11:00-7:00 A.M. shift and Resident #1 was assigned to her. CNA #8 said she received a verbal report from CNA #5, was told Resident #1 should be assisted out of bed in the morning. CNA #8 said she was not informed Resident #8 required a Hoyer (mechanical) Lift for transfer and was not informed about the CNA Care Cards. CNA #8 said CNA #9 assisted her to get Resident #1 out of bed in the morning on 9/5/2017. CNA #8 said she and CNA #9 physically lifted Resident #1 out of bed and into the wheelchair and they did not use a Hoyer (mechanical) Lift. The Surveyor interviewed CNA #9 at 1:46 P.M. on 10/6/2017. CNA #9 said she worked the 11:00-7:00 A.M. shift on 9/4/2017 on Resident #1's nursing unit and had received a verbal report about each resident on her assignment from CNA #5. CNA #9 said Resident #1 was not on her assignment. CNA #9 said she assisted CNA #8 to transfer Resident #1 out of bed to a wheelchair in the morning on 9/5/2017. CNA #9 said she did not know Resident #1 required a Hoyer (mechanical) Lift for transfers. CNA #9 said she and CNA #8 physically lifted Resident #1 out using a stand-pivot transfer, not a Hoyer Lift transfer, into the wheelchair.

Based on observation, record review and interviews, the facility failed to provide the necessary care and services in order to control the pain for 1 Resident (#2) out of a total sample of 22 Residents. Findings include: 1. Resident #2 was admitted to the Facility in 10/2015, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], indicated the Resident's cognition was severely impaired. The Resident's Health Care Proxy (HCP) was activated. Behaviors included yelling out which was controlled by letting the Resident chew gum. The Resident was totally dependent for all aspect of activities of daily living, non-ambulatory and transported in a tilt-in-space wheelchair, required a hoyer lift for transfers, and incontinent of bladder and bowel. The Resident was non-verbal. Review of the Admission MDS dated [DATE] and the Quarterly MDS dated [DATE], indicated that the sections for Pain did not include information for a pain assessment interview based on the Resident's non-verbal status. The section on staff assessment for pain or possible pain in the last 5 days for both the Admission and Quarterly MDS was checked as no signs of non-verbal, vocal complaints of pain, facial expressions, protective body movements or postures. Review of the MDS pain interview dated 10/17/15, indicated the form titled Comprehensive Pain Assessment was not completed because the Resident was non-verbal, unable to assess. Review of the Admission Physician order [REDACTED]. Review of the Quarterly Pain assessment dated [DATE], indicated the Resident demonstrated no signs of pain at the time of assessment and had a PRN (as needed) order for Tylenol for pain. Review of the Facility's Pressure Ulcer Weekly Wound Assessment sheet indicated the pressure ulcer was Facility acquired 6/6/16. The wound measurement was unable to be taken or fully assessed due to the extreme nature of the contracture - it was not visible because the pad of the little finger was lying upon the inside of the finger where the finger meets the palm. The preventative measure was to place a rolled up bandage gauze under the fingers and palm area. Review of the Physician order [REDACTED]. Apply [MEDICATION NAME] to tip of right 5th finger twice a day, 9:00 A.M. and 9:00 P.M. Review of the Nurse's Notes dated 6/6/16 at 2:45 P.M., indicated that the Resident's pinky was very contracted even after soaking in warm water and using Pliocene (cream applied to sore muscles for pain relief). Resident very uncomfortable. A lot of yelling/crying and increase in heart rate. Sore at bottom of finger due to rubbing against hand/palm guard/carrot. Occupational Therapy (OT) aware. Called (HCP) to discuss. Review of the medical record and nursing report book indicated there was no call to the physician regarding the Resident's pain during the procedure. Review of the Resident's care plan indicated there was a problem identified for Pressure Ulcer (start date 6/7/16) and that the Resident had a pressure sore on the pad of the pinky finger of the right hand due to inability to tolerate gentle passive range of motion (where the therapist or nurse moves the Resident's hand and fingers to prevent freezing of the muscles and bones) and orthotics for proper contracture management. Although, it was documented that the Resident could not tolerate even gentle range of motion, there were no measures to address pain. The care plan did not address observations made during painful interventions to cue staff on non-verbal ways the Resident communicates pain. Review of the Nurse Practitioner's notes dated 6/8/16, indicated that Patient has contractures in right hand. Hand is very tight and fingers are tight into palm. Staff is having difficult time washing inside her hand. (Resident) cries when staff attempt to wash the area. Staff notes some open areas on (Resident's) little finger. (Activated HCP) has set up appointment for [MEDICATION NAME]. Therapy continues to work with (Resident). The notes did not indicate a plan to address the Resident's pain during the procedure. Review of the Nurse Practitioner's notes dated 6/16/16, indicated that Patient continues with contracture of right hand with difficulty opening her/his fingers. OT noticed some drainage. Patient continues to cry when the finger is touched or moved. Right small finger red warm tender, there is large amount of reddish brown drainage from tip of finger. Assessment - [MEDICAL CONDITION] of right little finger. Documentation indicated that an antibiotic was prescribed, but there were no measures or medications prescribed for pain other than the original order for Tylenol. Review of the Nurse's Notes dated 6/18/16 at 7:00 A.M. - 3:00 P.M., indicated that the Resident continued on the antibiotic for the [MEDICAL CONDITION]. Resident continues to be verycontracted, very limited visual inspection able to be done. Resident in pain/discomfort when trying to work with her/him by opening fingers. Continuing to monitor. Review of the medical record and nursing report book indicated there was no call to the physician regarding the Resident's pain during the procedure. Review of the Nurse's Notes dated 6/18/16 at 3:00 P.M. - 11:00 P.M., indicated that the Resident continued on the antibiotic for infected tip of 5th finger. Finger very contracted limiting observation of tip of 5th finger. Very painful for Resident to have fingers manipulated. [MEDICATION NAME] role inserted into palm. Review of the medical record and nursing report book indicated there was no call to the physician regarding the Resident's pain during the procedure. Review of the Nurse's Notes dated 6/19/16 at 7:00 A.M. - 3:00 P.M., indicated that the Resident continued on the antibiotic. Resident screaming and crying while doing treatment, unable to get a good visualization on wound, however, it feels like a blister and it's white in color. Resident so contracted and shows nonverbal as well as physical distress with touching her/his hand, opening fingers. Review of the medical record and nursing report book indicated there was no call to the physician regarding the Resident's pain during the procedure. Review of the Nurse Practitioner's notes dated 6/20/16, indicated that Right little finger no redness or tenderness to touch. Continues stiff and difficult to open, but improved. Appointment for [MEDICATION NAME] per (activated HCP) at the beginning of July. Again, there was no plan addressing the Resident's continued pain during the treatments. Review of the Nurse's Notes dated 6/21/16 at 10:00 P.M., indicated that the Resident continued on the antibiotic. Unable to visualize tip of finger due to patient screaming and contracting. Review of the medical record and nursing report book indicated there was no call to the physician regarding the Resident's pain during the procedure. Review of the Nurse's Notes dated 6/22/16 at 3:00 P.M. - 11:00 P.M., indicated that the Resident continued on the antibiotic Resident tightens fingers so tightly, unable to visualize wound on tip of finger. Mupirocin (antibiotic ointment, also known as [MEDICATION NAME]) applied to as much of area as possible. Continue to monitor. Review of the medical record and nursing report book indicated there was no call to the physician regarding the nurse's inability to apply the cream effectively based on the severity of the contracture. Review of the Nurse's Notes dated 6/25/16, no time documented, indicated that the Resident's 5th fingertip remains extremely difficult to apply Mupirocin and very painful due to severe contracture of hand/fingers. Unable to visualize actual wound. Resident cries when right hand is manipulated. [MEDICATION NAME] powder/[MEDICATION NAME] ointment applied to 5th finger as much as possible. Lt. green drainage with slight blood on old dressing. No odor. Again, review of the medical record and nursing report book indicated there was no call to the physician regarding the nurse's inability to apply the cream effectively based on the severity of the contracture, nor the Resident's continued pain during the procedure. Review of the Nurse's Notes dated 7/1/16 at 3:00 P.M. - 11:00 P.M., indicated the 5th fingertip remained difficult to visualize and apply [MEDICATION NAME] due to severely contracted fingers and Resident crying out when fingers manipulated. Light brown/bloody drainage on old dressing. Again, review of the medical record and nursing report book indicated there was no call to the physician regarding the nurse's inability to apply the cream effectively based on the severity of the contracture, nor the Resident's continued pain during the procedure. Review of the PRN medications flowsheet for the month of June 2016, indicated that the Resident received Tylenol on 6/ 5/16, 6/10/16 and 6/24/16. The only documentation for the Tylenol was on 6/5/16 at 8:35 P.M. when the nurse documented it was given for crying, unrelieved by gum, cold drink and changing. No Tylenol was administered on the days of the treatment for [REDACTED]. Review of the Occupational Therapy (OT) Notes indicated that the Resident was evaluated several times for various splints and measures to prevent the development of the contracture. The OT was interviewed on 7/12/16 at 9:20 A.M. The OT said that the Resident was evaluated in May and given a carrot splint (a soft splint shaped like a carrot that is placed within the palm of the hand to prevent contractures) because several other splints had not been effective because they were not tolerated by the Resident, were difficult to place or were frequently found incorrectly positioned or off. On 6/1/16, the nursing staff requested an evaluation because the carrot splint was not working and the Resident's activated HCP was requesting the staff consider [MEDICATION NAME] injections (an injection of a paralytic agent to prevent muscle contraction). The OT said the Resident was evaluated on 6/6/16 and it was acknowledged that the Resident was not tolerating stretching at all and would cry out in pain when the OT would attempt movement. The OT said that services were put on hold due to the Resident's inability to tolerate stretching and for now, to place a gauze in the center of the palm of the hand - and even that was difficult to place due to the extreme flexion of the fingers into the palm of the hand. The OT said the staff decided to put further treatment on hold because they did not want to put the Resident through this, it's torture, and they would pursue approval of the [MEDICATION NAME] injection by insurance source. On 7/12/16 at 2:15 P.M., Surveyor #2 made the following observation of the treatment to apply [MEDICATION NAME] and apply the gauze roll in the Resident's right hand/5th finger. Nurse #1 informed Surveyor #2 that she had completed a warm soak of the right hand and administered Tylenol prior to the procedure. It was observed that all of Resident #2's fingers were extremely contracted/bent into the palms of the hand, with the 5th finger so severely contracted that it was in a complete circle with the fingernail resting on the back of the finger. As Nurse #1 opened the Resident's finger so that they could be washed and the [MEDICATION NAME] applied, the Resident began yelling and screaming out, kicking out the non-paralyzed leg. The Resident's face was bright and she/he began to sweat profusely and her/his head was shaking as she/he continued to scream. The Resident's chest was heaving and the respiratory rate was noted to be increased. The Resident's eyes were very wide and staring at Surveyor #2. The Nurse Practitioner (NP) was interviewed on 7/14/16 at 11:46 A.M. The NP said the Resident was not admitted with the contracture. The NP said it has worsened with the dementia and that the Resident was more and more resistant to care. (Review of the medical record did not indicate that the Resident was resistant to care in either the nursing notes or behavioral monitoring sheets). The NP said the OT was working diligently with the Resident and had tried several splints, which the Resident would remove. The NP said the infection was very uncomfortable and the Resident would cry when it was touched. The NP said they had tried [MEDICATION NAME] cream on the fingers as a measure to control pain, but it was not effective and it was discontinued. The NP said that she had not witnessed what Surveyor #2 had observed during the treatment. The NP said that she talks to the Resident and rubs the Resident's face, distracting her/him, so she does not need pain medications. The NP said the nurses did not inform her of pain during treatments, but that she/he is crying during the treatments. The NP said that she had no more information because the medical record was not with her. Unit Manager #2 (UM #2) was interviewed on 7/14/16 at 1:15 P.M. with Surveyor #1 and Surveyor #2 present. UM#2 said they had discussed pain during treatments with the NP, because they had originally tried [MEDICATION NAME] cream on the fingers and it was not effective. UM#2 said she does not witness dressing changes or treatments with the nursing staff. UM#2 said that she is not aware of pain issues with Residents unless the nurse who observes it brings it to her attention. UM#2 said that she would expect that if a Resident has pain during treatments, it would be addressed and an effective measure for pre-medication be established. Nurse #2, who performed the treatment with Surveyor #2 joined the interview at 1:30 P.M. Nurse #2 said the contracture had gotten worse and worse over time. Nurse #2 said that she would find the carrot out of the Resident's hand (which held it in a neutral position) , so the contracture got worse. Nurse #2 said the OT felt that stretching the fingers out at this point in time would be too painful. Nurse #2 said the Resident had been crying out during the treatments all of June and July, since she was working with her. Nurse #2 said the [MEDICATION NAME] cream was discontinued because it was not working and no one did anything else. The wound is now making things worse, and that had started 6/16/16. Surveyor #1 asked for clarification about the Resident crying - was it non-purposeful related to dementia or in response to the action of opening the fingers/treatment. Nurse #2 agreed the crying was in response to the action of opening fingers/treatment. Nurse #2 said she phoned the NP after the treatment on 7/12/16 and had obtained an order for [REDACTED]. The Facility failed to update the pain assessment to include pain during treatments to the right hand and incorporate comfort measures in the care plan.

Based on record review and interview for 1 of 5 sampled residents (Resident #1), the Facility failed to ensure staff immediately removed Certified Nurse Aide (CNA) #1 from the Unit to prevent reoccurrence of abuse. Nurse #1 said within 30 minutes of re-directing CNA #1 from using profanity in a frustrated tone of voice at the nursing station, Nurse #1 did not intervene when CNA #1 was then heard in an edgy, frustrated tone telling Resident #1 words to the effect of, I've dealt with you all day in response to requesting a drink. Nurse #1 proceeded to move another resident away from a meal truck, being moved by Dietary Aide #1 and left the Unit. Dietary Aide #1 said after he moved the meal truck, he stood by a small meal cart to observe CNA #1 in a frustrated manner tell Resident #1 words to the effect of, don't start this again and when he/she began to cry, CNA #1 said just stop, go back into your room. Dietary Aide #1 said then CNA #1 leaned forward to position her face approximately 6 inches from Resident #1's face and said in an elevated tone words to the effect of, I hope you understand the more you cry the less attention and care you're going to get. Dietary Aide #1 said when Resident #1 continued to cry, CNA #1 sighed, brought her finger forward approximately 6 inches from Resident #1's face and said words to the effect of, go to your room right now, I've had enough. Findings include: The quarterly Minimum Data Set assessment, dated 1/25/16, indicated Resident #1 was cognitively impaired and [DIAGNOSES REDACTED]. The Facility's Resident Abuse and Clinical Council Policy and Procedure, dated July 2015, indicated the following: staff will maintain a manner of courtesy and respect toward residents; refrain from actions that could be considered abuse, mistreatment, and/or neglect; and any employee with reasonable cause to believe a resident has been abused, mistreated or neglected shall (after ensuring the safety of the resident) immediately report the alleged incident to their Supervisor, the Director of Nursing and/or Administrator. The Surveyor interviewed Nurse #1 at 12:55 P.M. on 4/22/16. Nurse #1 said less than 30 minutes before being notified of the alleged incident after supper on 3/27/16, she redirected CNA #1 to stop when she heard her using profanity in a loud, frustrated manner while with another staff member at the nursing desk. Nurse #1 said a few moments later, she heard Resident #1 request a drink of [MEDICATION NAME] water and CNA #1 said in an edgy, abrupt tone of voice words to the effect of, I've dealt with you all day. Nurse #1 said she believed the statement was directed toward Resident #1. Nurse #1 said she did not approach CNA #1 to investigate or remove CNA #1 from the Unit. Nurse #1 said she did not immediately report the incident to another Nurse or to a Supervisor to intervene for her. Nurse #1 said after she returned to the Unit after retrieving a resident after supper from the dining room, it was discovered that CNA #1 had been removed from the Unit and an investigation was in process regarding another allegation. The Surveyor interviewed Dietary Aide #1 at 1:35 P.M. on 4/22/16, and at 1:30 P.M. on 4/29/16. Dietary Aide #1 said after moving the last food truck to the elevator, he went to get the small cart located by the nursing desk. The Dietary Aide said while standing at the meal cart, Resident #1 approached CNA #1. Dietary Aide #1 said although CNA #1 reassured Resident #1 that his/her appearance was fine should visitors arrive, Resident #1 began to sob. Dietary Aide #1 said CNA #1 responded in a frustrated manner by saying words to the effect of, don't start this again. Dietary Aide #1 said Resident #1 began to cry, and CNA #1 said words to the effect of, just stop, go back into your room. Dietary Aide #1 said when Resident #1 continued to cry, CNA #1 leaned forward to position her face approximately 6 inches from Resident #1's face and said in an elevated tone words to the effect of, I hope you understand the more you cry the less attention and care you're going to get. Dietary Aide #1 said when Resident #1 continued to cry, CNA #1 sighed, brought her finger forward approximately 6 inches from Resident #1's face and said words to the effect of, go to your room right now, I've had enough. Dietary Aide #1 said CNA #1 walked away and left Resident #1 crying. Dietary Aide #1 said had he been a resident experiencing the incident, he would have felt scared, threatened, in danger and upset. Dietary Aide #1 said he immediately reported the incident to Unit Manager #1 located on another unit. The Surveyor interviewed Unit Manager #1 at 2:30 P.M. on 4/22/16. Unit Manager #1 said immediately after Dietary Aide #1 reported the alleged incident, she removed CNA #1 from the Unit, informed the Nursing Supervisor and an investigation began.

Based on record review and interview for 2 of 6 sampled residents (Resident #1 and Resident #2) the Facility failed to provide care and prevent adverse events. Resident #1 was admitted to the Facility after lumbar (low back) surgery and required a dressing change treatment to his/her lumbar surgical incision site everyday, there was no indication Resident #1's lumbar surgical site received daily dressing changes or assessments of the area and Resident #1's lumbar surgical incision site became infected and required surgical intervention. Resident #2 was admitted to the Facility after heart surgery with orders to receive [MEDICATION NAME] (a medication used to treat fluid build up) everyday. Resident #2's orders for [MEDICATION NAME] were not transcribed onto the Facility admission records, Resident #2 did not receive [MEDICATION NAME] for 5 days after admission, developed a productive cough, chills and required antibiotics for pleural effusion (excess fluid build up around the lungs.) Findings include: Resident #1: 1. Resident #1 in July 2015 for rehabilitation services after lumbar (low back) surgery. The Facility's Weekly Wound Assessment Policy and Procedure Clinical Council, dated July 2015, indicated nursing staff should complete the Wound Assessment Progress Report tool upon initial identification of a wound and weekly thereafter, complete the initial identification site of the wound noting date, location, wound type, size, drainage, record size in centimeters, document and record assessment of the wound including margins and surrounding tissue, record the presence or absence of drainage, include odor, color, amount and document overall status of the wound - improving, declining or same. The Hospital Discharge Summary, dated 7/24/2015, indicated Resident #1's lumbar surgical incision site was clean, dry and intact. A Physician Order, dated 7/24/2015, indicated to change Dry Protective Dressing (DPD) to Resident #1's lumbar surgical incision site once a day. Nursing Notes, dated 7/24/2015 through 7/29/2015, indicated staff did not document any assessments of Resident #1's lumbar surgical incision site. This was not consistent with the Facility's Weekly Wound Assessment Policy and Procedure Clinical Council, dated July 2015. Treatment Sheets, dated 7/24/105 through 7/29/2015, indicated staff did not document that the dressing change was done on 7/25/2015 and 7/27/2015 and there was no documentation of any assessments of Resident #1's lumbar surgical incision site on the Treatment Sheets. This was not consistent with the Facility's policy for wound assessments: Weekly Wound Assessment Policy and Procedure Clinical Council, dated July 2015. The Surveyor interview the Unit Manager at 9:32 A.M. on 1/25/2016. The Unit Manager said any treatments, including dressing changes, completed by the nursing staff should be initialed by the nurse on the Treatment Sheets to indicate the treatment was completed and an assessment of the treatment site should be documented on the Treatment Sheets and Nursing Notes. The Surveyor interviewed Physician #1 at 1:47 P.M. on 1/25/2016. Physician #1 said Resident #1 was seen for a scheduled post-operative visit on 7/29/2015 and Resident #1's lumbar surgical incision site was infected. Physician #1 said the infection had to be present for days and he was concerned the nursing staff at the Facility had not identified the infection and had not called him to report the condition of the surgical incision site. Physician #1 said he was informed by Family Member #1 that Resident #1 was found sitting in fecal matter and FM #1 was concerned the surgical incision site may have been contaminated by the fecal matter. Physician #1 said he cultured the infected surgical incision site and determined the infection to be polymicrobial (multiple organisms) including Escherichia coli bacteria (a bacteria in human intestines) which would indicate the surgical incision site may have been infected by possible fecal matter. Physician #1 said Resident #1 was admitted to the hospital and required surgical intervention to for his/her infected surgical incision site. The Surveyor interviewed Physician #2 at 3:23 P.M. on 1/27/2016. Physician #2 said he did not think the Facility nursing staff had evaluated or inspected Resident #1's surgical incision site and he had instructed staff that all incisions must be inspected. Hospital records, dated 8/4/2015, indicated Resident #1 was admitted to the hospital, 5 days after admission to the Facility, for infection after surgery and postoperative wound breakdown and required surgical intervention. Resident #2: 2. Resident #2 was admitted to the Facility in July 2015 after surgery for [REDACTED].) The Hospital Discharge Summary, dated 7/31/2015, indicated Resident #2 had orders to receive [MEDICATION NAME] (a medication used to treat fluid build up) 40 milligrams everyday. Resident #2's Medication Administration Records (MAR) indicated [MEDICATION NAME] 40 milligrams was not transcribed onto Resident #2's MAR from the Hospital Discharge Summary when Resident #2 was admitted to the Facility and Resident #2 did not receive [MEDICATION NAME] 40 milligrams for 5 days after admission. A Physician Note, dated 8/5/2015, indicated Resident #2 had symptoms of productive cough, chills, a chest x-ray was ordered and [MEDICATION NAME] 40 milligrams everyday was prescribed. A chest x-ray, dated 8/5/2015, indicated Resident #2 had bibasilar consolidation/effusions (fluid build up in the lungs) The Surveyor interviewed the Unit Manager at 9:32 A.M. on 1/25/2016. The Unit Manager said he did not know why Resident #2's orders for [MEDICATION NAME] were not transcribed onto Resident #2's Admission Order Sheets and Medication Administration Records from the Hospital Discharge Summary and said the orders for [MEDICATION NAME] may have been missed. The Surveyor interviewed the Nurse Practitioner (NP) at 2:58 P.M. on 1/26/2016. The NP said when a resident is admitted to the Facility, the admitting nurse transcribes the orders onto the Admission Order Sheets and MAR and confirms the orders with the Physician and/or NP. The NP said she did not know why Resident #2's orders for [MEDICATION NAME] were not transcribed onto Resident #2's Medication Administration Records. The Surveyor interviewed the Director of Nurses (DON) at 2:57 P.M. on 1/27/2016. The DON said she did not know why Resident #2's orders for [MEDICATION NAME] were not transcribed onto Resident #2's Medication Administration Records. The Surveyor interviewed Physician #2 at 3:23 P.M. on 1/27/2016. Physician #2 said he assessed Resident #2 5 days after his/her admission and Resident #2 complained of chills, cough, and appeared to have fluid overload (excess fluid in the body) and he ordered [MEDICATION NAME] 40 milligrams everyday, a chest x-ray and antibiotics for possible pneumonia. Physician #2 said he did not know why Resident #2's orders for [MEDICATION NAME] were not transcribed onto Resident #2's Medication Administration Records, when Resident #2's was admitted to the Facility.

Based on record review and interviews, for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure a resident who had a fall was immediately assessed for injury and a physician notified. Resident #1, a cognitively impaired resident, complained of pain the morning of 6/26/2015, was sent to the hospital and diagnosed with [REDACTED]. After the transfer, the Certified Nursing Assistant (CNA) #2 said Resident #1 was found on the floor the prior evening (on 6/25/2015), and she and Nurse #1 picked Resident #1 off of the floor and placed him/her into bed. Although Nurse #1 denied Resident #1 fell , the Facility's investigation and hospital reports indicated and the Nurse Practitioner said Resident #1's injuries were consistent with a fall. Unit Manager and Nurse #1 said they did not think Resident #1 would have been able to get him/herself off the floor without assistance had he/she fallen. Findings include: Resident #1 was admitted to the facility on [DATE], Resident #1 was cognitively impaired and [DIAGNOSES REDACTED]. The Facility's Event/Incident Report, dated 6/2011 (Revised 7/2015), indicated in the event an accident or incident occurs the licensed nurse completes an evaluation of the environment and resident; the licensed nurse notifies the provider, responsible party and center administrative staff as needed; the licensed nurse documents a factual account of the event, initiates measures to prevent a re-occurrence and updates the resident's care plan and Certified Nursing Assistant (CNA) care card. The Surveyor interviewed CNA #1 at 10:29 A.M. on 9/17/2015. The Facility staffing schedule indicated CNA #1 worked the 7-3 A.M. shift on 6/26/2015. CNA #1 said Resident #1 screamed with pain when moving at approximately 7 A.M. on 6/26/2015 and the Unit Manager was informed. CNA #1 said she did not know why Resident #1 had pain and was not aware of any incident or accident which may have contributed to his/her complaints of pain. The Surveyor interviewed the Unit Manager at 9:50 A.M. on 9/17/2015. The Unit Manager said he was informed by one of the CNAs, between 7 A.M. and 8 A.M. on 6/26/2015, that Resident #1 was complaining of a lot of pain. The Unit Manager said he assessed Resident #1, and Resident #1 complained of pain with movement of his/her right leg, which appeared to be outwardly rotated (abnormal assessment finding indicative of a possible [MEDICAL CONDITION]). The Unit Manager said he informed the physician and obtained orders to transfer Resident #1 to the hospital. The Unit Manager said that Resident #1 was diagnosed with [REDACTED]. The Unit Manager said he did not receive any initial reports, on 6/26/2015, of Resident #1 sustaining a fall. The Unit Manager said a few days later, the DON informed him Resident #1 may have fallen in the evening on 6/25/2015. The Unit Manager said if Resident #1 fell , he did not believe Resident #1 would be capable of getting him/herself up off the floor and back to bed. The Hospital History and Physical, dated 6/26/2015, indicated Resident #1 presented with pain in his/her right hip and right elbow, was status [REDACTED]. The Surveyor interviewed the Nurse Practitioner (NP) at 1:43 P.M. on 9/17/2015. The NP said she was informed by the Facility at approximately 7:30 A.M. on 6/26/2015 that Resident #1 complained of pain and the Facility did not know if Resident #1 fell . The NP said that Resident #1 was sent to the hospital and his/her injuries were consistent with a fall. The Nurse Practitioner said she was informed by Facility staff Resident #1 would not have been able to get him/herself off the floor if he/she had a fall. The Surveyor interviewed the Director of Nursing (DON) at 7:55 A.M. on 9/17/2015. The DON said Resident #1 complained of right leg pain with movement and was transferred to the hospital on [DATE]. The DON said the hospital diagnosed Resident #1 with a right [MEDICAL CONDITION] and right elbow hematoma. The DON said she began an investigation, which included interviews with CNA #2 and Nurse #1, and initially there were no witnesses identified to explain Resident #1's injuries. The DON said that a few days later, CNA #2, recanted her story and informed her Resident #1 was found on the floor, on the evening of 6/25/2015, by Nurse #1 and she assisted Nurse #1 to help Resident #1 off the floor and transfer back to bed. The DON said CNA #2 told her she did not initially inform her about the incident because Nurse #1 asked her not to say anything. The DON said she met with Nurse #1, CNA #2 and the Regional Director of Nurses on Monday 6/29/2015. The DON said that Nurse #1 did not recant her initial story and denied Resident #1 was ever found on the floor and did not know what happened to Resident #1. The DON said she suspended CNA #2 and Nurse #1 during the investigation. The DON said she terminated CNA #2's employment on 7/15/2015 for failure to report an alleged incident and for providing conflicting accounts about Resident #1. The DON said the Facility concluded Resident #1 probably injured him/herself from an unwitnessed fall. The Surveyor interviewed CNA #2 at 11:13 A.M. on 9/17/2015. The Facility staffing schedule indicated CNA #2 worked during the 3-11 P.M. shift on 6/25/2015. CNA #2 said that Nurse #1 asked her, on 6/25/2015 at approximately 9:45 p.m., to assist with repositioning Resident #1 in bed. CNA #2 said as she approached Resident #1's room with Nurse #1, Nurse #1 told her that Resident #1 was on the floor. CNA #2 said Resident #1 was crying and was on the floor as she entered his/her room. CNA #2 said that Nurse #1 did an assessment and she and Nurse #1 assisted Resident #1 back into bed. CNA #2 said Resident #1 said to her and Nurse #1, I have something broke inside me. CNA #2 said she told Nurse #1 to send Resident #1 to the hospital and Nurse #1 did not. CNA #2 said that Nurse #1 asked her not to say anything about the incident because she did not want to tell the Facility what happened to Resident #1. CNA #2 said that she did not initially tell the Director of Nursing (DON) about Resident #1's incident because she was following what Nurse #1 asked her to do. CNA #2 said she felt sick over it and told a co-worker (CNA #3) on Friday night, 6/26/2015, about the incident with Resident #1. CNA #1 said she told the DON about the incident on Monday 6/29/2015, and she and Nurse #1 met with the DON and another lady. CNA #2 said Nurse #1 denied Resident #1 was ever on the floor. CNA #1 said the DON terminated her employment at the Facility, a few days after the meeting, for changing her story. The Surveyor interviewed Nurse #1 at 2:13 P.M. on 9/17/2015. The Facility staffing schedule indicated Nurse #1 worked during the 3-11 P.M. shift on 6/25/2015. Nurse #1 said that Resident #1 was never on the floor and she never asked CNA #2 to assist her to reposition Resident #1. Nurse #1 said that Resident #1 went to bed between 9 P.M. to 9:30 P.M. on 6/25/2015, and she did not see Resident #1 again that evening. Nurse #1 said she did not know why CNA #2 said that Resident #1 was on the floor. Nurse #1 said she never saw Resident #1 on the floor. Nurse #1 said she did not think Resident #1 would be able to get him/herself up from the floor if he/she fell . Nurse #1 said Resident #1 did not complain of any pain that evening. The Surveyor interviewed CNA #3 at 3 P.M. on 9/18/2015. The staffing schedule indicated CNA #3 worked the 3-11 P.M. shift on 6/26/2015. CNA #3 said CNA #2 told her, in the afternoon on 6/26/2015, she assisted Nurse #1 to transfer Resident #1 back to bed after Nurse #1 found Resident #1 on the floor in the evening on 6/25/2015 and CNA #2 did not report it. CNA #3 said she told CNA #2 to tell the DON about the incident. CNA #3 said she informed the nurse about what CNA #2 had said to her. The Surveyor interviewed Nurse #2 at 1:52 P.M. on 9/21/2015. Nurse #2 said he worked the 3-11 P.M. shift on 6/25/2015. Nurse #2 said he was not aware, or informed, of any incident or accident which may have involved Resident #1 and was not informed, on 6/25/2015, by either Nurse #1 or CNA #2, that Resident #1 may have been found on the floor in the evening on 6/25/2015. The Surveyor interviewed Nurse #3 at 3:47 P.M. on 9/21/2015. The Surveyor interviewed CNA #5 at 3:51 P.M. Nurse #3 and CNA #5 said they worked the 11-7 A.M. shift on 6/25/2015. Nurse #3 and CNA #5 said they were not aware of any accident or incident which may have involved Resident #1. Nurse #3 and CNA #5 said Resident #1 slept the night and did not complain of pain. The DON said that the Facility concluded Resident #1 probably injured him/herself from an unwitnessed fall. However, staff agreed that Resident #1 was incapable of getting him/herself up of the floor and back into bed without assistance.

Based on record review, interview and observation for 1 of 3 residents (Resident #1), the Facility failed to adequately provide supervision to prevent Resident #1 from leaving the unit and the building. On 8/26/14, staff found Resident #1 alone at the bottom of a hill (on a paved roadway) on the Facility grounds, lying face down and his/her wheelchair tipped over. Staff were unaware Resident #1 had been missing from his/her unit. Resident #1 was diagnosed with [REDACTED]. Resident #1 was cognitively impaired and wheelchair dependent. Findings include: Resident #1's interim activity of daily living and mobility impairment care plan, dated 8/22/14, indicated he/she required staff supervision when ambulating. Resident #1's fall care plan, dated 8/22/14, indicated he/she was at risk for falls due to a history of falls and cognitive impairment related to advancing Alzheimer's dementia and psychotropic medication use. Interventions to manage this risk included a clutter-free environment. Resident #1's Interdisciplinary Education form, dated 8/22/14, indicated he/she exhibited poor safety awareness. Resident #1's Behavior/Intervention Monthly Flow Record, dated 8/22/14, indicated he/she was monitored for "verbalizing exit-seeking." The Flow Record indicated none of these behaviors were documented as having been exhibited. The Assistant Director of Nurses (ADON) was interviewed at 9:00 A.M. on 9/10/14. The ADON said Resident #1 had a [DIAGNOSES REDACTED]. The ADON said it was not safe for Resident #1 to go outside by himself/herself without supervision. Resident #1's incident report, dated 8/26/14, indicated at approximately 5:00 P.M., staff found him/her lying on the ground outside the building after an apparent elopement and fall. The report indicated Resident #1 had blood on his/her hands and face and staff transferred him/her to the Hospital for further evaluation. Resident #1's Nurse Practitioner's note, dated 8/27/14, indicated Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 12:55 P.M. on 9/10/14. CNA #1 said between approximately 4:45 P.M. to 5:00 P.M. on 8/26/14, he was outside in the back of the building on a work break when he heard someone yelling for help. CNA #1 said he saw Resident #1 lying face down at the bottom of the hill, on the roadway, and his/her wheelchair was tipped over. CNA #1 said Resident #1 was bleeding from his/her nose. CNA #1 said he ran and informed staff inside the building that Resident #1 had eloped and fallen. Review of Nurse #1's written statement, dated 8/26/14, that at 4:55 P.M., she last saw Resident #1 on the unit. The Surveyor interviewed the Administrator at 9:00 A.M. on 9/10/14. The Administrator said recorded video showed Resident #1 leaving the building, unsupervised, through an outside service door at 4:55 P.M. The Administrator said no one reported seeing Resident #1 leave the unit, or the building. The Administrator said none of the staff reported hearing the unit's exit door alarm. The Administrator said it was possible someone either deactivated the alarm or Resident #1 passed through the service door at the back of the elevator. The Administrator said it was against Facility policy to allow the elevator service door to remain open at the same time the elevator's door to the unit was open. The Surveyor observed at 9:40 A.M. on 9/10/14, the elevator service door and the unit's alarmed door opened into a passageway which led to the outside door, through which Resident #1 exited on 8/26/14.

Based on observations, staff interviews and review of documentation, the Facility staff failed to identify and properly assess an area on the left lateral foot until it was an open wound for 1 Resident (#15) in a sample of 24 residents. Findings include: Resident #15 was admitted to the facility in 11/2012. The resident's [DIAGNOSES REDACTED]. The resident's Significant Change in Status Minimum Data Set ((MDS) dated [DATE] identified resident #15 as being alert and oriented, requiring total assistance of 2 plus persons for transfers and being non-ambulatory in his/her room and corridor. The resident was also identified as having functional limitations in range of motion to his/her upper and lower extremities. The resident was further identified as being at risk for developing pressure sores, but was not identified as having a pressure ulcer. The resident's Norton Plus Pressure Ulcer Scale dated 12/6/13 was 6 (indicates high risk for the development of a pressure ulcer.) The resident's Quarterly MDS dated [DATE] identified the same areas noted above in the Significant Change MDS dated [DATE]. There were no skin issues identified. On 2/11/14 at 4:15 P.M., the resident was observed seated in his/her Tilt-In-Space wheelchair in the Day Room. He/she was improperly positioned in his/her chair as he/she was slouched down on his/her left side. The resident's left foot rest was dangling sideways, and his/her left foot, covered only with a non-skid sock, was observed positioned partially behind the left foot rest and touching the left foot rest. At that time, Surveyor #1 spoke to the Unit Manager (U.M.) and requested that she observe the resident's left foot with the Surveyor in the resident's room. With the resident's permission, the U.M. removed the resident's left sock and a large reddened area could be seen on top of the resident's left foot. The U.M. measured the area to be 7 centimeters (cm) by 4 cm from the outer left ankle and across the top of the foot. The U.M. said she observed the resident's left foot be behind the resident's left foot rest and that the resident's left foot rest was improperly upright due to the resident's frequent involuntary movement in the chair. On 2/12/14 at 8:10 A.M., the U.M. informed Surveyor #1 that nursing staff reported to her that morning that there were no skin issues during the skin check conducted during the 11:00 PM.-7:00 A.M. shift. However, the U.M. said that she completed a skin check earlier that morning on 2/12/14 and found an unstageable area on the lateral side of the resident's left foot. The U.M. said this new area was not identified during the resident's skin check at 4:15 P.M. on 2/11/14 during which Surveyor #1 was present and the U.M. said she did not assess that area of the resident's foot. Forty-five minutes later, at 8:45 A.M on 2/12/14, the U.M. told Surveyor #1 that she now believed the newly identified area was a plantar wart (a wart on the sole of the foot caused by [MEDICAL CONDITION]. The wart is commonly obtained from a communal shower, gym or swim area). At that time, Surveyor #1 consulted with the Surveyor #2 and requested that she evaluate the skin area of the resident's left foot. Review of the written "Witness Statement" prepared by the U.M. and presented to Surveyor #1, indicated that "This writer found a area on the left side of foot with a scab 15 cm x 1.5 cm with pink area surrounding area (hard in appearance). This writer questioned a plantar wart due to hard appearance and after skin prep put on area, area had small opening like a callous." The U.M. was interviewed on 2/12/14 at 9:45 A.M. The U.M. said that Resident #15 had an area on the lateral side of the left foot that was scabbed and had fallen off. The U.M. said she thought the area was a plantar wart. Review of the Facility policy titled: "Wound and Skin Care Protocols" indicated that in the section titled Documentation, point 3 indicated that "A weekly visual inspection and assessment of skin will be completed on each resident and signed and dated by a licensed nurse." The Policy, section on "Weekly Skin Assessment" indicated that weekly skin assessments will be conducted on each resident. Procedure: 1) "The licensed nurse will examine the skin of each resident weekly, paying close attention to common areas of pressure." 2) "Each abnormality, e.g., redness not resolved within 30- 45 minutes when pressure is relieved, skin tear, rash excoriation, maceration, denudation, abrasion, burn, cut, open lesion, bruise and surgical wound will be checked on list. Earlier signs and symptoms such as change in skin temperature, mushy or boggy soft areas over bony prominences and or complaints of pain or itching. Colors such as red and purple are late signs." 3) "If an abnormality is found, then a weekly pressure ulcer progress report form is initiated and the physician, Director of Nursing/designee and family are notified. All positive results will be reviewed at the weekly skin meeting." 4) "The form is signed and dated by the licensed nurse completing it." 5) Maintain the Weekly Skin Assessment in the treatment book until completed, then file it in the assessment section of the residents medical record. Review of the Treatment Flowsheet for Resident #15, orders section, indicated that the nursing staff were to conduct "skin checks weekly Sunday 11-7, Once a day on Sunday, (starting) 10/19/13 - open ended." Documentation indicated that the skin check was initialed as done on 2/2/14, but documentation in the Treatment Notes was not recorded until 2/4/14, 3:00 P.M.-11:00 P.M., treatment #5, "feet slightly dry, intact." Documentation indicated that the skin check was initialed as done on 2/9/14, but there was no documentation about the skin condition in the Treatment Notes Section. An observation was made on 2/12/14 at 10:05 A.M. of Resident #15's left foot with Surveyor #2 and the Director of Nursing (DON). The lateral side of the left foot was observed to be reddened, but blanchable. The area observed was a 1.5 cm blanchable reddened area around a 0.5 cm center located on the lateral aspect of the left foot, approximately 7.6 cm's up from the heel. The center area was circular, beige in the center with a red perimeter. The DON told Surveyor #2 during the observation that the area was an unstagable pressure ulcer. Surveyor #2 observed Resident #15's skin area to be unstagable due to the presence of slough tissue. Surveyor #2 observed a 1.5 cm horizontal, oval, open area with yellow slough in the wound bed. Within the oval area was a 0.5 cm circular open area near the outer, circular perimeter of the wound. Following this review, during a discussion, the DON informed Surveyor #1 and #2 that she believed the area was unstageable. However, review of the DON's documentation on the Wound Assessment Progress Report received on 2/12/14 at 11:26 A.M. indicated that the DON documented that the area was a "callous (hardened skin, usually over a bony area) - ? pressure sore" with "beige center" (indicating slough which is dead tissue). Further consultation and observation of Resident #15's wound with the Assistant Director of Nursing (ADON), who rounds with the consulting Wound Physician on Mondays and is the clinical consultant for the Facility on pressure ulcers, was made on 2/12/14 at 10:40 A.M. Surveyor #2 accompanied the ADON during her assessment of the area. The ADON indicated that her assessment of the wound was a Stage II pressure ulcer (Category/Stage II: Partial thickness. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.) A Wound Assessment Progress report provided to Surveyor #2 by the ADON on 2/12/14 at 11:26 A.M. indicated that the wound was documented as reported, a Stage II pressure ulcer, as she said during the observation. The ADON also documented that she recommended Santyl be applied to the wound, but had not obtained an order from the Physician at that time. The Wound Assessment Progress report prepared by the ADON concluded the wound was a stage II pressure ulcer which differed from the Wound Assessment Progress report prepared by the DON which concluded the wound was a callous/? pressure ulcer with beige center. Review of further documentation on Resident #15's wound by the Nurse Practitioner, dated 2/12/14, time not documented, but reported to have occurred during the evening, indicated that she assessed the wound to be a "calloused" area. The Nurse Practitioner was interviewed by telephone on 2/13/14 at 9:20 A.M. The Nurse Practitioner said Resident #15's left foot area was very dry and rough and calloused. When questioned further about the open area, the Nurse Practitioner repeated that it was her opinion it was a callous, she did not think it was a pressure area, "nothing else is going on." Review of the Physician orders dated 2/12/14 at 10:11 P.M. indicated that the Nurse Practitioner wrote orders to apply skin prep to the calloused area twice a day. The above observations and staff interviews revealed wide disagreement among the disciplines in regards to Resident #15's open area. None of the staff interviewed could explain why this area was not discovered until the area was opened, had slough on the wound and required medical treatment. In addition, the Facility could not explain why the area had not been identified from 2/4/14, as per the treatment sheet, through 2/11/14 skin check, despite their policy which indicated that close attention would be paid to common areas of pressure. Review of the Wound and Skin Protocols provided by the Facility failed to include the identification, assessment and treatment on non-pressure areas. Please refer to F 312.

Based on record review, interview and observation for 1 of 3 sampled residents, the Facility: - failed to separate Family Member #1 from Resident #1 after Family Member #1 inserted his hand into Resident #1's vagina, in the presence of Nurse #1 on 3/05/13 at approximately 10:30 P.M.; - failed to immediately report the alleged abuse to administrative staff; - failed to immediately investigate an allegation of abuse, and - failed to protect Resident #1 after the alleged abuse and allowed Family Member #1 to remain with Resident #1 in his/her bedroom, unsupervised, for approximately 4 hours. Findings include: The Facility's (1st) investigation report to the Department of Public Health, dated 3/06/13, 5:40 P.M., indicated Family Member #1 inappropriately touched Resident #1. The investigation report indicated the Facility would follow-up with a complete report on 3/07/13. The Facility's (2nd) investigation report to the Department of Public Health, dated 3/07/13, indicated Family Member #1 inappropriately touched Resident #1's vagina on 3/05/13 at approximately 10:30 P.M. The Facility's investigation report indicated Resident #1 was diagnosed with [REDACTED]. Resident #1's admission record, dated 5/29/12, indicated he/she had the following Diagnoses: [REDACTED]. Resident #1's urinary incontinence care plan, dated 12/13/12, indicated Resident #1 had a urinary catheter and it was to be changed as needed. Resident #1's care plan also indicated he/she was dependent on others for all activities of daily living care. Resident #1's quarterly minimum data set (MDS) assessment, dated 2/22/13, indicated the following conditions: rarely/never understood by others; rarely/never understood others; short and long-term memory deficits; severely impaired cognitive skills for daily decision-making (never/rarely made decisions); dependent on others for all activities of daily living; dependent on staff for ambulation, and required an indwelling urinary catheter. Resident #1's nurse's note, dated 3/06/13, 11:00 P.M. to 7:00 A.M. shift, indicated at 12:00 A.M. Nurse #2 inserted a new urinary catheter into Resident #1, without difficulty. The police report, dated 3/06/13 indicated the Facility telephoned the police to report the incident on 3/06/13 at 5:44 P.M. The police report indicated Family Member #1 was charged with indecent assault and battery against Resident #1. The police report indicated Nurse #1 told the Director of Nurses (DON) that Family Member #1 "sexually assaulted" Resident #1. The police report indicated Nurse #1 told police she witnessed Family Member #1 insert his whole hand into Resident #1's vagina. The police report indicated Nurse #1 was "very troubled by (Family Member #1's) action and that this behavior was clearly criminal and amounted to rape", or words to that effect. The police report indicated Resident #1 did not appear injured, but that Resident #1 had moved back slightly when Family Member #1 inserted his whole hand into Resident #1's vagina. The police report indicated that "this small movement was the most (Nurse #1) had ever seen (Resident #1) move", or words to that effect. The police report indicated Nurse #1 told police "there was no medical reason or explanation on why he put his hand into (Resident #1's) vagina or why he smelled his hand afterwards", or words to that effect. The police report indicated the investigating officer then requested that a sexual assault detective respond to the incident. Resident #1's physician's note, dated 3/09/13, indicated there was an incident between Resident #1 and a family member. The physician's note indicated staff reported Resident #1 seemed to be comfortable and was in no pain. The Surveyor interviewed Nurse #1 on 3/14/13 at 3:35 P.M. Nurse #1 said on 3/05/13, at approximately 10:30 P.M., she attempted to flush Resident #1's urinary catheter. Nurse #1 said Family Member #1, who was also in the bedroom, grabbed the flush syringe out of her hand and tried to flush the catheter, but it remained clogged. Nurse #1 said Family Member #1 then stuck his ungloved hand into Resident #1's vagina. Nurse #1 said Family Member #1 withdrew his hand from Resident #1's vagina and then smelled his hand. Nurse #1 said she felt "horrified" by the incident and felt she would faint if she did not leave Resident #1's bedroom immediately. Nurse #1 said she believed the behavior of Family Member #1 toward Resident #1 was abusive. Nurse #1 said she told Family Member #1 she would return with a nurse from the oncoming shift to reassess Resident #1's catheter and then she left the bedroom. Nurse #1 said Family Member #1 and Family Member #2 remained in the bedroom with Resident #1. Nurse #1 said she immediately told Nursing Supervisor #1 about the incident in full detail. Nurse #1 said she (Nurse #1) was distraught. Nurse #1 said Nursing Supervisor #1 told her that Family Member #1 had poor boundaries with Resident #1 and had been problematic for a long time. Nurse #1 said she asked Nursing Supervisor #1 if she could ask Family Member #1 to leave the bedroom while she provided care to Resident #1 and Nursing Supervisor #1 replied that she could, but Family Member #1 would likely become angry at Nurse #1. Nurse #1 said she believed Family Member #1's behavior was abusive and was surprised by Nursing Supervisor #1's lack of concern. Nurse #1 said she told Nursing Supervisor #1 she intended to telephone the DON in the morning to talk about the incident. Nurse #1 said Nursing Supervisor #1 told her she could call the DON, but that "the Facility knows what's going on", or words to that effect, and the DON would not be surprised by the telephone call. Nurse #1 said Nursing Supervisor #1 did not get up from the desk or leave to speak with Family Member #1 of Family Member #2, or to see Resident #1. Nurse #1 said Nursing Supervisor #1 did not ask for a written statement about the incident and Nursing Supervisor #1 did not appear to report the incident to the DON. The Surveyor obtained a floor plan of Resident #1's unit and measured the distance from Resident #1's bedroom doorway to the entrance of the unit's nurses station. The Surveyor observed the distance from the bedroom to the station was approximately 25 feet. Nurse #1 said, after the incident at approximately 10:30 P.M., she did not return to Resident #1's bedroom before leaving the Facility. Nurse #1 said Family Member #1 and Family Member #2 remained with Resident #1 and staff did not tell them to leave Resident #1's bedroom and staff did not supervise Resident #1 after the incident. Nurse #1 said at approximately 1:30 A.M. Nursing Supervisor #2 told Nurse #1 she heard about the incident involving Resident #1 and Family Member #1. Nurse #1 said Nursing Supervisor #2 asked Nurse #1 to provide a written statement about the incident. Nurse #1's (1st) written statement, dated 3/05/13, indicated all five of Family Member #1's fingers, past the mid-knuckle, were inside Resident #1's vagina. Nurse #1's statement indicated Nurse #1 assessed Resident #1 for signs of pain or injury and determined Resident #1 did not appear to be in any pain or have sustained an injury. Nurse #1's written (2nd) statement, dated 3/07/13, indicated when Nurse #1 told Nursing Supervisor #1 about the incident, Nursing Supervisor #1 "laughed stating that (Family Member #1) always does things like that", or words to that effect. Nurse #1's statement indicated Nursing Supervisor #1 told her "everyone knows what (Family Member #1) does and nothing ever gets done about it", or words to that effect. Nurse #1's written statement, dated 3/07/13, indicated Nursing Supervisor #2 approached her at the nurses desk and Nurse Supervisor #2 told Nurse #1 she heard about the incident involving Resident #1 and Family Member #1. Nurse #1 indicated Nursing Supervisor #2 said "this has been going on and it makes her sick to work at night with (Family Member #1 and Family Member #2) walking around all night", or words to that effect. The Surveyor interviewed Nursing Supervisor #1 on 3/14/13 at 12:06 P.M. Nursing Supervisor #1 said Nurse #1 did not talk to her about Family Member #1 inserting his hand into Resident #1's vagina. Nursing Supervisor #1 said she did not enter Resident #1's bedroom, or see Resident #1, during the shift. Nursing Supervisor #1 said she left the building at approximately 12:00 A.M. Nursing Supervisor #1 said staff did not tell Family Member #1 of Family Member #2 to leave Resident #1's bedroom and staff did not supervise Resident #1 while Family Member #1 of Family Member #2 were in Resident #1's bedroom. Nursing Supervisor #1 said there were past occasions during which Family Member #1 and Family Member #2 broke the sterile field while a nurse changed Resident #1's urinary catheter. Nursing Supervisor #1 said Family Member #1 and Family Member #2 sometimes spread Resident #1's labia while a nurse inserted a urinary catheter and during these procedures Family Member #1 and Family Member #2 did not wear sterile gloves. Nursing Supervisor #1 said nursing staff frequently expressed to her concerns about Family Member #1's and Family Member #2's degree of involvement in Resident #1's intimate care and that they often became upset with staff when staff set limits on their involvement. Nursing Supervisor #1 said, despite repeated limits and education provided by staff, Family Member #1 and Family Member #2 broke the sterile field and refused to leave Resident #1's bedroom when nursing staff provided intimate care. The Surveyor interviewed Nurse #2 on 3/14/13 at 1:39 P.M. Nurse #2 said on 3/05/13, at approximately 11:00 P.M., she arrived to the unit and took change of shift report from Nurse #1. Nurse #2 said Nurse #1 told her about the incident involving Resident #1 and Family Member #1, in detail. Nurse #2 said Nurse #1 told her that Nurse #1 reported the incident in detail to Nursing Supervisor #1 and Nursing Supervisor #2. Nurse #2 said between approximately 12:00 A.M. to 12:50 A.M. she changed Resident #1's catheter while Family Member #1 and Family Member #2 were in the bedroom. Nurse #2 said Family Member #1 and Family Member #2 continued to stay in Resident #1's bedroom from 12:00 A.M. until between approximately 2:00 A.M. to 3:00 A.M. Nurse #2 said she saw Family Member #1 and Family Member #2 leave the building between approximately 2:00 A.M. to 3:00 A.M. The Surveyor interviewed Nursing Supervisor #2 on 3/14/13 at 3:25 P.M. Nursing Supervisor #2 said between approximately 1:30 A.M. to 2:00 A.M. Nurse #1 told her she witnessed Family Member #1 inserting his hand into Resident #1's vagina and then he smelled his hand. Nursing Supervisor #2 said Nurse #1 was distraught. Nursing Supervisor #2 said she told Nurse #1 to write a statement describing the incident and at approximately 2:00 A.M., Nurse #1 provided the statement. Nursing Supervisor #2 said at approximately 5:00 A.M. she telephoned the DON to report the incident. Nursing Supervisor #2 said she did not enter Resident #1's bedroom during the 11:00 P.M. to 7:00 A.M. shift, or see Resident #1 during the shift. Nursing Supervisor #2 said she did not ask Family Member #1 or Family Member #2 to leave Resident #1's bedroom and she did not instruct nursing staff to supervise Resident #1 while Family Member #1 or Family Member #2 were in the bedroom. Nursing Supervisor #2's written statement (undated) indicated Nurse #1 told her about the incident involving Family Member #1, Family Member #2 and Resident #1. Nursing Supervisor #2 referred to the incident described by Nurse #1 as "(Family Member #1) being sexually inappropriate with (Resident #1)", or words to that effect. Nursing Supervisor #2 indicated "(Nurse #1) said she had reported the incident on her shift. But expressed concern that the issue may not get addressed", or words to that effect. The Surveyor interviewed the Physician 3/18/13 at 3:35 P.M. The Physician said she was aware of the allegation Family Member #1 inserted his hand into Resident #1's vagina on 3/05/13. The Physician said she was not aware of any medical reason why Family Member #1 would put his hand inside Resident #1's vagina. The Physician said nursing staff did not indicate Resident #1 bled or exhibited signs of pain following the incident, and as a result the Physician did not examine his/her perineum area. The Surveyor interviewed the DON on 3/14/13 at approximately 8:15 A.M. The DON said, after Family Member #1 inserted his hand into Resident #1's vagina, nursing staff should have intervened and told Family Member #1 and Family Member #2 to leave the building. The DON said from approximately 10:30 P.M. on 3/05/13 until sometime between 2:00 A.M. to 3:00 A.M. Family Member #1 and Family Member #2 visited with Resident #1 in his/her bedroom. The DON said the only known times during which staff were in Resident #1s bedroom during this time period was at approximately 10:30 P.M. and between approximately 12:00 A.M. to 1:00 A.M. on 3/06/13. The DON said nursing staff should have immediately reported the incident to management. The DON said Nursing Supervisor #1 told the DON she "did not understand there was a report of sexual assault", or words to that effect. The Surveyor interviewed the Administrator on 3/14/13 at approximately 8:15 A.M. The Administrator said on 3/06/13, at approximately 11:30 A.M., Family Member #1 arrived to the Facility and visited Resident #1 in a common area. The Administrator said she and the DON then met with Family Member #1 and told him, in detail, about the allegation. The Administrator said Family Member #1 told them he "would not do it again", or words to that effect, and hoped the Facility's management would put the incident "behind us", or words to that effect. The Surveyor attempted to interview Family Member #1, and left 2 voice mail messages on 3/18/13, but as of the completion date of this report there had been no response. The Surveyor attempted to interview Family Member #2, and left 2 voice mail messages on 3/18/13, but as of the completion date of this report there had been no response. The police report, dated 3/06/13, indicated investigating police officers interviewed Family Member #1 about the incident. The police report indicated Family Member #1 denied inserting his hand into Resident #1's vagina and he denied smelling his fingers afterwards. The police report indicated the investigating officer characterized the incident as "elder abuse", or words to that effect. The Administrator said the Facility obtained a no-trespass order against Family Member #1 and Family Member #2 and the Facility is pursuing obtaining temporary guardianship for Resident #1.

Based on observation, record review, and resident and staff interviews, the facility failed to ensure that 7 of 13 Residents (#5, #6, #9, #10, #11, #12, and #19) in the original sample of 24 and 1 of 3 sampled residents in the extended sample (ES #27), were provided adequate supervision and effective interventions to prevent accidents. Findings include: 1. For Resident #6, the facility failed to ensure that effective interventions were in place to prevent the resident's fall on 11/25/12, which resulted in the resident's hospitalization for a dislocation of the right hip. Review of the resident's clinical record on 1/7/13 indicated that the resident was admitted to the facility in 7/2006 with [DIAGNOSES REDACTED]. The resident was readmitted to the facility in 10/2012 after a fall in the facility that resulted in a right hip hemiarthroplasty (replacement of the ball portion of the hip joint, not the socket portion). The Fall Assessments, dated 9/13/12 and 10/23/12, indicated that the resident was at high risk for falls. The Significant Change Minimum Data Set (MDS) assessment, dated 11/7/12, indicated that the resident had severe cognitive impairment, did not ambulate, and required a mechanical lift for all transfers. The MDS indicated that the resident had two falls, one fall which a hip fracture was sustained. The plan of care for the prevention of falls, dated 11/7/12, included the use of a low bed with floor mats on both sides of the bed. The plan of care also included the use of an air mattress to prevent skin breakdown because of the resident's immobility due to his/her recent hip fracture. A. The Event/Incident Report, dated 11/8/12, indicated that the resident was found lying on the floor in his/her room on his/her left side 4:00 P.M., with the right leg bent at the knee. The Report indicated that the resident's air mattress was set at 200 pounds. It also indicated that the resident did not sustain an injury due to the fall. The Report further indicated that the resident's air mattress was reset to 135 pounds (the correct inflation rate for the resident's body weight) and bolster pads were added to the bed to prevent the resident from rolling off the bed. There was no documentation that the nursing staff was educated concerning the correct inflation rate of the resident's air mattress after his/her fall on 11/8/12. B. The Event/Incident Report, dated 11/25/12, indicated that the resident was found on the floor in his/her room at 9:50 A.M., in a sitting position with his/her right leg internally rotated. The Report indicated that the physician was notified and the resident was transferred to the hospital for an evaluation. The Report further indicated that the resident was admitted to the hospital with [REDACTED]. During interview with the Assistant Director of Nurses (ADON) on 1/8/13 at 8:30 A.M., she said that on 11/25/12, the resident was found sitting on the floor with the abductor pillow between his/her legs, the air mattress was inflated above the prescribed inflation rate of 130 pounds, and the left bolster pad dangling off the bed. The ADON said that the air mattress inflation rate was based on the resident's current weight. The resident's weight at the time of the fall was 130 pounds. The ADON said she believed that the air mattress was set too high causing the air mattress to act like a "bouncy" pad and that the bolster pads at the base of the bed were not secured in place to prevent the resident from falling. On 1/8/13 at 10:10 A.M. during a demonstration recreating the resident's fall of 11/25/12, the ADON said because the resident was not strong enough to push the left bolster pad off the bed (she was unable to dislodge the left bolster pad without great effort and heels on both feet) and the air mattress set too high causing a "bouncy" effect, the resident was able to slide off the bed to floor. She said the floor mats were in place as ordered. The ADON said that on 11/27/12 because the air mattress was set too high, the nursing staff was educated on the proper setting for the resident's air mattress. The ADON said she was unable to locate documentation that the nursing staff was educated after the resident's fall on 11/8/12 due to the air mattress being over-inflated. 2. For Resident #9, the facility failed to provide adequate supervision to prevent 3 falls for Resident #9. Review of Resident #9's clinical record on 1/3/13 indicated that the resident was admitted in December of 2010, with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS), dated [DATE], indicated that the resident scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. In addition, the MDS indicated that the resident was totally dependent for activities of daily living, required extensive assistance in the bathroom and the physical assistance of one staff member. A. Review on 1/4/13 of the Resident's Event/Incident report, dated 3/23/12, indicated that the resident was left unattended on the toilet in the resident's bathroom and fell . The fall resulted in a hematoma (a localized mass of extravasted blood that is confined in an organ, tissue or space) on the resident's head. The Event/Incident report indicated the cause of the resident's fall was due to being left alone on the toilet by Certified Nurses Aide (CNA) #1. Review of the statements by staff, indicated CNA #1 placed the resident on the toilet as CNA #2, who was assigned to the resident, was not available. The Event/Incident report statements indicated that CNA #1 informed CNA #2 that the resident was on the toilet. The statements did not indicate how much time elapsed from the time that CNA #1 told CNA #2 about the resident being left alone in the bathroom and the time when the resident was heard yelling after the fall. Review of the bladder incontinence care plan, initiated on 1/7/11, did not indicate how much supervision the resident needed in the bathroom. One of the approaches indicated that the resident required assistance with toileting and the specific plan for the supervision (as needed and extensive assist of two) were crossed out. The care plan lacked information as to what amount of assistance the resident required in the bathroom. The Event/Incident report included an inservice, dated 3/23/12, entitled "Residents are not to be left alone in the bathroom" was presented to the staff caring for Resident #9. During an interview with Unit Manager #1 on 1/4/13 at 7:30 A.M., she said that the resident should not have been left alone in the bathroom. B. Review on 1/4/13 of the Resident's Event/Incident report, dated 9/12/12, indicated that Resident #9 sustained a skin tear to his/her left leg due to sliding off the bed. The facility failed to keep the resident from falling and sustaining an injury secondary to not having two staff members transfer the resident from bed to chair. Review of the resident's quarterly MDS, dated [DATE], indicated the resident had moderately impaired cognition and that he/she required extensive assistance for transfers with 2 staff members. Review of the resident's care plan, dated 9/12, indicated that the resident required extensive assistance of two staff members for transfers and mobility. Review of the resident's nurses notes, dated 9/12, indicated that the resident sustained [REDACTED]. During an interview with Unit Manager #1 and CNA #3 (the CNA who was with the resident during the transfer) on 1/8/13 at 9:00 A.M., the Unit Manager said that the resident did need two people for a safe transfer. CNA #3 said that on occasion, the resident will help with transfers but on this date, CNA #3 said the resident could not help and slid from the bed to the floor. CNA #3 said she was waiting for another CNA to come and help her with the transfer just before the resident's fall. The Event/Incident report contained some inconsistencies in the written statements of CNA #3 and Unit Manager #1. CNA #3 indicated that the resident did not fall and it was not until she transferred the resident back to bed did she notice blood on the resident's left leg. Unit Manager #1 indicated that the resident became weak when being transferred and sustained a skin tear to his/her left leg via the leg of his/her wheelchair. Record review indicated that the resident required 2 staff members for all transfers. In addition, the conclusion written in the Event/Incident report indicated that the resident was being transferred by CNA #3 which was in conflict with CNA #3's interview statement that she had not attempted to transfer the resident but rather just had the resident sitting on the side of the bed. The Event/Incident summary report did not contain documentation that an inservice was conducted with CNA #3 which included having another CNA with her to safely transfer the resident. C. Review on 1/4/13 of the resident's Event/Incident report, dated 10/14/12, indicated that Resident #9 was found in the dayroom with blood pooling under his/her head after falling from the wheelchair while trying to reach for something. Review of Unit Manager #1's written conclusion of the Event/Incident report indicated that the resident had been sitting in a tilt in space wheelchair which should have been in the reclined position when the resident was not engaged in an activity. Review of the facility's incident report, dated 10/14/12, indicated the resident sustained [REDACTED]. Review of the resident's care plan for 9/12 indicated that the resident required a reclining wheelchair when not engaged in an activity. Another approach written on the same care plan indicated that the resident should be reminded to call for assistance with all transfers. During an interview with the Director of Nurses (DON) on 1/8/13 at 2:00 P.M., the DON said that the resident's wheelchair should have been tilted and that the resident should have been supervised in the day room. The DON said that Resident #9's fall from the wheelchair was the "catalyst" that initiated constant supervision by staff of residents sitting in the day room. 3. For Resident #10, the facility failed to provide adequate supervision to prevent 8 falls. Review of the resident's clinical record on 1/4/13, indicated that the resident was admitted in March of 2011, with [DIAGNOSES REDACTED]. In addition, the resident had difficulty with the English language, making communication difficult for staff and the resident. Review of the resident's annual Minimum Data Set (MDS), dated [DATE], indicated that the resident had a moderately impaired memory problem. The resident's functional status indicated that the resident required limited assistance of one staff member to ambulate in the corridor. Review of the Care Area Assessment (CAA), dated 3/1/12, indicated that the resident is at risk for falls as he/she takes antidepressants and needs rest periods. In addition, it indicated that she ambulates with a walker and is supervised with ambulation on the unit and assisted with ambulation for longer distances. A. Review of the Event/Incident Report dated 3/21/12, indicated that the resident had an unwitnessed fall at 8:30 P.M. in the bathroom nearby the nurses' station. There were no reported injuries. The report indicated that the assessment of the cause of the fall was due to dementia. There was no evidence of how much supervision the resident required. There were no conclusions brought forward in the Report which would help to prevent future falls for this resident. B. Review of the resident's Event/Incident Report, dated 4/20/12, indicated that the resident had an unwitnessed fall in the day room at 10:00 A.M., having possibly tripped on the wheelchair of another resident. In addition, the report indicated that the day room was very crowded. The report indicated that a 3 centimeter round open area on his/her forehead was found and the resident was sent to the hospital. Review of the emergency room record verified that the resident was treated for [REDACTED]. A final assessment of the fall was not part of this Report and the intervention was to offer the resident a clutter free environment. There were no conclusions brought forward in the Report regarding supervision that the resident required. C. Review of the resident's Event/Incident Report, dated 5/20/12, indicated that the resident had another unwitnessed fall and was found lying on the floor in the day room at 8:00 P.M. The Report indicated that the resident was uninjured. In addition, the Report indicated that the resident required some distant supervision, yet the Report did not indicate who was supervising the resident. The assessment of this fall in the Report was that the resident had decreased safety awareness. Review of a falls care plan, dated 4/23/12, indicated that the resident needed supervision for ambulation but it was crossed out and not signed or dated. There were no conclusions brought forward in the Report regarding supervision that the resident required. D. Review of the resident's Event/Incident Report, dated 6/3/12, indicated that the resident had an unwitnessed fall in front of a chair in the day room at 4:45 P.M. The Report indicated that he/she sustained a bruise on his/her forehead and a skin tear on his/her lower left elbow. Review of the forty-eight hour nursing admission note, dated 6/6/12, indicated that the Resident was treated at the hospital and returned on 6/6/12. The Report indicated that the resident was ambulating to the bathroom without his/her walker. Review of the quarterly MDS, dated [DATE], indicated that the resident required supervision when walking in or off the unit. There were no conclusions brought forward in the Report regarding supervision that the resident required. E. Review of the resident's Event/Incident Report, dated 9/4/12, indicated that the resident had lost his/her balance and fell at 9:15 P.M., while walking with a CNA. The Report indicated that the Resident did not sustain an injury. The Report indicated that the CNA did not utilize a gait belt when walking the resident. The Report indicated that this fall was the direct result of staff not utilizing proper equipment. The Report indicated that staff were inserviced but a copy was not attached to the incident and there was no statement from the CNA who was involved. F. Review of the resident's Event/Incident Report, dated 9/9/12, indicated that the resident fell at 12:15 A.M. while walking in the day room. The Report indicated that the resident tripped over a metal graded strip and was sent to the hospital where he/she was diagnosed with [REDACTED]. The Report did not indicate that the resident required supervision after the previous fall of 9/4/12. The statements in the Report indicated that the staff were at the nurses' station while the resident was walking out of the day room. The resident's care plan, initiated on 4/23/12, indicated the resident needed supervision for ambulation but it was crossed out and not signed or dated. The Report describes the resident as needing to walk with a walker and continual supervision. The Report did not indicate the type of supervision needed by the resident according to the previous Event/Incident Reports. The supervision level for this resident had not increased despite 6 previous falls. There were no conclusions brought forward in the Report regarding the amount of supervision that the resident required. This incident has conflicting statements. One written statement by the Unit Manager #1 indicated that the resident was supervised at all times but a copy of the report that was sent to the Department of Public Health, indicated that staff were at the nurse's station at least 5 feet away when the resident fell . G. Review of the resident's Event/Incident Report, dated 9/17/12, indicated that the resident fell at 4:00 A.M. The resident was found by staff on his/her back in his/her room between the bed and the chair. The Report included the falls investigation and post fall assessment that indicated the resident walked with supervision. A team statement in the Report indicated that this resident was independent with ambulation and walked independently with a rolling walker. This statement further indicated that the resident was usually slow and steady and the facility felt that this fall was an "isolated incident". However, prior to this fall, the resident had approximately 6 falls, some with injury. There were no statements as to when the resident was last checked for safety. There were no conclusions brought forward in the Report regarding supervision that the resident required. H. Review of the resident's Event/Incident Report, dated 9/28/12, indicated that the resident had an unwitnessed fall in his/her bedroom at 9:15 P.M. The resident was found on the floor next to his/her bed. The Report indicated that the resident did not sustain an injury but the report lacked information about her level of supervision. The Report indicated that the resident was checked 15 minutes prior during intentional rounding. The resident's care plan for 9/28/12 indicated that the resident should have supervision checks every 10 minutes, however, this was not mentioned in the conclusion for this incident. 4. For resident #11, the facility failed to provide proper supervision to a resident who required total care and was at risk for falls. Resident #11 was admitted to the facility in October 2011. The resident's [DIAGNOSES REDACTED]. The resident's care plan dated 11/08/11 identified the area of falls and included the following information: The resident is at risk for falling related to impaired cognition and poor safety awareness; history of falls; dependent on staff for care; psychotropic meds and narcotics use. On 6/19/12, the intervention of anti-tippers on Tilt-in Space chair-only upright during meals otherwise tilt backwards was added to the care plan. Review of an incident report dated 11/8/12, indicated the resident leaned forward in his/her Tilt-in Space wheelchair and fell to the floor. Assessment of the cause of the fall indicated that the certified nurse aide (CNA) did not return the resident to the reclined position in his/her Tilt-in Space wheelchair after lunch as required and left the resident unattended. The resident sustained [REDACTED]. He/she required the application of an adhesive bonding agent to close the wound (a liquid skin adhesive that is used to close wounds that might otherwise need stitches). Review of the Long Term Care Fax Report to the Department of Public Health indicated that an investigation was conducted that included the following information: On 11/08/12, this severely cognitively impaired resident who is non-ambulatory, was seated in a Tilt-in Space wheelchair in the day room at 12:50 P.M., when the C.N.A. did not return the resident's chair back to the reclined position as required and left the resident unattended. The resident leaned forward and fell from the chair. He/she sustained a laceration above his/her left eye brow and was transferred to the hospital and returned with Dermabond adhesive applied to the laceration. The resident's Quarterly Minimum Data Set ((MDS) dated [DATE], identified the resident as having short and long-term memory loss, being severely cognitively impaired, requiring total assistance in transfers, being non-ambulatory in the previous 7 day period and experiencing no accidents. The resident is a recipient of Hospice services (as of 5/12). Interview with Unit Manager #2 on 1/3/13 at 2:00 P.M. confirmed that the CNA failed to return the resident's chair back to the reclined position as required and left the resident unattended. As a result, the resident fell out of the chair and sustained a laceration that required Dermabond treatment to close this wound. An interview was held with CNA #13 on 1/23/13 at 2:00 P.M. She stated that she had received training by facility staff on how to properly operate the Tilt-in Space wheelchair prior to using it with the resident. 5. For resident #5, the facility failed to provide proper supervision to a resident who sustained 4 falls out of bed during the 11P.M.-7 A.M. shift during a 3 month period between 5/12-8/12 while attempting to self-transfer himself/herself to the bathroom. The resident fell again 2 months later in 10/12 while actually self-transferring himself/herself independently out of bed and falling in the bathroom while toileting himself/herself. Finally, the resident sustained [REDACTED]. The resident's record was reviewed on 1/22/13. Resident #5 was admitted to the facility in 11/10. The resident's [DIAGNOSES REDACTED]. The resident's Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15 and requiring limited assistance of 1 person in transfers and ambulation. Specifically, the resident's balance was not steady during transitions and walking and he/she was only able to stabilize himself/herself with staff assistance when: moving from a seated to a standing position, walking, and moving on and off the toilet. In addition, he/she required extensive assistance of 1 person in toileting and was continent of bladder. The resident's care plan identified the problem area of falls and it indicated the following: Resident has history of falling: is deconditioned and has potential for falls; psychotropic med use, impaired judgement at times. Approaches included: * 2/12 top sidereails for bed mobility, weight distribution and to help identify bed parameters * bed in low position with fall mat * provide reacher * scoop mattress, no satin pajamas * ambulated with rolling walker, assist with transfers and mobility * give verbal reminders not to ambulate/transfer without assistance * provide toileting assistance as needed * mats both sides of bed * bed alarm The resident also had a care plan addressing activities of daily living (ADLs). It indicated the resident had impaired ability to complete his/her ADLs due to weakness, decreased endurance and impaired balance. Approaches included assist with....toileting....ambulation and wheelchair mobility. A. An Event/Incident Report dated 5/16/12 identified the resident as having confusion and depression and indicated the resident fell out of bed and was found lying on the floor on his/her stomach at 1:55 A.M. The Falls Investigation/Post Fall assessment dated [DATE] indicated the resident told the staff that he/she fell after trying to walk to the bathroom and toilet himself/herself. The resident's bed alarm was not sounding and the resident's call bell was on his/her bed rail. The resident was continent at the time of the fall. The immediate intervention taken was the resident was toileted and brought back to bed. Steps taken to avoid reoccurrence: toilet early on rounds. Included in the investigation was the question, "Was interim plan of care developed with interventions to address this incident, and prevention of further similar incident?" "If no, you must explain!" This question was left blank with no further information given, thereby rendering the report incomplete. The resident continued to fall: B. The resident sustained [REDACTED]. An Event/Incident Report dated 7/9/12 identified the resident as having dementia, confusion and depression and indicated the resident was found on the floor between both beds at 12:30 A.M., sustaining an abrasion to his/her right elbow. The resident stated he/she used his/her walker to go to the bathroom and lost his/her balance. The resident did not use the call light. The report further indicated the resident had a history of [REDACTED].M. It further indicated the resident's call light was within reach and that non-skid slippers were in place. Assessment of the cause of the fall was: resident got out of bed without staff knowing. Immediate intervention taken: 20 minute checks initiated. This intervention was carried over to the resident's care plan. The resident's Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as having a BIMS score of 14 out of 15 and requiring limited assistance of 1 person in transfers and ambulation. Specifically, the resident's balance was not steady during transitions and walking and he/she was only able to stabilize himself/herself with staff assistance when: moving from a seated to a standing position, walking, and moving on and off the toilet. In addition, he/she required extensive assistance of 1 person in toileting and was continent of bladder. Interview with the Administrator and Director of Nurses on 1/23/13 revealed the facility implemented a new Safety program in 7/12 called Intentional Rounding. This program required nursing staff to observe each resident very hour from 7 A.M.-11 P.M. and then every 2 hours from 1 A.M.-6 A.M. If the resident was asleep, nursing staff was to enter the room and check the resident. The resident continued to fall: C. The resident sustained [REDACTED]. An Event/Incident Report dated 8/15/12 identified the resident as having dementia and confusion and indicated the resident was toileted at 2 A.M. A statement given by nursing staff was that he/she observed the resident again 2 and 1/2 hours later (not 2 hours as required) at 5:30 A.M. when he/she was was found on the floor. He/she slid to the floor and used the call light after falling to call nursing staff. The report identified the following injuries: left wrist and forearm-skin tear and abrasion. The resident was wearing non-skid slippers and was continent at the time of the fall. The report further indicated the resident was non-compliant (the call light was at bedside at the time of the fall), alert and oriented and did not like to ask for assistance. A question pertaining to whether an alarm was in use as an intervention was left blank. Assessment of the cause of the fall was: reminded resident (he/she) needs to ask first for help to transfer. Immediate intervention taken: (L) forearm and lower wrist washed with normal saline and dressed, attempted to approximate skin. Steps taken to avoid reoccurrence: re-educate, unit rounds. The care plan was updated on 8/15/12 to include the falling information: fall from bed attempting to go to bathroom. Inservice staff (rounds). The resident continued to fall: D. The resident sustained [REDACTED]. An Event/Incident Report dated 8/28/12 identified the resident as having Parkinson's disease and depression and indicated the resident was found on the floor at 6:40 A.M. on his/her buttocks. The resident stated he/she was trying to go to the bathroom and fell . The resident was continent at the time of the fall. The report indicated a bed alarm was non-applicable and was not being used as an intervention and a call bell was within reach (the resident's care plan continued to identify a bed alarm as an intervention). Assessment of the cause of the fall: resident tried to toilet self and lost balance. A review of the Resident Rounding log indicated the resident was observed asleep at 5:00 A.M. The next documented observation of the resident was 1 hour and 40 minutes later, at 6:40 A.M., when the housekeeper observed the resident on the floor. The immediate intervention taken: toileted. Nursing staff indicated that the resident is to be toileted before 6:00 A.M. The resident's Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as having a BIMS score of 14 out of 15 and requiring extensive assistance of 1 person in transfers and limited assistance in ambulation. Specifically, the resident's balance was not steady during transitions and walking and he/she was only able to stabilize himself/herself with staff assistance when: moving from a seated to a standing position, walking, and moving on and off the toilet. In addition, he/she required extensive assistance of 1 person in toileting and was continent of bladder. The resident continued to fall: E. The resident sustained [REDACTED].!2. An Event/Incident Report dated 10/31/12 identified the resident as having Parkinson's disease and indicated the resident was found on the floor against the wall in the bathroom at 10:30 A.M. The resident stated he/she went to sit on the toilet and instead sat on the floor. The report indicated the resident has impaired balance, Parkinson's disease, impaired safety awareness, has a kyphotic posture and requires assistance for transfers. It also indicated that he/she strives for a level for high independence. Dycem was added to his/her wheelchair. F. The resident experienced another fall, this time sustaining a fractured right hip, 80 days later on 1/19/13. An Event/Incident Report dated 1/19/13 identified the resident as having Parkinson's disease and being occasionally confused and indicated the resident's roommate was yelling for help at 9:00 P.M. Staff found the resident on the floor. The resident stated he/she was trying to get up to go to the bathroom and fell . The immediate intervention taken was that the resident was evaluated for injury. A step taken to avoid reoccurrence was: to toilet between 9:00 P.M. and 10:00 P.M. A nursing note written at 9:00 P.M. indicated that an X-Ray was ordered by the Nurse Practitioner. A review of the 72 hour occurrence monitoring form written on 1/19/13 at 9:00 P.M. indicated the resident did not complain upon assessment. Once up and in bed after being toileted, the resident complained of his/her right thigh hurting. The next note written was on 1/20/13 during the 11PM.-7A.M. shift. The report indicated the resident's range of motion was poor and the resident was complaining of pain in his/her right leg and right hip. The report indicated the X-Ray results were pending. The resident suffered a delay in treatment as the X-Ray results were not sent back to the facility in a timely manner and nursing staff did not contact the Nurse Practitioner for another 11 and 1/2 hours to inform her of the delay. It was not until the following morning, 1/20/13 at 8:30 A.M., that Charge Nurse #1 wrote a progress note indicating the following: the resident was complaining of pain to his/her right hip/femur extending down to the knee. An X-Ray was taken the previous evening and the results were unavailable. She indicated that she did call for them and ordered the results stat. The resident at that time was unable to move and bear any weight. The Nurse Practitioner was notified and ordered the resident to be sent to the hospital. The resident was sent out admitted to the hospital and admitted with a fractured right hip. The facility failed to provide adequate supervision to an alert and oriented resident who suffered a fractured hip after repeatedly falling while attempting to self-transfer himself/herself to the bathroom. Please refer to F508. 6. For Resident #12, the facility failed to develop effective interventions consistent with the resident's needs and provide adequate supervision to prevent 6 avoidable falls, culminating in injury for the 11/7/12 fall. These falls

Based on review of the Quality Improvement Plan and staff interviews, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and developed and implemented an appropriate corrective action plan to ensure satisfactory outcomes. Findings include: An interview was held on 1/24/13 at 2:00 P.M. with the Assistant Director of Nurses (ADON), and the Administrator regarding Quality Assurance (QA) Activities in the facility. The QA committee consists of all department heads, the Administrator, the Medical Director and the Director of Nurses (DON) They met on a quarterly basis. The Administrator said the department heads, the nurse managers, the Minimum Data Set (MDS) nurse, and the Social Workers met weekly to determine if there were quality deficiencies. During this interview, a discussion was held on the current areas of focus, which included the high number of falls, the lack of continuing education for the Certified Nurse Aides (CNAs), and the lack of proficiencies for the nursing staff. The QA Nurse referred to looking at interventions to prevent falls during these meetings. In addition, they referred to the use of Intentional Rounding started in July 2012 to help with the reduction of falls. The Administrator said the Director of Nursing developed an action plan in December 2012 because there was an increase in falls. The action plan included re-education concerning Intentional Rounding, identifying those residents who were at high risk for falls and an audit tool to determine if the action plan was effective. The Administrator said there was no decline in falls. The Quality Assurance Committee failed to develop and implement appropriate plans of corrective action, to address and correct identified quality deficiencies as mentioned above.

Based on interviews and record review, the facility failed to provide timely radiology results for 2 residents (#5 and #19) in the original sample of 24 and an extended sample of 3 residents. Findings include: 1. For Resident #5, the facility failed to obtain results of a right hip x-ray in a timely manner. Review of Resident #5's clinical record indicated that the resident was admitted to the facility in November 2010 with [DIAGNOSES REDACTED]. The Event/Incident Report dated 1/19/13 at 9:00 P.M indicated that the resident was found on the floor after attempting to toilet himself/herself. The Report indicated that the resident was assessed for injury. The nurse's note dated 1/19/13 at 9:00 P.M. indicated that the resident complained of pain in the right hip area; the nurse practitioner (NP) was notified, and she ordered an x-ray of the right hip. Further documentation indicated that the x-ray was obtained at 11:15 P.M. The nurse's note, dated 1/20/13 at 8:30 A.M. by Charge Nurse #1, indicated that the resident was complaining of pain in his/her right hip/femur extending down to the knee; the results of the x-ray taken the previous evening was unavailable; this writer called the x-ray department and asked for a STAT (immediate) reading; the resident was unable to move and/or bear weight; the NP was notified, and the NP ordered the resident transferred to the hospital for an evaluation. Further documentation indicated that the resident was admitted to the hospital with [REDACTED]. During interview with the Director of Nursing (DON) on 1/24/13 at 2:15 P.M., she said that there was a delay in radiology reporting the results of the resident's x-ray. The DON said the resident's right [MEDICAL CONDITION] was reported to the facility at 7:08 P.M., nearly a 20 hour delay. 2. For Resident #19, the facility failed to receive the results of a left shoulder x-ray for 30 hours after the order for the x-ray was obtained from the physician. The findings were positive for a fractured clavicle. Review of Resident #19's clinical record indicated that the resident was admitted to the facility in June 2012 with [DIAGNOSES REDACTED]. Review of nurses' notes, dated 1/19/13 from 7:00 A.M. to 3:00 P.M., indicated the resident began to report pain in the chest and shoulder area along with restriction of movement. The physician was notified of the resident's pain and restriction of movement and ordered an x-ray of the left shoulder at 12:00 P.M. The Mobile X-Ray Company arrived at 5:00 P.M. and obtained an x-ray of the resident's left shoulder. Documentation indicated that the facility was unable to obtain the resident's x-ray results until 1/20/13 at 6:45 P.M or approximately 30 + hours after the x-ray was ordered and 26 hours after the x-ray was completed. The results of the x-ray indicated a fractured clavicle. During an interview with the Director of Nurses (DON) on 1/24/13 at 2:00 P.M., she said that a "Vendor Concern" was filed on 1/23/13 regarding the delay in notifying the facility that Resident #19 had a fractured clavicle greater than 26 hours after the x-ray was completed. The DON said the nursing staff should have informed either the Administrator, DON, or the ADON (Assistant Director of Nurses) that the facility was unable to obtain the results of a STAT x-ray which was not done. The DON said the expectation for the x-ray turnaround after an x-ray was obtained was within 4 to 6 hours. The Administator faxed a report from the Mobile x-ray Company to the Department of Public Health on 1/28/13 at 4:58 P.M.. The Report indicated that the facility filed the Concern on 1/24/13 not 1/23/13 as was told to the survey team. The report indicated that the average STAT (immediate) radiology turnaround time had not exceeded approximately 4 hours during the past 13 months.

Based on observations, record reviews and interviews with staff, the Administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as evidenced by the multiple findings in this statement of deficiencies affecting 11 of 24 Residents (#3, 5, 6, 7, 9, 10, 11, 12, 17, 19, and 24) in the original sample of 24 and 2 of 3 residents in the extended sample (ES #26 and ES #27). Findings include: Please refer to deficient practices cited under: Resident Rights: F151. The facility failed to ensure that the best interest of the resident was guaranteed and free of interference from the Health Care Proxy for Resident #3. Resident Rights: F157. The facility failed to ensure that the physician was promptly notified of a change in the resident's treatment plan per the wound specialist's recommendation for Resident #17. Resident Rights: F164. The facility failed to ensure that the resident's right to privacy was adhered to during the operation of a video camera for Resident #19. Resident Behavior and Facility Practice: F225. The facility failed to ensure that the Facility's Abuse Protocol was followed for Residents #19 and #24. Resident Assessment: F279 and F282. The facility failed to evaluate, revise and follow the plan of care for Residents #5, #9, #10 and #12. Quality of Care: F309, F314, and F323. The facility failed to provide the necessary care and services in a timely and effective manner for Resident #19. The facility failed to ensure that the residents with pressure sores received the necessary treatment and services to promote healing for Resident #17. The facility failed to ensure adequate supervision for the prevention of accident hazards for Residents #5, #6, #7, #10, #11, #12, #19 and ES #27. Physician Services: F387. The Facility failed to ensure that the resident was seen by the physician every 60 days as required for Residents #17, ES #26 and ES #27. Administration: F497, F508 and F520. The facility failed to ensure that 10 of 10 sampled Certified Nursing Assistant (CNAs #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12) were provided the necessary education and annual performance reviews. The facility failed to provide timely Radiology results for Residents #5 and #19 with acute fractures. The facility failed to ensure that the Quality Assurance Committee developed and implemented appropriate corrective action plans to ensure satisfactory outcomes.

Based on record review and staff interview, the facility failed to ensure timely care for 1 resident (#19) with an acute fracture of unknown etiology in the original sample of 24 and the extended sample of 3 residents. Findings include: The clinical record was reviewed on 1/22/13. Subsequently, documentation related to a bruise and fracture of unknown etiology was also reviewed. Resident #19 was admitted to the facility in 6/2012. The resident's [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) of December 2012, indicated that the resident was severely cognitively impaired, had moderately impaired vision and minimal difficulty with hearing. The resident required extensive assistance with bed mobility, dressing, toileting, bathing and personal hygiene. The resident also utilizes limited assistance with transfer, walking and setup with eating. The resident is unsteady with ambulation and always incontinent with bowel and bladder. The resident is 98 lbs. and requires an antidepressant medication. During document review, according to Social Worker #1, she wrote that it was brought to her attention by the Activity Director on 1/16/13, that there was an altercation between Resident #19 and his/her roommate. The Activity Director saw the roommate move his/her arm/hand forward in what could be described as a "slap", "push", "grabbing motion to the forearm of Resident #19. The Activity Director was certain that some type of contact was made. Resident #19 did not cry out, stumble or acknowledge that anything had occurred. On 1/19/13 on the 7-3 shift, Resident #19 began to report pain in the chest and shoulder area along with a restriction of movement. Charge Nurse #1 assessed the resident on 1/19/13 on the 7-3 shift and found no bruising, redness or swelling. The MD was notified of pain and restricted movement and ordered an x-ray of the left shoulder on 1/19/13 at 12:00 P.M. Mobile x-ray arrived on the same day 5 hours later at 5:00 P.M. and obtained an x-ray. The resident was medicated for pain. On the 3-11 shift, Charge Nurse #2 and CNA #3 noted a "yellowish bruise on the left clavicle area." Results of this x-ray was not available until 1/20/13 at 6:45 P.M. (30+ hours later) as there was was an IT or systems malfunction. Although the facility nurse continued to call Mobile x-ray, there was no evidence that the physician was notified once the Mobile results could not be obtained. Nor was there evidence that efforts were made to transfer the resident to the hospital for an x-ray once a bruise was identified and the Mobile results could not be obtained. The resident continued to report pain. Thirty hours after the x-ray was ordered, the Mobile x-ray identified a fractured clavicle of unknown etiology. The facility confirmed through interview with the Administrator and the Director of Nurses on 1/24/13 at 2:00 P.M., that the Mobile x-ray malfunction had not been reported to Resident #19's physician, nor had the x-ray company administrator been contacted about this significant delay. The facility failed to ensure timely care for an identified acute fracture. Please refer to F323 and F508.

Based on record review and staff interview, the facility failed to provide services in accordance with the plan of care for 2 residents (#5 and #9) in a total sample of 24 residents in the original survey and 3 residents in the extended survey. Findings include: 1. For Resident #9, the facility failed to implement a plan of care to provide the supervision necessary to keep the resident safe and to recline the back of the resident's wheelchair for additional safety. Review of the resident's clinical record on 1/3/13, indicated that the resident was admitted in 12/2010, with [DIAGNOSES REDACTED]. The resident had falls on 3/23/12, 9/12/12 and 10/23/12. Review of the resident's care plan for falls, dated 1/7/11, indicated that the resident required monitoring for safety issues. The plan lacked specifics as to what supervision the resident required. Review of the resident's Event/Incident report, dated 3/23/12, indicated that the resident was left unattended on the toilet in the resident's bathroom and fell . The fall caused the resident to develop a hematoma on the resident's head. During interview on 1/4/13 at 11:00 A.M., Unit Manager #1 said that the resident should not have been left alone. Review of the resident's Event/Incident report, dated 9/12/12, indicated that the resident sustained [REDACTED]. Review of the resident's Event/Incident report, dated 10/14/12, indicated that the resident's wheelchair should have been tilted back and as a result, the resident fell and sustained a laceration to his/her head. Review of Unit Manager #1's statement on the Event/Incident report indicated that the staff should have elevated the back of the reclining wheelchair to keep the resident from falling forward. On 1/8/13 at 2:00 P.M., during an interview with the Administrator, Director of Nurses and Assistant Director of Nurses, the facility fall protocol was discussed and it was noted that the above staff members said that they recognized that they had a problem with the systems of supervision and falls. They discussed the lack of follow through with falls investigations as an issue and said that the fall that resident #9 suffered on 10/23/12 was the "catalyst" for their new supervision schedules for the day rooms. Please refer to F323. 2. For Resident #5 the facility failed to implement the plan of care to promote pressure ulcer healing. Resident #5 was admitted to the facility in 11/10 with [DIAGNOSES REDACTED]. Review of the resident's most current MDS (Minimum Data Set) Assessment, dated 12/14/12, indicated a BIMS score of 15, which indicated that the resident is cognitively intact. She/He requires assist for transfer, ambulation, dressing, and bathing. The resident is frequently incontinent of bowel and bladder. The resident is also coded as receiving pressure reducing devices for bed and chair. On 1/3/13, review of the clinical record indicated that the resident developed a stage 3 pressure ulcer to the coccyx on 12/18/12. A plan of care was developed on 12/18/12 and included the following interventions: * Follow-up with wound doctor * Rehab screen * Complete treatment as ordered * Measure and document size, drainage, odor weekly On 1/3/13, review of the Certified Nurse Aide Care Card indicated that the resident did not have a chair cushion. The resident was seen by the wound doctor on 12/18/12 and he gave the following recommendations: * Group 2 mattress (low air loss mattress) * Off load wound * Limit sitting to 60 minutes * Reposition per facility protocol * Dry protective dressing, Santyl once a day The resident was also seen by the Rehab staff on 12/18/12 (10 days after the rehab screen was ordered) and they issued the resident a pressure relieving wheelchair cushion. On 1/3/13 at 7:30 A.M., the resident was observed in bed, lying directly on her/his coccyx. The mattress in use was a scoop foam pressure reducing mattress. (Not the pressure relieving low air loss mattress or off loading of the wound as recommended by the wound doctor). On 1/3/13, the resident was observed out of bed at 11:30 A.M. and did not return to bed until after the movie activity at 3:30 P.M. The resident did have the wheelchair cushion in place, but it was difficult to see the inflation level with the resident sitting on it. This exceeded the 60 minute sitting limit that was recommended by the wound doctor. On 1/4/13, the resident was observed out of bed from 10:30 A.M. until she/he was asked to get back into bed for her/his treatment to be completed. The resident did have the wheelchair cushion in place, but it was difficult to see the inflation level with the resident sitting on it. This was confirmed by Unit Manager #2. This exceeded the 60 minute sitting limit that was recommended by the wound doctor. On 1/4/13 at 5:15 P.M., the resident was observed lying in bed directly on her/his coccyx. (Not off loaded as the wound doctor recommended). During the treatment observation on 1/4/13 at 4:45 P.M., the surveyor observed the resident's pressure relieving wheelchair cushion. It was partially deflated. Unit Manager #1 called the Rehab. Department to assess the cushion. During interview on 1/4/13 at 5:00 P.M., Physical Therapist (PT) #1 said that the cushion in place was not promoting pressure relief because if was partially deflated. He continued to say that he would assess the resident for a more appropriate cushion. He felt that a gel cushion would be more appropriate. During interview on 1/4/13 at 5:10 P.M., Unit Manager #1 said they do not have a system to monitor the inflation of the inflatable wheelchair cushions.

Based on record review, staff interviews and review of the Abuse Prevention Policy, the facility failed to comprehensively investigate and report, per facility policy, an allegation made by 1 sampled Resident (#24) and failed to comprehensively investigate a fracture of unknown etiology for 1 sampled Resident (#19) in the original sample of 24 and an extended sample of 3 residents. Findings include: 1. Review of the facility policies for Abuse Prevention on [DATE] indicated the following: * When abuse, mistreatment, neglect, involuntary seclusion, or misappropriation of resident property is observed by, reported to, or suspected by any employee at the facility, staff immediately notifies the Administrative or Nursing Supervisor on duty, who will immediately investigate the alleged incident during the shift on which the alleged abuse occurred. * Interview the resident and other resident witnesses. The interviews are to be dated, documented and signed by the supervisor. * Interview the staff member implicated. Have the employee document, in writing, their knowledge/version of the incident. Ensure the employee's written narrative is signed and dated. * When a staff member is implicated in a potential resident abuse situation, the employee is to be removed from all patient care areas and sent home after the written narrative is obtained from the employee. * The Administrator, Director of Nursing or their designee will assemble the investigation file. * The Administrator or his/her designee will complete the summary of the investigation. For Resident #24, the facility failed to investigate and address an allegation made by the resident and the resident's daughter in regard to a staff member's inappropriate tone of voice while caring for the resident. Resident #24 was admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. The resident expired in the facility in ,[DATE]. She/He was receiving hospice services. During record review on [DATE], a nurse's note, dated [DATE], indicated "spoke with daughter to inform her of a notification that perhaps her mother may have been addressed in an inappropriate tone. No complaints from resident and her daughter, the health care proxy." Further review of the medical record indicated a social service progress note, dated [DATE]-late entry from [DATE]. "It was brought to this writers attention that an alleged incident took place with a staff member. Social services has been monitoring for changes in mood or behavior which have not changed. The resident told this writer she/he feels safe in her environment and has no concerns." During an interview on [DATE] at 2:00 P.M., Unit Manager #1 said that she was aware of the incident and that it was brought to her attention by a daughter who isn't in regularly. She continued to say that because she spoke with the staff member involved, as well as, the resident's daughter (who is the health care proxy), she felt comfortable with the responses and did not report it to her supervisor. She also said that she did not get any written statements from the staff member involved or any other staff members working that day. Unit Manager #1 said she did not follow up with the daughter who lodged the concern and if she could do it over she would have reported it immediately for more guidance. 2. For Resident #19, the facility failed to comprehensively investigate the root cause of a fracture of unknown etiology which was identified 3 days after a Resident to Resident altercation. The clinical record was reviewed on [DATE]. Resident #19 was admitted to the facility in [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) of [DATE], indicated that the resident was severely cognitively impaired, had moderately impaired vision and minimal difficulty with hearing. The resident required extensive assistance with bed mobility, dressing, toileting, bathing and personal hygiene. The resident also utilizes limited assistance with transfer, walking and setup with eating. The resident is unsteady with ambulation and always incontinent with bowel and bladder. The resident is 98 lbs. and requires an antidepressant medication. Document review on [DATE] indicated that the facility Social Worker #1 wrote that it was brought to her attention by the Activity Director on [DATE], that there was an altercation between Resident #19 and his/her roommate. The two residents were heard arguing over an item on the floor. The Activity Director went into the room and saw the roommate slap Resident #19 on the left upper arm. The roommate was immediately removed from the room and the altercation reported to the Social Worker. Due to cognitive deficits and a [DIAGNOSES REDACTED]. The incident was reported to the town Police per the Elder Justice Act on [DATE]. The summary documented by the Director of Nurses, dated [DATE], stated that the Activity Director's view may have been partially obstructed. The Activity Director saw the roommate move his/her arm/hand forward in what could be described as a "slap", "push", "grabbing motion" to the forearm of Resident #19. The Activity Director was certain that some type of contact was made. Resident #19 did not cry out, stumble or acknowledge that anything had occurred. On [DATE] on the 7:00 A.M.-3:00 P.M. shift, Resident #19 began to report pain in the chest and shoulder area along with a restriction of movement. Charge Nurse #1 assessed the resident on [DATE] on the 7:00 A.M.-3:00 P.M. shift and found no bruising, redness or swelling. The MD was notified of pain and restricted movement and ordered an x-ray of the left shoulder on [DATE] at 12:00 P.M. Mobile x-ray arrived on the same day 5 hours later at 5:00 P.M. and obtained an x-ray. The resident was medicated. On the 3:,[DATE]:00 P.M. shift, Charge Nurse #2 and CNA #3 noted a "yellowish bruise on the left clavicle area." Results of this x-ray were not available until [DATE] at 6:45 P.M. (30+ hours later) as there was an IT or systems malfunction. Although the facility nurse continued to call Mobile x-ray, there was no evidence that the physician was notified once the Mobile results could not be obtained. Nor was there evidence that efforts were made to transfer the resident to the hospital for an x-ray once a bruise was identified and the Mobile results could not be obtained. Thirty hours after the x-ray was ordered, the Mobile x-ray identified a fractured clavicle of unknown etiology. An investigation was initiated on [DATE]. This was 3 days following the Resident-to-Resident altercation. There was no reference to the "yellowish bruise" which suggests that this was not a new bruise, but because of the yellowish color, it indicated that the trauma had occurred several days prior. The only recent incident that was identified was on [DATE], three days prior to the appearance of the yellowing bruise. There was no evidence that the facility linked the two incidents through investigation. Please refer to F323.

Based on interviews and record review, the facility failed to notify the physician of the Wound Specialist's recommendation for 1 of 6 residents (#17) with pressure sores in the original sample of 24 and 3 residents in the extended sample. Findings include: For Resident #17, the facility failed to notify the physician of the recommendations by the Wound Specialist on 12/25/12 and 1/1/13 to change the resident's treatment program concerning the pressure sore which resulted in a decline in the resident's pressure sore. Review on 1/8/13 of Resident #17's clinical record indicated that the resident was admitted to the facility in 12/2010 with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 10/12/12, indicated that the resident was cognitively intact, required limited assistance with bed mobility, ambulation, and transfers, and had no pressure sores. The Norton Plus Pressure Sore Scale, dated 10/15/12, indicated that the resident was at moderate risk for pressure sores. The plan of care for an actual skin breakdown, dated 12/17/12, indicated that the resident had "an unstageable coccyx pressure sore stage III". (Full thickness tissue loss) Documentation on the Wound Care Specialist Initial Evaluation, dated 12/18/12, indicated that the resident had a pressure sore Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) on the coccyx for less than 5 days duration measuring 0.2 cm (centimeters) by 0.8 cm by 0.1 cm with a surface area of 0.16 cm squared. The Wound Specialist indicated that the dressing to the pressure sore was to be foam and changed daily. The Wound Specialist documented that the resident was to limit sitting to 60 minutes and to be repositioned according the facility policy. Facility Policy (undated) for positioning indicated that the resident was to repositioned every two hours and as needed. The physician order, dated 12/20/12, indicated that a [MEDICATION NAME] dressing (a water based protective foam dressing) was to be applied to the resident's right buttocks and changed every third day and as need. Documentation on the Wound Care Specialist Evaluation, dated 12/25/12, indicated that the resident's pressure sore on his/her coccyx measured 0.4 cm by 0.8 cm by 0.2 cm and the surface area increased to 0.32 cm squared. The Wound Specialist indicated that there was 30% necrotic tissue present which was debrided. The Wound Specialist recommended a change in the treatment from the foam dressing alone to Santyl (a [MEDICATION NAME] agent) with a foam dressing applied and changed daily. Review of the physician orders, dated 12/25/12 indicated that there was no change in the resident's dressing to the coccyx. Documentation on the Wound Care Specialist Evaluation, dated 1/1/13, indicated that there was a light serous exudate (drainage) associated with the pressure sore. The pressure sore on the coccyx measured 1.0 cm by 0.3 cm by 0.2 cm with a surface of 0.30 squared. The Wound Specialist indicated that the wound was debrided of necrotic tissue. The Wound Specialist documented that the dressing was to have Santyl and a foam dressing to be changed daily. The Wound Specialist documented that the resident's pressure sore was stable. Review of the physician's orders [REDACTED]. treatment. The physician order [REDACTED]. The order indicated to cleanse the coccyx area with wound cleanser, then apply Santyl and foam dressing daily. The Wound Care Specialist Evaluation, dated 1/8/13, indicated that the resident's wound measured 3.0 cm by 2.0 cm by 0.2 cm with surface area of 6.0 cm squared. The Wound Specialist indicated that the resident now required a group 2 bed mattress. The Wound Specialist indicated that the wound had not improved. During interview with Unit Manager #1 on 1/9/13 at 10:15 A.M., she said that the Wound Specialist printed his findings after each visit to the facility and it was her responsibility to check for changes in the resident's treatment plan after each visit. Unit Manager #1 said she did not notify the physician until 1/6/13 that the Wound Specialist recommended a change in the resident's treatment program on 12/25/12 and again on 1/1/13. The facility failed to notify the physician of the recommendations by the Wound Specialist on 12/25/12 and 1/1/13 to change the resident's treatment program concerning the pressure sore which resulted in a decline in the resident's pressure sore. Please refer to F314.