Every finding on record at Vantage at Hampden LLC

Based on observations, interviews, and record review, the facility failed to provide an environment that was free from restraints imposed for purposes of discipline or convenience for two Residents (#66 and #9) out of a total sample of 19 residents. Specifically, the facility failed to:1. For Resident #66, the facility failed to identify and assess the use of an abduction pillow (a soft, firm foam pillow that is placed between the thighs and strapped onto the patient's legs while they are in a resting position) that was fastened with a Velcro strap wrapped around the Resident's legs as a potential restraint. 2. For Resident #9, the facility failed to assess the use of bolsters to both sides of the Resident's bed as a physical restraint when staff applied the bolsters to restrict the Resident's attempts to get out of bed. Findings Include: Review of facility policy titled Use of Restraints, undated, indicated: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. -Restraints shall only be used to treat the residents' medical symptoms, and never for discipline, staff convenience, or the prevention of falls. -When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the on-going re-evaluation for the need for restraints will be documented. -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. -Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. -Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: >using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bad >tucking sheets so tightly that a bed-bound resident cannot move >placing a resident in a chair that prevents the resident from rising >placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising -Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: >treat the medical symptom. >protect the resident's safety. >help the resident attain the highest level of his/her physical or psychological well-being. -Treatment restraints may be used for the protection of the resident during treatment and diagnostic procedures if the resident and/or resident representative has consented to the treatment or procedure and the use of treatment restraints. Treatment restraints shall be applied for no longer than the time required to complete the treatment. -Restraints shall only be used upon written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the following: >the specific reason for the restraint (as it relates to the resident's medical symptoms); >how the restraint will be used to benefit the resident's medical symptoms; and >the type of restraint, and period of time for the use of the restraint. -Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints and the alternatives to restraint use. -Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms. -Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. 1. Resident #66 was admitted to the facility in April 2017 with diagnoses including Alzheimer's Disease, muscle wasting and atrophy. Review of Resident #66's Minimum Data Set (MDS) assessment, dated 3/18/26, indicated that a Staff Assessment for Mental Status had to be completed as the Resident was unable to respond to question, which indicated that the Resident's cognitive skills for daily decision making were severely impaired. Further review of the MDS Assessment failed to indicate that restraints were utilized for Resident #66. Review of Resident #66's medical record failed to indicate evidence of: -A pre-restraint assessment. -A Consent for a restraint signed by the responsible party. -A Physician's order for restraint. -A care plan for restraint. On 4/28/26 8:31 A.M., the surveyor observed Resident #66 resting in the day room waiting for breakfast. The Resident was observed with a knee abduction pillow placed between their legs that had a strap secured around their legs with a Velcro fastener. During an interview at the time, the Rehabilitation Director said that Resident #66 had been wearing the pillow for approximately five months and that the Resident could take it off themself. During an interview on 4/29/26 at 9:19 A.M., the Rehabilitation Director said that the rehabilitation department had recommended the abduction pillow on 4/18/25 for the goal of wheelchair management for the Resident's positioning in a new wheelchair. The Rehabilitation Director said that the device does restrict the Resident's movement while in the chair to prevent skin breakdown and from crossing their legs at the knee and ankle. The Rehabilitation Director also said that the Resident can remove the device, but he did not believe that the Resident could remove the abduction pillow on demand. On 4/29/26 at 9:26 A.M., the surveyor observed Resident #66 resting in the day room with the knee abduction pillow in place between their legs and a leg strap secured around the legs with a Velcro fastener. During an interview on 4/29/26 at 9:30 A.M., the Director of Nursing (DON) said that the facility staff did not consider Resident #66's device a restraint because the Resident was unable to move. The DON also said that the Resident was too cognitively impaired to remove the Velcro strap on the abduction pillow. During an interview on 4/29/26 at10:49 A.M., the DON said that Resident #66 should not have been restrained and they had been restrained. The DON said that the facility did not have the consent of the Resident's responsible party for the restraint because staff did not realize it was a restraint until they observed the Velcro leg strap tied around the wedge cushion themselves. 2. Resident #9 was admitted to the facility in November 2022 with diagnoses including Dementia with behavioral disturbance, Muscle Weakness, and Abnormalities of Gait and Mobility. Review of Resident #9's Active Care Plan indicated: -at risk for falling (11/22/22). -performs chair/bed to chair transfers with substantial/maximal assistance (11/16/23). -may self-transfer unsafely without assistance (2/29/24). -uses quarter siderails for independent bed mobility enablers, to feel safe and secure (7/14/25). -At no time should siderails be used that restrict the Resident from being unable to get in or out of bed (7/14/25). Review of Resident #9's Nursing Progress Note dated 2/3/26, indicated: -Staff heard alarm sounding. -Staff observed Resident #9 sitting on his/her bedroom floor, near his/her bed. Review of Resident #9's Minimum Data Set (MDS) Assessment, dated 2/10/26, indicated: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of one out of 15 total possible points. -upper and lower extremity range of motion was not impaired. -required substantial/maximal assistance (helper does more than half the effort) for bed/chair transfers. Review of Resident #9's April 2026 Physician Orders indicated: -Two quarter siderails up in bed to promote bed mobility, safety and positioning, initiated 11/22/22. -Bed/chair alarm at all times for safety, every shift, related to Unspecified Dementia, Moderate, with other behavioral disturbance, initiated 10/13/23. -Behavior monitoring: Self transferring unsafely without assistance ., initiated 4/21/26. Review of Resident #9's Nursing Progress Note, dated 4/20/26, indicated: -Resident attempts to self-transfer out of chair every 20 minutes. -Only redirectable for a few moments until he/she attempts again. On 4/28/26 at 9:25 A.M., the surveyor observed Resident #9 as follows: -The Resident was sleeping in bed. -Bilateral padded quarter siderails were in the up position. -Both sides of the mattress were bolstered, and the bolsters were positioned under the Resident's fitted sheet. During an interview on 4/29/26 at 11:19 A.M., Certified Nurse Aide (CNA) #1 said Resident #9 does swing his/her legs over the edge of the bed when he/she is in bed, so CNA #1 is always sure to place bolsters on both sides of the bed to keep the Resident safe. CNA #1 said she places the bolsters under the fitted sheet to make sure the bolsters stay in place and to keep the Resident from getting his/her legs over the edge of the bed and falling. During an interview on 4/29/26 at 11:40 A.M., CNA #2 said Resident #9 does move his/her feet and will occasionally try to get out of bed and out of his/her wheelchair. CNA #2 said he uses bolsters on both side of the Resident's bed by attaching the bolsters to the frame of each quarter siderail and pulling the fitted sheet over the bolsters to keep the bolsters in place. At this time, CNA #2 picked up one of the bolsters from behind the Resident's room door and demonstrated how he attaches the bolster to the quarter siderail using a Velcro strap. CNA #2 said he uses the bolsters on the bed when the Resident is in bed to make sure the Resident does not fall out of bed. On 4/29/26 at 11:53 A.M., the surveyor observed Resident #9 sitting in his/her wheelchair in the common area near the nurses station and was actively moving his/her legs, from the knee down, in bending and straightening motions, and using his/her right hand to pull him/herself toward his/her left side in the wheelchair. During an interview at the time, Nurse #2 said the Resident was enjoying the music that was playing and was moving his/her body with the music. Review of Resident #9's clinical record failed to indicate: -An assessment of the Resident relative to the use of bolsters on the Resident's bed as a physical restraint. -A written order from the Physician for the use of bolsters as a restraint, the type of restraint, benefit, and period of time for the use of the restraint on the Resident's bed. -Consent for the use of bolsters as a restraint on the Resident's bed. During an interview on 4/29/26 at 1:27 P.M., the DON said staff should not use bolsters to keep Resident #9 in bed. The DON said attaching the bolsters to the siderails and tucking the bolsters under the fitted sheet to prevent the Resident from getting his/her legs over the edge of the bed is a restraint.

Based on observations, interviews, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice relative to the cleaning and storage of oxygen and respiratory equipment for one Resident (#33) out of a total sample of 19 residents. Specifically, for Resident #33, the facility failed to ensure that the Resident's oxygen concentrator (device used to deliver supplemental oxygen) filter was cleaned as required, and that the Resident's nasal cannula (medical device that delivers supplemental oxygen directly into the nostrils), nebulizer (a medical device that converts liquid medicine into a mist) mask and a non-invasive mechanical ventilator mask were appropriately stored when not in use, to mitigate the risk of contamination, spread of infection, impaired oxygen delivery and equipment malfunction. Findings include: Resident #33 was admitted to the facility in March 2026 with diagnoses including Chronic Obstruction Pulmonary Disease (COPD) and Acute and Chronic Respiratory Failure. Review of Resident #33's Person-Centered Care Plan, initiated 3/24/26, indicated: -oxygen settings: oxygen via nasal prongs. as ordered by Physician.-give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #33:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15.-required partial to moderate assistance from staff for personal hygiene.-received oxygen therapy and non-invasive mechanical ventilator. Review of Resident #33's current Physician orders indicated: -Albuterol Sulfate Nebulization Solution 2.5 Milligrams (mg)/3 Milliliters (ml) inhale orally via nebulizer every four hours as needed [PRN], start date 4/16/26.-BiPAP (Bi-level positive airway pressure - noninvasive ventilation device that helps patients breathe by delivering two levels of air pressure: Inspiratory and Expiratory) [sic] on every hour of sleep and remove every morning with a start date of 3/23/26.-disconnect air tubing from BiPap machine unit, hang in dry place until next use, start date 3/23/26. -Administer oxygen at 3 Liters (L) via nasal cannula continuously every shift, start date 3/23/26.-Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml, 1 applicator inhale via nebulizer four times a day, start date 3/23/26. During an interview on 4/28/26 at 9:10 A.M., Resident #33 who was observed on portable oxygen and getting ready to leave his/her room said that he/she had no concerns with his/her care and gave permission to the surveyor to observe the respiratory supplies in his/her room as he/her was on his/her way out of the room. On 4/28/26 at 9:10 A.M., the surveyor observed the following in Resident #33's room:-an oxygen concentrator with a filter located on the left side of the device. The filter was completely covered in a light gray colored dusty film, when touched with a finger the dust came off to reveal a dark black filter underneath with a portion of the dust falling to the floor and the other remaining on the surveyor's finger. The oxygen tubing and nasal cannula attached to the oxygen concentrator was unbagged and laying directly on the Resident's used bedding next to his/her used urinal.-the tubing and mask connected to the non-invasive ventilator -NIV (Astral) mask was unbagged and laying on top of a garbage can. -the tubing and mask for the nebulizer device was unbagged and laying on the Resident's bedside table. During an interview on 4/29/26 at 7:45 A.M., Resident #33 said that his/her room is very dusty. The surveyor and the Resident observed the filter of the oxygen concentrator in the room remained covered in dust. Resident #33 said he/she was concerned because he/she has had oxygen concentrators stop functioning in the past and he/she needs oxygen to breathe. Resident #33 also said that he/she had not been given storage bags for his/her nasal cannula, nebulizer or ventilator mask when they are not in use. Resident #33 said that he/she uses a portable oxygen device, oxygen concentrator, nebulizer and NIV daily. During an interview on 4/29/26 at 10:59 A.M., Resident #33 said that he/she informed staff about the dirty oxygen concentrator filter because he/she was concerned and asked someone to clean it. The surveyor observed that the oxygen concentrator and filter were clean and no longer dusty. The surveyor observed that the nebulizer and NIV masks in the room remained unbagged. During an interview on 4/29/26 at 11:13 A.M., the Director of Nursing (DON) said that the oxygen concentrator filter should have been cleaned weekly and that the facility did not have Physician's orders for the staff to complete this task and there should have been. The DON also said that the oxygen tubing and masks should have been bagged when not in use. During an interview on 4/29/26 at 1:06 P.M., Maintenance Staff #1 said that he had cleaned Resident #33's oxygen concentrator filter this morning after he had been instructed to by the facility Administrator. Maintenance Staff #1 said that the filter appeared dirty, gray colored and fuzzy and that he had cleaned it with dish soap and water. Maintenance Staff #1 said that he had never cleaned Resident #33's filter before and that there is no system to clean the oxygen concentrator filters in the facility by the maintenance staff. During an interview on 4/29/26 at 1:35 P.M., the Infection Control Nurse said that the concern with nasal canula, nebulizer mask and non-invasive ventilator mask not being bagged is a potential for bacteria to transfer onto the mask and potential spread of infection to the Resident. The Infection Control Nurse said that the concern for an unclean oxygen concentrator filter is the potential for the machine to malfunction, not enough oxygen being delivered to the nasal cannula for the Resident to breathe and the possibility of infection if the filter is unclean.

Based on interviews, and record reviews, the facility failed to ensure the required documentation was provided to the receiving facility/health care provider for two Resident's (#4 and #10) of four applicable residents reviewed for hospitalizations, out of a total sample of 19 residents, to ensure a safe and effective transition of care.Specifically for Resident #4, the facility failed to provide information that included but not limited to the following: provider contact information, resident representative contact information, advanced directives (legal document that outlines an individual's wishes regarding future major medical decisions), and any special care instructions and precautions for ongoing care.Specifically, for Resident #10, the facility failed to provide evidence that the following documentation had been provided to the receiving health care provider relative to the Resident's transfer to the hospital: the Resident's clinical status, the reason for the transfer, recent vital signs, recent relevant lab results, and comprehensive care plan goals. Findings include:Review of the facility policy titled Transfer or Discharge, undated, indicated the following: -if the resident is being transferred or discharged because his or needs cannot be met at the facility, documentation will include: -the specific resident needs that cannot be met -facility's attempt to meet those needs -the receiving facility's service that are available to meet those needs -contact information of the practitioner responsible for the care of the resident -resident representative contact information -advanced directive information -all special instructions or precautions for ongoing care. -comprehensive care plan goals, and -all other information necessary to meet the residents' needs including but not limited to: -resident status including baseline and current mental, behavioral and functional status, -recent vital signs, -diagnoses and allergies, -medications, -most recent relevant labs, other diagnostic tests, and recent immunizations, -a copy of the resident's discharge summary, and -any other documentation, as applicable, to ensure a safe and effective transition of care. Resident #4 was admitted to the facility in October 2023 with diagnoses including Dysphagia (difficulty swallowing), Depression, history of falling, Dementia, Type II Diabetes Mellitus and Hypertension (high blood pressure). Review of a Nurses Progress Note dated 2/4/26 indicated in part that at approximately 5:00 P.M., Resident #4 was found by the Nurse lying on the floor in the dining area with bleeding to the right side of his/her head.911 was called and he/she was transferred to the hospital via ambulance, emergency contact and Provider both notified. Further review of Resident #4's medical record indicated no evidence that the required documentation had been completed and provided to the receiving health care Provider. Review of the document titled History and Physical Hospital, encounter/observation date 2/4/26, indicated the following: -Patient unable to provide history despite talking to him/her in their primary language (not-English). -Most of the information obtained by reviewing previous records as well as ER (Emergency Room) and EMS (Emergency Medical Services) note. During an interview on 4/29/26 at 9:25 A.M., Nurse #1 said when a resident was sent out to the hospital, the staff complete the following: obtain vitals, notify the Provider and obtain an order, if emergent- call 911, complete the transfer assessment in the electronic medical record (EMR), copy the Massachusetts Order for Life-Sustaining Treatment (MOLST), copy the medication list, update family and complete the packet for bed hold notices including the intent to transfer. The surveyor and Nurse #1 reviewed Resident #4's medical record and did not find the required documentation available to review for the hospital transfer on 2/4/26. During an interview on 4/29/26 at 10:56 A.M., Unit Manager (UM) #1 said the Nurse who transferred Resident #4 out to the hospital on 2/4/26 was an agency Nurse and no longer worked at the facility, so the UM was unable to contact her. UM #1 said she reviewed Resident #4's medical record and could not find any evidence that the transfer assessment had been completed or that any of the required documentation had been sent with the Resident when he/she was transferred to the hospital. During a follow-up interview on 4/29/26 at 11:33 A.M., UM #1 said it was important that the required information be sent with a resident when being transferred to the hospital so the receiving facility could properly treat the resident, especially when a resident like Resident #4 had dementia and was unable to provide accurate information themselves. UM #1 said a binder was located on each unit (and showed the surveyor an example of the binder located on the South Unit at the nurses station) that consisted of detailed steps for the staff to follow when sending a resident to the hospital. UM #1 additionally said that all staff, including agency staff may not be aware of the binder or where it was located. 2. Resident #10 was admitted to the facility in February 2021 with diagnoses including Schizophrenia, Parkinsonism, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #10: -scored a ten out of a possible 15 points on the Brief Interview for Mental Status (BIMS) exam, indicating the Resident was moderately cognitively impaired. -has active diagnoses including Schizophrenia. -has behavioral symptoms not directed toward others that occurred four to six days during the Assessment observation period. Review of a General Note signed by Nurse #3 on 4/6/26 indicated that Resident #10 was transferred to the hospital and a warm handover [verbal communication] was given to Emergency Services. Review of Resident #10's Emergency Medicine Note dated 4/6/26, indicated the Resident's history was obtained from the Resident and Emergency Medical Services (EMS). Review of Resident #10's Hospital admission Note dated 4/7/26, indicated that not much of the history was able to be obtained from the Resident due to confusion. Review of Resident #10's clinical record failed to indicate that the following information was communicated to the receiving hospital relative to the Resident's transfer to the hospital on 4/6/26: -The Resident's clinical status. -The reason for the Resident's transfer to the hospital. -The Resident's recent vital signs. -The most recent relevant lab results. -The Resident's comprehensive care plan goals. During an interview on 4/30/26 at 10:42 A.M., UM #1 said the Transfer Assessment should have been completed for Resident #10 at the time of the Resident's transfer to the hospital on 4/6/26, and it had not been completed. UM #1 said the Transfer Assessment would have included the Resident's most recent vital signs and the reason for the Resident's transfer to the hospital. UM #1 said that in addition to sending the Transfer Assessment, the Resident's face sheet, Physician's orders, and Medication Administration Record (MAR) should have been sent to the hospital. UM #1 said there was not any evidence in the Resident's medical record that this documentation had been provided to the hospital relative the Resident's transfer to the hospital on 4/6/26. During an interview on 4/30/26 at 11:00 A.M., the Director of Nursing (DON) said the importance of providing documentation to the hospital at the time of residents' transfer to the hospital was to ensure consistency of care.

Based on observation, and interview, the facility failed to ensure a homelike environment for resident dining on three units (South Unit, North Unit and East Unit) of three units observed. Specifically, the facility failed to: -provide meals and/or meal assistance timely to Residents (#23, #59, #3, and #11), who were seated with other residents during meals. -remove resident meals off the meal trays before serving meals during communal dining. Findings include: On 2/4/25 from 8:10 A.M. through 8:48 A.M., the surveyors observed the following: a. On the South Unit: -8:10 A.M., the meal cart arrived and breakfast meal trays were provided to residents seated in the day room. Resident #23 was seated at a table in the day room with another resident who was provided with his/her breakfast meal. Resident #23 was awake, dressed and seated in a modified wheelchair at the time and was not provided with a breakfast tray. -8:30 A.M., Resident #23 was provided with his/her breakfast meal tray (20 minutes after another resident seated at the same table). Staff were observed to sit beside Resident #23 and assist him/her with the breakfast meal. The resident who was seated at the same table with Resident #23 had finished the breakfast meal at this time. -All breakfast meals provided to residents in the day room were served on meal trays. b. On the North Unit: -Approximately 8:35 A.M., numerous residents were observed in the Lounge area and the day room across from the Lounge area. -The breakfast meals for the residents in the Lounge area and the day room were served on meal trays. c. On the East Unit: -8:27 A.M., the first meal cart arrived on the unit. Seven residents were observed in the day room. One of the seven residents received their breakfast meal. Two other residents were observed seated at the same table as the served resident and were not provided with their meals at the time. -8:35 A.M., the second meal cart arrived on the unit. -8:36 A.M. through 8:38 A.M., meals were provided to the two residents who were seated next to the resident previously served his/her meal and was eating (9 and 11 minutes later respectively) -8:48 A.M., all breakfast meals were provided to the remaining residents in the day room. -All of the breakfast meals provided to the residents in the day room were served on meal trays. On 2/5/25 from 12:01 P.M. through 12:18 P.M., the surveyors observed the following: a. On the South Unit: -12:01 P.M., 14 residents were observed in the day room and four residents were seated at a small table in the alcove near the nursing station. Two of the four residents seated at the dining table in the alcove had their lunch meals and were being assisted by staff while the other two residents seated at the table did not have their meals. One of the 14 residents in the day room was observed without a meal and was seated among other residents who were eating and/or being assisted by staff. During an interview at 12:06 P.M., Nurse #2 said the residents without a lunch tray need assistance from staff to eat. Nurse #2 said the residents' lunch trays are on the meal cart at this time. -12:10 P.M., (9 minutes later), the three residents (two residents in the alcove area and one resident in the day room) previously observed without their lunch meals were provided assistance with their lunch meal. -All of the lunch meals provided to the residents in the day room and alcove area were served on meal trays. b. On the North Unit: -12:17 P.M., ten residents were seated in the Lounge area at tables or with tray tables positioned in front of them. -12:18 P.M., seven residents were observed in the day room. Resident #59 and Resident #3 were seated at a table across from each other. Resident #11 was seated next to the table in a modified wheelchair. Resident #59 was provided with his/her lunch tray and was being assisted by a Certified Nurses Aide (CNA). Resident #3 had a covered lunch tray in front of him/her and was not being assisted. Resident #11 did not have a lunch meal provided at the time. -12:20 P.M., Resident #11 was observed to call out Nurse give me mine. When the surveyor asked Resident #11 what he/she was looking for, the CNA who was assisting Resident #59 said Resident #11 was looking for his/her lunch meal. -12:23 P.M., Resident #11 was provided his/her lunch tray and was assisted by a CNA. Resident #3's covered lunch tray remained positioned in front of him/her, and he/she was observed to be looking around. -12:29 P.M. (11 minutes later), Resident #3 was assisted with his/her lunch meal. -All of the lunch meals provided to the residents in the Lounge area and the day room were served on meal trays. c. On the East Unit: - 12:18 P.M., the residents seated in the day room for lunch were served on meal trays. On 2/7/25 from 7:51 A.M. through 8:34 A.M. the surveyors observed the following: a. On the South Unit: -7:51 A.M., the first meal cart arrived on the unit. Numerous residents were observed in the day room seated at tables or in chairs/wheelchairs with tray tables positioned in front of them. Several residents were also observed at the table in the alcove near the nursing station. -8:19 A.M., all residents were provided their breakfast meals and were eating or being assisted by staff. -All of the breakfast meals provided to residents in the day room and alcove area were served on meal trays. b. On the North Unit: -7:54 A.M., the first meal cart arrived on the unit. Three residents were observed in the day room and eight residents were observed in the Lounge area. Staff were observed starting to distribute the breakfast meals. -8:07 A.M., the second meal cart arrived to the unit. -8:16 A.M., Resident #59 was seated with Resident #3 at a table in the day room. Resident #11 was positioned next to the table in a modified wheelchair. Resident #59 was provided with a covered meal tray at the time. -8:22 A.M., Resident #11 was provided with a covered breakfast tray on an overbed table which was positioned behind him/her. Resident #59 remained seated with the covered breakfast tray positioned in front of him/her. Resident #3 did not have a meal, was awake and observed to be looking around the room. -8:25 A.M., Resident #11 was provided assistance with his/her breakfast meal. -8:32 A.M., Resident #59 was provided assistance with his/her breakfast meal (16 minutes after being provided the breakfast tray). Resident #3 remained without a meal. -8:34 A.M., Resident #3 was provided with his/her breakfast meal and was assisted by a CNA. -All of the breakfast meals provided to residents seated in the Lounge area and day room were served on meal trays. During an interview on 2/7/25 at 9:20 A.M., CNA #1 who worked regularly at the facility, said the resident meals have always been served on meal trays. During an interview on 2/7/25 at 9:52 A.M., Unit Manager (UM) #1 said the residents who eat in the communal areas on the North and South Units have always been served on meal trays. UM #1 said she was made aware of the concerns about some of the residents who were seated at tables without being provided assistance or without a meal and said this should not occur. UM #1 said a covered meal tray should not be provided to a resident until assistance could be provided. UM #1 further said serving meals on trays was not homelike for the residents and she could understand the concern. During an interview on 2/7/25 at 10:37 A.M., with UM #1, the Assistant Director of Nurses (ADON) and the Director of Nursing (DON), the DON said the residents who eat in the communal areas have been served on meal trays since she could remember. The DON said she was not sure why this was, and that she could understand why this was not homelike and could be a dignity concern. UM #1 said they have also started discussing having assigned seating for the tables so that residents who are able to converse and feed themselves can be seated together and those that need assistance from staff were provided with their meals and assistance at the same time.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#37) out of a total sample of 19 residents, was free from physical restraints. Specifically, the facility failed to ensure that Resident #37 was assessed for the use of a rectangular cushion, which was positioned on his/her right side of the bed under the fitted sheet, and being used to prevent the Resident from putting his/her feet over the side of the bed. Findings include: Review of the facility policy titled Use of Restraints, dated 2001, indicated restraints shall only be used for the safety and well-being of the resident (s) and only after other alternatives have been tried unsuccessfully. The policy also included the following: -restraints shall only be used to treat the resident's medical symptom (s) and never for discipline or staff convenience, or for the prevention of falls -when the use of a restraint is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -if the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. -prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. -restraints should only be used upon the written order of a physician and after obtaining consent from the resident and/or representative . Resident #37 was admitted to the facility in July 2019 with diagnoses including Dementia with behavioral disturbance, lymphedema, abnormal gait and mobility and need for assistance with personal care. Review of the Falls Care Plan, initiated 1/20/20, included the following interventions: -Resident will attempt to self transfer, initiated 5/15/23 -keep bed in lowest position with brakes locked, initiated 1/20/20 -keep call light and frequently used items within reach at all times, initiated 1/20/20 -non-skid socks on at all times, initiated 4/10/20 -pressure bed alarm while in bed, initiated 10/8/20 Review of Resident #37's Restraint Assessment, last completed on 2/17/21, indicated: -no restraints were in use. -bilateral side rails were in place for transfers and positioning. Review of the Side Rails Care Plan, initiated 3/20/22, indicated the Resident utilized 1/4 side rails for independent bed mobility enablers to feel safe and secure, and included the following intervention: -at no time should full side rails be used that restrict the Resident from being able to get in/out of bed, initiated 3/20/22 Review of the Minimum Data Set (MDS) Assessment, dated 1/14/25, indicated Resident #37: -had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 2 out of 15 -utilized a wheelchair -required substantial/maximum assistance of staff with activities of daily living (ADLs), repositioning and transfers -utilized a bed alarm daily -did not utilize restraints Review of the Nursing Evaluation, dated 1/17/25, indicated Resident #37: -was not independently mobile -had cognitive impairment -was a high risk for falls due to score of 12 (high risk - score of greater than or equal to 10) -1/4 side rails have been requested for use when the Resident was in bed -had periods of agitation and confusion and no alternatives to side rails have been tried -was likely to roll, slip or slide from bed Review of the February 2025 Physician's orders indicated the following: -pressure bed alarm at hour of sleep (HS) every evening shift, initiated 10/8/20 -two 1/4 side rails when in bed to assist with positioning and transfers, initiated 3/15/22 -elevate lower extremity when in bed every day and evening shift, initiated 5/5/23 -remove ace wraps from bilateral lower extremities at HS every night, initiated 10/30/24 -TEDS (Thrombo-embolic deterrent stockings) stockings or ace wraps after morning care every day for edema, initiated 11/21/24 Review of the Resident #37's current Certified Nurses Aide (CNA) Care Card (instructions for specific care) indicated the following under safety: -will attempt to self transfer -non-skid socks on at all times -pressure bed alarm while in bed On 2/4/25 at 8:51 A.M., the surveyor observed Resident #37 lying upright in bed during the breakfast meal. The surveyor observed the Resident's left side of the bed was against the wall and a bolster was on the Resident's entire right side. The surveyor observed that bilateral 1/4 side rails were positioned on both sides of the bed and a bed alarm was on the bedside table. On 2/5/25 at 9:16 A.M., the surveyor observed the following: -Resident #37 was dressed, and uncovered while lying in bed. -Bilateral 1/4 side rails were in place. -the Resident's left side of the bed was flush against the wall. -a bolster mattress (mattress with raised edges on the upper and lower sections. The middle of the mattress is flat to allow access out the bed) was in place. -a rectangular cushion was observed under the fitted sheet on the Resident's right side of the bed where the flat part of the mattress was. At this time, Unit Manager (UM) #1 entered the Resident's room, and the surveyor asked about the rectangular cushion positioned under the fitted sheet on the right side of the Resident's bed. UM #1 said she thought the rectangular cushion was probably under the fitted sheet so that the Resident was made aware of bed boundaries but she was not sure. During an interview on 2/5/25 at 9:28 A.M., CNA #1, who regularly worked with Resident #37, said the Resident required assistance from staff to get in and out of bed. CNA #1 said the Resident no longer attempted to get out of bed anymore, but liked to hang his/her feet/legs over the edge of the bed. CNA #1 said Resident #37 had issues with edema (swelling), so the rectangular cushion was placed under the fitted sheet to prevent the Resident from putting his/her legs over the edge of the bed. CNA #1 said they had tried to use pillows on the bed, but the Resident kicks the pillows off the bed. On 2/7/25 at 8:43 A.M., the surveyor observed Resident #37's left side of the bed was against the wall, bilateral 1/4 side rails were in the up position and a bolster mattress was in place. The surveyor further observed a rectangular cushion was on the floor between the Resident's right side of the bed and the bedside table. The Resident was not in the room at the time. Resident #37 was observed up, dressed and in the common area seated in a wheelchair. During a follow-up interview on 2/7/25 at 9:22 A.M., CNA #1 said she worked the 7:00 A.M. to 3:00 P.M. shift and from 3:00 P.M. to 9:00 P.M. CNA #1 said when she worked the evening shift and assists Resident #37 to bed, she would put the rectangular cushion under the fitted sheet on the Resident's right side of the bed in the middle between the raised edges of the mattress. CNA #1 said when the rectangular cushion was in place, the Resident was unable to put his/her legs over the edge of the bed. CNA #1 said the Resident used to attempt to get out of bed without assistance, so he/she had a bed alarm, but no longer attempted to get out of bed. CNA #1 said the rectangular cushion was put into place about a month ago to prevent the Resident from putting his/her legs over the side of the bed. CNA #1 said it was discussed by the CNAs and relayed to the Nurses who were also in agreement. On 2/7/25 at 9:45 A.M., the surveyor and UM #1 observed the Resident's room and UM #1 said she was unaware that the rectangular cushion was being used for Resident #37 until it was observed on 2/5/25. UM #1 said if the rectangular cushion was put under the fitted sheet to prevent the Resident from putting his/her feet/legs over the side of the bed, it would be considered a restraint because the Resident should be able to move his/her legs at will. UM #1 said the Nurses have been applying wraps to the Resident's lower legs to assist in managing his/her edema, and that the Resident would not be able to remove the rectangular cushion because it was positioned under the fitted sheet. UM #1 said that if the rectangular cushion was an intervention that was going to be used, an assessment would need to be completed to determine if it was necessary and if it could be considered a potential restraint. UM #1 said if the rectangular cushion was assessed and indicated for use, the Resident's care plan would need to include this intervention. Review of the Resident's clinical record indicated no documented evidence for the use of the rectangular cushion, bolster mattress or the Resident's bed placement against the wall. During an interview on 2/7/25 at 10:31 A.M., with UM #1, Assistant Director of Nurses (ADON) and the Director of Nursing (DON), the DON said the Resident's bolster mattress has a flattened surface in the middle to allow movement/access in and out of bed. The DON said if the rectangular cushion was placed under the Resident's fitted sheet (where the flattened mattress surface was), it would prevent the Resident's body from moving in and out of bed. The DON said if the rectangular cushion was going to be used as an intervention, it would need to be assessed and care planned. The DON said other interventions, like body pillows placed on top of the fitted sheet, that could be removed easily by the Resident could have been trialed first. The DON further said that a recent fall event had occurred in the facility and that the facility staff have been super aware in ensuring interventions were in place to prevent further resident falls, and that staff may be initiating interventions without communicating with management's awareness. The DON said education needed to be provided to the staff about devices that are going to be utilized for residents so that these devices can be assessed and if other options were more appropriate.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was a functional quadriplegic (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), who was totally dependent on staff to meet all of his/her needs, the facility failed ensure he/she was provided with an adequate level of staff supervision during the provision of care to maintain his/safety to prevent an incident/accident resulting in serious injury. On [DATE], Nurse Aide (NA) #1, prepared Resident #1, who was in bed, for incontinent care. NA #1 raised the bed from the low position, repositioned Resident #1 on his/her right side, and left Resident #1 unattended while she went into the bathroom to fill the wash basin with water. Although Nurse Aide #1 said she was able to monitor Resident #1 while she was in the bathroom, while standing at the sink, the facility determined during their investigation that NA #1 could not visualize him/her. NA #1 said she saw Resident #1 start to slide out of bed, and after Resident #1 was on the floor, NA #1 reported to nursing that she had lowered him/her to the floor. Over the next several days Resident #1 was noted to have visual signs discomfort, he/she verbalized being in pain and at one point when moved by staff, he/she yelled out my neck and was noted to have bruising, swelling to his/her neck and it was tilted off to one side. On [DATE], Resident #1 was transferred to the Hospital Emergency Department (ED) and was diagnosed with multiple cervical spine fractures, that typically occur as a result of an impact injury, like a fall, he/she was placed in an Aspen (rigid neck brace used to support neck by limiting movement) collar, was admitted to Hospice Services at the Hospital, and on [DATE] he/she died . Findings include: The Facility's Policy, titled Falls-Clinical Protocol, dated 2017 indicated but was not limited to: - As part of the initial assessment the physician will help identify individuals with a history of falls and risk factors of subsequent falling - The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. - Falls should be categorized as those that occur while trying to rise from sitting or lying to an upright position, those that occur while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor. The Facility's Policy, titled Accidents and Incidents - Investigating and Reporting, revised [DATE] indicated but was not limited to: - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Review of the Emergency Department Notes, dated [DATE], indicated the following: - Patient has pretty significant elevated blood pressure mildly elevated temperature and some tachycardia (heart rate higher than normal), not on antihypertensives (medication used to treat high blood pressure), or any other medications other than occasional Motrin for perceived discomfort. - Computerized Tomography (CT scan, a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) to be obtained of soft tissue of the neck and CT without contrast C-spine (cervical spine - area of the neck), to evaluate for fracture, abscess or hematoma. - Patient non-verbal, eyes open, bruise to right neck under right ear. Patient cries out in pain with palpation to swollen area and making noises like he/she wants to clear his/her throat. Facility staff report this is baseline to Emergency Medical Services, family states this is not baseline. - Neurosurgery consulted, patient placed in cervical collar (device that supports the neck and limits its movement) for stability and pain control with Dilaudid (a potent opioid medication to control pain). Review of Resident #1's Hospital Admission History and Physical, dated [DATE], indicated the following: - CT of cervical spine with unstable fractures through T7 vertebral bodies (referring to part of the seventh thoracic vertebra found in the middle of the chest between the seventh and eighth pair of ribs) extending through the lamina, facets, and spinous process. The fracture extends through the lateral masses of the C5, fracture involves all three columns of the spine. -CT of the soft tissue of the neck with nondisplaced transverse fracture of the C5 vertebral body (fracture to part of the C5 vertebra where the broken bone pieces have not moved out of alignment) extending through the posterior elements (the back side of the vertebra which includes the spinous process and lamina which affect the supporting ligaments and bony structures at the back of the spine) with slight kyphosis (forward bend in the spine) at the fracture site but no fragment displacement. Mild paraspinal hemorrhage and edema, no associated mass effect. Resident #1 was admitted to the facility in [DATE], diagnoses included Dementia and Functional Quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated he/she was severely cognitively impaired, had unclear speech, was rarely/never understood, and was totally dependent on staff for all levels of care. Review of Resident #1's ADL Care Plan, reviewed and renewed with his/her [DATE] MDS, indicated he/she was dependent for care and required one to two staff members for toileting/incontinence care needs. Review of Resident #1's Care Kardex (utilized by Certified Nurse Aides, provides direct care staff with a brief overview of each resident's needs) indicated that he/she was dependent with personal hygiene, and required one to two staff members for toileting/incontinence care. During a telephone interview on [DATE] at 1:30 P.M., Family Member #1 said when she went to visit Resident #1 on Thursday, [DATE] she noticed there were several people in his/her room, and she heard Resident #1 yelling out like he/she was in pain. Family Member #1 said she noticed that Resident #1's head was tilted sideways so far that his/her left ear was touching his/her left shoulder and saw that Resident #1 had a red and purple lump behind his/her right ear. Family Member #1 said she was unaware of any recent falls or injuries Resident #1 may have sustained that would have explained his/her condition. Family Member #1 said she call Resident #1's Guardian to inform her of the situation and that the Guardian requested Resident #1 be sent to the hospital immediately. Family Member #1 said Resident #1 was dependent on nursing staff for all his/her care needs. Family Member #1 said Resident #1 was unable to move on his/her own [he/she was dead weight], would generally just lay where he/she was placed and to her knowledge had never fallen out of bed. Family Member #1 said she went to the hospital after Resident #1 was transferred, and was informed that Resident #1 had several fractures in his/her neck that caused bleeding, and due to his/her age and condition, he/she was not a surgical candidate. Family Member #1 said Resident #1 was provided comfort measures at the Hospital and died on [DATE]. During a telephone interview on [DATE] at 2:28 P.M., (which included a review of her Written Witness Statement, dated [DATE]) NA #1 said on the evening of [DATE], she and another Certified Nurse Aide (CNA) utilized a Hoyer lift (a mechanical device that helps move people with limited mobility from one place to another) to transfer Resident #1 into bed. NA #1 said the other CNA left the room, she removed the Hoyer sling that was underneath Resident #1 and then positioned Resident #1 on his/her right side with his/her left leg crossed over the top of his/her right leg. NA #1 said she left Resident #1 in this position because she needed to provide incontinent care. NA #1 said left Resident #1 on his/her side, unattended, and went into the bathroom to began to fill a wash basin and wet some washcloths. NA #1 said she monitored Resident #1 by looking out the bathroom door, because she knew Resident #1's bed was raised in a higher position. However, based on staff interviews and the facility's investigation into the incident, it was determined that while NA #1 was filling the basin with water at the sink, NA #1 did not have a direct view of and could not visualize Resident #1, to ensure his/her safety. NA #1 said at one point she saw that Resident #1 had started to roll towards the edge of the bed with his/her legs extending over the side of the bed, so she immediately returned to Resident #1's bedside. NA #1 said she removed her gloves, lowered the position of the bed so it was closer to the floor, grabbed a nearby cushioned fall mat, pulled it towards Resident #1's bedside, wrapped her arms around Resident #1's upper body, held his/her torso against her chest and lowered him/her to the floor. NA #1 said she called out for help several times and when nobody came, she went to Resident #1's doorway, saw Nurse #1 at the medication cart and asked for assistance. NA #1 said Nurse #1 entered the room and asked her what happened and then asked Resident #1 if he/she was ok. NA #1 said she and Nurse #1 transferred Resident #1 back to bed using the Hoyer lift. During an interview on [DATE] at 2:58 P.M., (which included a review of her Written Witness Statement, dated [DATE]), Nurse #1 said while she was in the hallway at the medication cart, NA #1 came to Resident #1's doorway and asked her for assistance. Nurse #1 said when she entered Resident #1's room, she saw Resident #1 lying face up on the floor next to his/her bed. Nurse #1 said she concluded he/she did not have any injuries, and she, along with NA #1 transferred Resident #1 back to bed using a Hoyer lift. Nurse #1 said she asked NA #1 several times in several different ways what happened, and that NA #1 said Resident #1 was slipping off his/her bed, so she lowered Resident #1 to the floor. Nurse #1 said NA #1 told her that Resident #1 did not fall, and he/she did not hit his/her head. Nurse #1 said this incident occurred around 8:00 P.M. on [DATE]. Nurse #1 said although she assessed Resident #1 prior to returning him/her back to bed, she did not assess his/her vital signs, nor did she document anything in his/her medical record or write a report related to this incident, and said she did not report the incident to anybody. During an interview on [DATE] at 11:10 A.M., (which included a review of her Written Witness Statement, undated), Nurse #2 said on [DATE], she had just finished passing her morning medications, was seated at the nursing station and Resident #1 was seated in the common area in his/her wheelchair directly across from the Nurse's Station. Nurse #2 said she heard Resident #1 screaming which was unusual for him/her. Nurse #2 said she asked a CNA to assist her to transfer Resident #1 back to bed so she could assess him/her. Nurse #2 said when she assessed Resident #1's upper extremities, Resident #1 yelled, my neck! Nurse #2 said this was very unusual behavior for Resident #1 as he/she does not often form words when talking. Nurse #2 said she immediately contacted Unit Manager #1 to update her on the situation. Nurse #2 said given they had no knowledge of, and there was no documentation of any accidents or trauma involving Resident #1, after speaking with the Nurse Practitioner (NP), it was thought the pain was muscular in nature and she administered pain medication to Resident #1, according to the NP's order. During an interview on [DATE] at 11:40 A.M., Unit Manager #1 said, looking back on things, staff noticed a change in Resident #1 after [DATE], when he/she had an [unreported] fall. Unit Manager #1 said on [DATE], Resident #1 vomited and stayed in bed the whole day, which was unusual for him/her. Unit Manager #1 said on [DATE], Nurse #2 alerted her that Resident #1 was yelling out in pain and complained of neck pain. Unit Manager #1 said that was odd because Resident #1 did not often verbalize words that made sense. Unit Manager #1 said on [DATE], she observed a CNA feeding Resident #1 in bed and noticed his/her posture seemed off. Unit Manager #1 said Resident #1's bed was slightly reclined and that she asked the CNA to sit Resident #1 in a more upright position, but the CNA told her that Resident #1 exhibited signs of pain when the head of the bed was too upright. Unit Manager #1 said she assessed Resident #1, noted he/she still had neck pain, so she contacted the NP again and requested an order for a neck X-ray. Unit Manager #1 said during the neck X-ray, Resident #1 was in significant pain any time they tried to position his/her head and neck for the X-ray. Unit Manager #1 said she noticed that Resident #1 had bruising along the back right side of his/her neck that had not been observed previously. Unit Manager #1 said Resident #1's granddaughter was present and on the telephone with Resident #1's Guardian who consented to him/her being transferred to the Hospital ED for evaluation. Unit Manager #1 said she notified the Director of Nurses who began an investigation, and that it was during that investigation that they learned that on [DATE], that NA #1 said she lowered Resident #1 to the floor because he/she was falling out of bed. Unit Manager #1 said Resident #1 was unable to roll him/herself if placed on his/her back, but he/she could have possibly rolled over by him/herself if he/she were left on his/her side. Unit Manager #1 said Resident 1's bed was not visible to staff who were at the bathroom sink, and he/she should not have been left unattended in the position NA #1 described because it was unsafe. During an interview on [DATE] at 3:30 P.M., the Director of Nurses (DON) said she was sitting in the Nursing office located near Resident #1's room on [DATE] and overheard Resident #1 yelling in pain. The DON said she went to see what was happening and observed Resident #1 cry out in pain every time the X-ray Technician and nursing staff attempted to adjust his/her position. The DON said nursing staff also observed bruising to Resident #1's neck during the X-ray process. The DON said they immediately stopped the process, determined that Resident #1 needed to be transported to the Emergency Department and called 911. The DON said she immediately began an internal investigation. The DON said that during her interviews with staff, Nurse #1 reported that on [DATE], Resident #1 was lowered to the floor by NA #1 during the evening shift. The DON said after she learned that NA #1 had reportedly lowered Resident #1 to the floor on [DATE], she had NA #1 show her exactly what had happened by having NA #1 do a re-enactment demonstration in Resident #1's room. The DON said they recreated the incident with herself (DON) assuming the role of Resident #1. The DON said she positioned herself by lying in the bed on her right side, left leg crossed over her right leg, with the side rail down, and the bed not in the lowest position. The DON said NA #1 then re-enacted the incident by trying to lower her (DON) to the floor just as she said she lowered Resident #1 to the floor. The DON said there was no way Resident #1's head or neck did not encounter the side rail, despite the side rail being lowered, because the top edge of the side rail extended above the mattress. The DON also said Resident #1 was not visible to NA #1 from the bathroom, that his/her bed should have been in the lowest position and was not, and he/she should not have been left unattended and out of direct view of NA #1. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, The Plan of Correction is as follows: A) [DATE], Resident #1 was transferred to the Hospital for further assessment and treatment, and did not return to the facility. B) [DATE] through [DATE], Administrative staff reviewed previous incident reports for the potential for residents with suspected injury of unknown origin, with review of individual residents nursing Plans of Care and CNA Care Kardex, no concerns for failure to report where identified, reviews will continue as needed. C) [DATE], Facility Administration conducted an ad hoc Quality Assessment and Performance Improvement (QAPI) meeting, with review of current facility policies, and development of an Action Plan, review of the meeting minutes indicated the Facility Leadership team met and developed a plan of correction related to the deficient practices. D) [DATE], Facility Administration suspended Certified Nurse Aide (CNA) #1 and Nurse #1, and as as a result of the facility's internal investigation, they were both terminated. E) [DATE] through [DATE], the Staff Development Coordinator and Director of Nursing educated all clinical staff regarding the following: -Facility policy's related to Falls and Clinical Protocols which included nursing assessments and nursing documentation and the Facility Policy related to Accidents/Incidents, Investigating and Reporting, - Incident reports and staff statements must be completed at the time of the incident. - Events that required reporting to the nurses, Nursing Supervisor(s), the on-call Nurse, or the Director of Nursing - Falls: witnessed, unwitnessed, which included if a resident is lowered to the floor, - Abuse: verbal, physical, neglect, and reporting requirements, - Skin issues: skin tears, bruises, documentation and reporting, - Plans of Care/ CNA Care Kardex review of interventions for appropriateness and current based on care needs. - Resident safety related to positioning (seated and in bed), siderails, call bells within reach, bed/chair alarms, bed in lowest position and floor safety mats. F) [DATE] through [DATE], The Director of Nursing initiated and conducted facility-wide audits to ensure all incidents that have occurred had appropriate and complete incident and accident reports and reviewed that any new onset of pain, skin changes and changes in condition to determine if they should be further investigated. Audits to be continued as needed. G) The Director of Nursing or designee will conduct daily audits of incidents and condition changes, and findings will be reviewed at the Quarterly QAPI meetings, ongoing. H) The DON and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was a functional quadriplegic (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), was essentially non-verbal, unable to participate in his/her care, and was totally dependent on staff to meet all of his/her care needs, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality, when on [DATE], after Nurse #1 was notified by Nurse Aide (NA #1) that during care Resident #1 began to slide out of bed and she (NA #1) lowered him/her to the floor, although Nurse #1 said she assessed Resident #1 for the potential for injury prior to moving him/her off the floor, Nurse #1 was unable to say what she did to assess him/her. There were no nursing assessments and no progress note to support Nurse #1 assessed Resident #1 at all. Nurse #1 also never reported the incident to anyone. Over the next several days Resident #1 was noted to have visual signs of discomfort, he/she verbalized being in pain and at one point when moved by staff, he/she yelled out my neck, was noted to have bruising, swelling to his/her neck and his/her head was tilted to one side. On [DATE], Resident #1 was transferred to the Hospital Emergency Department (ED) and was diagnosed with multiple cervical spine fractures, that typically occur as a result of an impact injury, he/she was placed in an Aspen (rigid neck brace, used to support neck by limiting movement) collar, was admitted to Hospice services in the Hospital, and on [DATE], he/she died . Findings include: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulations (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and function of a Registered Nurse and Practical Nurse, respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define the Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility Policy, titled Falls- Clinical Protocol, dated 2017, indicated but was not limited to: - The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. - Falls should be identified as witnessed or unwitnessed events. - For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. - Falls should be categorized as those that occur while trying to rise from sitting or lying to an upright position, those that occur while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor. - Delayed complications such as late fractures and major bruising may occur hours or several days after a fall. Review of the Facility Policy, titled Accidents and Incidents - Investigating and Reporting, revised [DATE], indicated, but was not limited to: - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. - The Nurse Supervisor/Charge Nurse and/or Department Director or Supervisor shall promptly initiate and document investigation of the accident or incident. - The following data, as applicable, shall be included in the Report of Incident/Accident Form: - The date and time accident took place - The nature of injury/illness (e.g., bruise, fall, nausea, etc.). - The circumstances surrounding the accident or incident. - Where the accident or incident took place. - The name(s) of witnesses and their accounts of the accident or incident. - The injured person's account of the accident or incident. - The time the injured person's attending Physician was notified as well as the time the Physician responded and his/her instructions. - The date/time the injured person's family was notified and by whom. - The condition of the injured person, including his/her vital signs. - The disposition of the injured (i.e., transferred to hospital, put to bed .). - Any corrective action taken. - Follow-up information. - Other pertinent data as necessary and required. - The signature of the person completing the report. Resident #1 was admitted to the facility in [DATE], diagnoses included Dementia and Functional Quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated he/she was severely cognitively impaired, had unclear speech, was rarely/never understood and was totally dependent on staff for all Activities of Daily Living (ADLs). Review of Resident #1's ADL Care Plan, reviewed and renewed with his/her [DATE] MDS, indicated he/she was dependent on staff for care, that he/she required an assist of two for transfers and required one to two staff members to provide toileting/incontinence care needs. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted [DATE], indicated that Resident #1 began exhibiting non-verbal signs of pain on [DATE], the pain was thought to be muscular in nature and was treated with Ibuprofen. However, on [DATE], Resident #1 continued to express non-verbal signs of pain, the provider was notified, X-rays were ordered, bruising was noted on the right side of Resident #1's neck and an internal investigation was conducted. The Report indicated that on the evening of [DATE], NA #1 lowered Resident #1's siderail, rolled him/her over to remove the mechanical lift sling from underneath him/her and left his/her bedside to go into the bathroom to wet washcloths [to provide incontinence care]. Shortly thereafter, Nurse Aide (NA) #1 observed Resident #1's legs/lower torso sliding over the side of the bed, she went back to his/her bedside, lowered him/her to the floor and called out to Nurse #1 for help. The Report indicated Nurse #1 assessed Resident #1, determined there were no visible injuries, and assisted NA #1 with transferring Resident #1 back to bed. The Report further indicated that the facility concluded upon re-enactment of the incident, that NA #1 left Resident #1 unattended in his/her bed lying on his/her right side, on the right-hand side of the mattress with the right siderail down, with the bed in a high (raised) position while she went into the bathroom to wet washcloths with warm water. The Report also indicated that it was determined that the bruising [to Resident #1's neck] was likely a result of Resident #1's neck coming into contact with the bed's lowered siderail while he/she was being lowered to the floor. The Report indicated the hospital determined that Resident #1 had sustained neck fractures. Review of the Emergency Department Notes, dated [DATE], indicated the following: - Patient has pretty significant elevated blood pressure mildly elevated temperature and some tachycardia (heart rate higher than normal), not on antihypertensives (medication used to treat high blood pressure), or any other medications other than occasional Motrin for perceived discomfort. - Computerized Tomography (CT scan, a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) to be obtained of soft tissue of the neck and CT without contrast C-spine (cervical spine - area of the neck), to evaluate for fracture, abscess or hematoma. - Patient non-verbal, eyes open, bruise to right neck under right ear. Patient cries out in pain with palpation to swollen area and making noises like he/she wants to clear his/her throat. Facility staff reported this is his/her baseline to Emergency Medical Services, family states this is not his/her baseline. - Neurosurgery consulted, patient placed in cervical collar (device that supports the neck and limits its movement) for stability and pain control with Dilaudid (a potent opioid medication to control pain). Review of Resident #1's Hospital Admission History and Physical, dated [DATE], indicated the following: - CT of cervical spine with unstable fractures through T7 vertebral bodies (referring to part of the seventh thoracic vertebra found in the middle of the chest between the seventh and eighth pair of ribs) extending through the lamina, facets, and spinous process. The fracture extends through the lateral masses of the C5, fracture involves all three columns of the spine. -CT of the soft tissue of the neck with nondisplaced transverse fracture of the C5 vertebral body (fracture to part of the C5 vertebra where the broken bone pieces have not moved out of alignment) extending through the posterior elements (the back side of the vertebra which includes the spinous process and lamina which affect the supporting ligaments and bony structures at the back of the spine) with slight kyphosis (forward bend in the spine) at the fracture site but no fragment displacement. Mild paraspinal hemorrhage and edema, no associated mass effect. Review of a National Institutes of Health (NIH) .gov article titled Cervical Spine Fractures Overview, last updated [DATE], indicated fractures of the cervical spine result from abnormal movement or a combination of movements including hyperflexion, hyperextension (injuries that occur when a joint is moved beyond its normal range of motion), rotation (moving from side to side too far), axial loading (applying force directly along the axis of a structure), and lateral bending (caused by excessive sideways bending) of the spinal column, and sub-axial spine (C3-C7) fractures are commonly seen with high impact accidents such as motor vehicle accidents. Further review of the NIH.gov article indicated three-column fractures extending through the anterior vertebral body all the way through to the posterior ligaments are highly unstable, and cervical spine fractures are high-risk injuries with the potential for devastating neurological sequelae. Review of Resident #1's Hospital Hospice Consultation Notes, dated [DATE], indicated the following: - Patient lying in bed pale, resting with eyes closed, and unresponsive to verbal or physical stimulation. Bruising and swelling noted to right side of neck with Aspen collar in place. Respiratory rate 12 breaths per minute with shallow, irregular breathing noted. - Patient requiring the following medications for symptom management: Fentanyl (a potent pain medication) 12 micrograms (mcg) patch to right arm, change every 72 hours, Hydromorphone 0.5 milligrams (mg) intravenous (through the vein) administered seven times and Glycopyrrolate (a medication used to alleviate excess oral secretions in terminal patients) 0.2 mg intravenous administered one time, Lorazepam (a medication used to alleviate anxiety and/or restlessness) 0.5 mg administered five times. - Symptoms unable to be managed in alternative setting as patient continues to require frequent Registered Nurse (RN) assessment and IV medication titration (adjustments) that would not be possible outside of an acute care environment. Death appears imminent and moving patient out of this environment would be contraindicated. During a telephone interview on [DATE] at 1:30 P.M., Family Member #1 said when she went to visit Resident #1 on Thursday, [DATE] she noticed there were several people in his/her room, and she heard Resident #1 yelling out like he/she was in pain. Family Member #1 said she noticed that Resident #1's head was tilted sideways so far that his/her left ear was touching his/her left shoulder. Family Member #1 said she saw that Resident #1 had a red and purple lump behind his/her right ear. Family Member #1 said she was unaware of any recent falls or injuries Resident #1 may have sustained that would have explained the injury. Family Member #1 said she called Resident #1's Guardian to inform her of the situation and she said the Guardian requested Resident #1 be sent to the hospital immediately. Family Member #1 said Resident #1 was dependent on nursing staff for all his/her care needs. Family Member #1 said Resident #1 was unable to move on his/her own [he/she was dead weight], would generally just lay where he/she was placed and to her knowledge had never fallen out of bed. Family Member #1 said she went to the hospital after Resident #1 was transferred, and was informed that Resident #1 had several fractures in his/her neck that caused bleeding, and due to his/her age and condition, he/she was not a surgical candidate. Family Member #1 said Resident #1 was provided comfort measures at the Hospital and died on [DATE]. During a telephone interview on [DATE] at 2:28 P.M., (which included a review of her Written Witness Statement, dated [DATE]), Nurse Aide (NA) #1 said on the evening of [DATE], after she and another Certified Nurse Aide (CNA) transferred Resident #1 into bed utilizing a Hoyer lift, the other CNA left the room, and she removed the hoyer sling out from underneath him/her. NA #1 said she positioned Resident #1 on his/her right side, [on the right-hand side of the bed per facility re-enactment] with his/her left leg crossed over the top of his/her right leg, and left Resident #1 in that position because she needed to provide incontinent care. NA #1 said she left Resident #1 on his/her side and proceeded to go into the bathroom [which did not provide a direct view of Resident #1] and began to fill a wash basin and wet some washcloths. NA #1 said at one point, she looked out the bathroom door and noticed that Resident #1 had started to roll towards the edge of the bed with his/her legs extending over the side of the bed. NA #1 said she immediately returned to Resident #1's bedside, removed her gloves, lowered the bed closer to the floor [because she left Resident #1's bed in a higher position to provide care] grabbed a nearby cushioned fall mat, pulled it towards Resident #1's bedside, wrapped her arms around Resident #1's upper body, held his/her torso against her chest and lowered him/her to the floor. NA #1 said after she lowered Resident #1 to the floor, she called out for help several times and when nobody came, she went to Resident #1's doorway, saw Nurse #1 at the medication cart and asked for assistance. NA #1 said Nurse #1 entered the room and asked her what happened. NA #1 said she heard Nurse #1 ask Resident #1, are you o.k.? NA #1 said Nurse #1 assisted her in using the Hoyer lift to transfer Resident #1 back to bed. During an interview on [DATE] at 2:58 P.M., (which included a review of her Written Witness Statement, dated [DATE]), Nurse #1 said on [DATE], while she was in the hallway at the medication cart, NA #1 came to Resident #1's doorway and asked for assistance. Nurse #1 said when she entered Resident #1's room, she saw Resident #1 lying face up on the floor next to his/her bed. Nurse #1 said she concluded he/she did not have any injuries, and she, along with NA #1, they transferred Resident #1 back to bed using a Hoyer lift. Nurse #1 said she asked NA #1 several times in several different ways what happened, and that NA #1 said Resident #1 was slipping off the bed, so she (NA #1) lowered Resident #1 to the floor, that Resident #1 did not fall, and he/she did not hit his/her head. Nurse #1 said this incident occurred around 8:00 P.M. on [DATE]. Nurse #1 said although she assessed Resident #1 prior to helping transfer him/her back to bed, she did not assess his/her vital signs, nor did she document anything or tell anybody about this incident. When the surveyor asked Nurse #1 to describe her assessment of Resident #1 prior to transferring him/her back to bed, Nurse #1 was unable to explain how she concluded that Resident #1 was not injured. Nurse #1 could not say what she conducted for assessments, including whether or not she checked for range of motion, or since Resident #1 was non-verbal, if she assessed him/her for visual signs of pain or discomfort and there was no documentation to support Nurse #1 even obtained a set of vital signs for Resident #1. During the interview, Nurse #1 never said she asked Resident #1 if he/she was o.k., or if she got a response at all from him/her. Nurse #1 said she was aware of the Facility's policies related to falls and reporting incidents, and said if NA #1 told her that Resident #1 fell , she would have completed the Fall Packet (documentation the facility requires nurses to complete after a resident falls), but said as far as she knew, Resident #1 had not fallen out of bed, but had been assisted to the floor with the help of NA #1. During an interview on [DATE] at 11:10 A.M., (which included a review of her Written Witness Statement, undated), Nurse #2 said on [DATE], she had just finished passing her morning medications, was seated at the nursing station, that Resident #1 was seated in the common area in his/her wheelchair directly across from the Nurse's Station and she heard Resident #1 screaming, which was unusual for him/her. Nurse #2 said she asked a CNA to assist her to transfer Resident #1 back to bed so she could assess him/her. Nurse #2 said she began her assessment of Resident #1 from the legs up and when she got to her upper extremities, Resident #1 yelled, my neck! Nurse #2 said she recognized that this was very unusual behavior for Resident #1 as he/she did not often form coherent words when talking. Nurse #2 said she immediately contacted Unit Manager #1 to update her on the situation and requested Unit Manager #1 contact the Nurse Practitioner (NP). Nurse #2 said given that she had no knowledge of, and there was no documentation of any accidents or trauma involving Resident #1, it was thought that his/her pain was muscular in nature and she administered pain medication to Resident #1 according to the NP's orders. When asked if an incident occurred in which a staff member had to lower a resident to the floor, would that be considered a fall? Nurse #2 said absolutely, it would be considered a fall. Nurse #2 also said for any incident deemed to be a fall, the Nurse is required to complete a Fall Packet which includes checklist to ensure a resident is thoroughly assessed for potential injury(s) and the incident itself, is documented and followed up on by nursing. Nurse #2 reviewed the Fall Packet with the surveyor. The Fall Packet checklist included the following: - Assess vital signs and initiate Neuros (Neurological Assessments - A neurological exam completed at fixed intervals that evaluates brain and nervous system functioning) if the fall was unwitnessed or the resident hit their head). - Witness statements obtained from everyone on the unit. - In the Electronic Health Record (EHR), document a Pain Assessment, Fall Assessment, and Skin Assessment. - Notify Physician and family, document person and time. - Initiate intervention specific to fall/injury and update Certified Nurse Aide (CNA) Care Card (instructions meant for the CNA relative to residents' individual care needs). - Document Nursing Note in EHR - Send screen request to rehab, and for evening and night shift, slide under therapy door. - Complete Risk Management Assessment in EHR - Return to Unit Manager/Supervisor when completed. Nurse #2 further said she had no knowledge Resident #1 had experienced a fall prior to his/her expression of severe pain on [DATE], and said had the Fall Packet been completed, subsequent shift nursing staff would have been aware he/she fell , that the reason for his/her pain would have been apparent and treatment interventions would likely have been different. During an interview on [DATE] at 11:40 A.M., Unit Manager #1 said looking back at things now, staff noticed a change in Resident #1 after [DATE] [the day of the unreported fall]. Unit Manager #1 said on [DATE], Resident #1 vomited and stayed in bed the whole day, [which was unusual for him/her] but he/she did not have any outward signs or complaints of pain. Unit Manager #1 said on [DATE], Nurse #2 alerted her that Resident #1 was yelling out in pain and complained of neck pain. Unit Manager #1 said that was unusual because Resident #1 did not often verbalize words that made sense. Unit Manager #1 said she notified the Nurse Practitioner (NP) who asked if Resident #1 had fallen or gotten hurt in any way. Unit Manager #1 said she told the NP Resident #1 had not had any falls, not that she was aware of, and the NP prescribed Motrin because he felt Resident #1's pain was likely muscular in nature. Unit Manager #1 said Resident #1 was administered pain medication, appeared comfortable, and upon assessment there did not appear to be any visible evidence of an injury. Unit Manager #1 said on [DATE], she observed a CNA feeding Resident #1 in bed and noticed his/her posture seemed off. Unit Manager #1 said Resident #1's bed was slightly reclined so she asked the CNA to sit Resident #1 up in a more upright position, but that the CNA then told her that Resident #1 exhibited signs of pain when the head of the bed was upright. Unit Manager #1 said she assessed Resident #1, noted he/she still had neck pain, so she contacted the NP again and requested an order for X-ray of his/her neck. Unit Manager #1 said during the X-ray, Resident #1 was observed to be in significant pain any time they tried to help position his/her head and neck for the X-ray. Unit Manager #1 said it was at that time, she noticed Resident #1 had bruising along the back right side of his/her neck that had not been observed previously and she knew Resident #1 needed to be sent to the Emergency Department (ED) for further evaluation. Unit Manger #1 said Resident #1's granddaughter was present and on the telephone with Resident #1's Guardian who consented for him/her to be transferred to the Hospital. Unit Manager #1 said she notified the Director of Nurses who began an investigation, and that it was during that investigation that they learned NA #1 had lowered Resident #1 to the floor on [DATE], because he/she was falling out of bed. Unit Manager #1 said Nurse #1 did not follow facility protocol relative to falls. Unit Manager #1 said that Nurse #1 should have completed the Fall Packet as well as the Risk Management Assessment in the Electronic Health Record (EHR) which includes Fall Risk, Pain, and Skin Assessments as well as a Neurological Assessment if the resident hit their head or if the fall was unwitnessed. Unit Manager #1 said the Nurse is required to fully assess the resident at the time of the fall [which includes when a resident is lowered to the floor] and only if the resident was assessed as being stable, then the resident could be moved and transferred back to a chair or bed. Unit Manager #1 said for Resident #1, none of this documentation was completed for the incident on [DATE], and had this been done, they would have known that his/her pain was likely related to the fall and would have been treated as such. During an interview on [DATE] at 3:30 P.M., the Director of Nurses (DON) said she was sitting in the Nursing office located near Resident #1's room on [DATE] and overheard Resident #1 yelling out in pain. The DON said she went to see what was happening and observed Resident #1 cry out in pain every time the X-ray Technician and nursing staff attempted to adjust his/her position. The DON said they immediately stopped the process, determined that Resident #1 needed to be transported to the Hospital ED and called 911. The DON said Nursing staff observed bruising to Resident #1's neck during the X-ray process, and she began an internal investigation. The DON said that during her interviews with staff, Nurse #1 said during the evening shift on [DATE], NA #1 had reported to her that she lowered Resident #1 to the floor to prevent him/her from falling out of bed, and that Nurse #1 said she never reported, documented or told anybody about the incident. The DON said she was made aware of Resident #1's increasing pain, as well as the interventions put in place to alleviate it, but if it had been known that Resident #1 had been lowered to the floor, different interventions would likely have been implemented when he/she began to exhibit pain. The DON said Nurse #1 should have completed an A&I (Accident/Incident) Report, completed the Risk Management documentation in the Electronic Health Record (EHR) which included Pain, Fall and Skin Assessments, should have written a Progress Note, and obtained witness statements on the spot, however Nurse #1 did none of this. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, The Plan of Correction is as follows: A) [DATE], Resident #1 was transferred to the Hospital for further assessment and treatment, and did not return to the facility. B) [DATE] through [DATE], Administrative staff reviewed previous incident reports for the potential for residents with suspected injury of unknown origin, with review of individual residents nursing Plans of Care and CNA Care Kardex, no concerns for failure to report where identified, reviews will continue as needed. C) [DATE], Facility Administration conducted an ad hoc Quality Assessment and Performance Improvement (QAPI) meeting, with review of current facility policies, and development of an Action Plan, review of the meeting minutes indicated the Facility Leadership team met and developed a plan of correction related to the deficient practices. D) [DATE], Facility Administration suspended Certified Nurse Aide (CNA) #1 and Nurse #1, and as as a result of the facility's internal investigation, they were both terminated. E) [DATE] through [DATE], the Staff Development Coordinator and Director of Nursing educated all clinical staff regarding the following: -Facility policy's related to Falls and Clinical Protocols which included nursing assessments and nursing documentation and the Facility Policy related to Accidents/Incidents, Investigating and Reporting, - Incident reports and staff statements must be completed at the time of the incident. - Events that required reporting to the nurses, Nursing Supervisor(s), the on-call Nurse, or the Director of Nursing - Falls: witnessed, unwitnessed, which included if a resident is lowered to the floor, - Abuse: verbal, physical, neglect, and reporting requirements, - Skin issues: skin tears, bruises, documentation and reporting, - Plans of Care/ CNA Care Kardex review of interventions for appropriateness and current based on care needs. F) [DATE] through [DATE], The Director of Nursing initiated and conducted facility-wide audits to ensure all incidents that have occurred had appropriate and complete incident and accident reports and reviewed that any new onset of pain, skin changes and changes in condition to determine if they should be further investigated. Audits to be continued as needed. G) The Director of Nursing or designee will conduct daily audits of incidents and condition changes, and findings will be reviewed at the Quarterly QAPI meetings, ongoing. H) The DON and/or designee are responsible for overall compliance.

Based on observations, record reviews and interviews, the facility failed to ensure that one Resident (#79) who required assistance with bed mobility, out of a total sample of 18 residents, received mobility assistance while in bed. Findings include: Resident #79 was admitted to the facility in October 2023 with the following diagnoses: Diabetes Type II Mellitus (DM - when the body does not produce enough insulin to maintain normal blood sugar levels) with other circulatory complications, adult failure to thrive (FTT- syndrome of global decline, that includes weight loss, decreased appetite, and poor nutrition), muscle weakness, need for assistance with personal care and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -Resident required substantial maximal assistance for the following while in bed: rolling left to right, sit to lying, lying to sitting on the side of the bed -Resident is able to make self understood -Resident usually understands verbal content During an observation and interview on 12/20/23 at 8:55 A.M., the surveyor observed Resident #79 in bed eating breakfast, with the head of the bed elevated. His/her feet were observed to be pressed against the foot board. When the surveyor asked if he/she was comfortable, the Resident said no. Resident #79 said that he/she required someone to help boost (to be re-adjusted in the bed so that the person is closer to the head of the bed) him/her up in the bed, so his/her feet did not touch the footboard. During an observation and interview on 12/21/23 at 8:34 A.M., the surveyor observed Resident #79 in bed eating breakfast, with the head of the bed elevated. His/her feet were observed to be pressed against the foot board. When the surveyor asked the Resident if he/she was comfortable, he/she answered no and said that he/she needed someone to help boost him/her up in bed, so his/her feet did not touch the footboard. The surveyor requested Nurse #1's assistance to boost Resident #79. During an observation and interview on 12/21/23 at 8:36 A.M., Nurse #1 said that the Resident required a boost in the bed and that his/her feet should not be pressed against the footboard. Nurse #1 further said that typically the Resident would be boosted up in the bed as he/she is tall, required a maximum assist for bed mobility, and when the head of bed was elevated, a bolster under his/her knees and wedge at the end of the bed so that his/her feet were not pressed against the foot board.

Based on observation, record review, and interview, the facility failed to complete an accurate comprehensive assessment, according to the required Resident Assessment Instrument (RAI) process, for one Resident (#61) out of a total sample of 18 residents. Specifically, the facility staff failed to assess Resident #61's cognitive status and mood through the required resident interview process when the Resident had adequate hearing, clear speech, and sometimes made him/herself understood and sometimes understood others. Findings include: Resident #61 was admitted to the facility in September 2021 with diagnoses including Dementia with behavioral disturbance. Review of Resident #61's comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated the following: - The Resident had adequate hearing. - The Resident had clear speech. - The Resident could sometimes make him/herself understood. - The Resident sometimes understood others. - The Brief Interview for Mental Status (BIMS) should be attempted with all residents. - The BIMS was not conducted with the Resident because he/she was rarely/never understood. - The Mood interview should be attempted with all residents. - The Mood interview was not conducted with the Resident because he/she was rarely/never understood. On 12/20/23 at 8:32 A.M., the surveyor observed Resident #61 seated upright on his/her bed. The Resident was looking at the surveyor and speaking in a language that was not English. On 12/20/23 at 2:30 P.M., the surveyor observed Resident #61 seated in the Activity Room with Activities Aide (AA) #1. AA #1 held the Resident's hand and the Resident's eyes were closed. During an interview at the time, AA #1 said Resident #61 primarily spoke Spanish. AA #1 said she also spoke Spanish and the Resident could sometimes understand her when he/she was spoken to in Spanish. AA #1 further said that the Resident could sometimes make him/herself understood in Spanish. During an interview on 12/21/23 at 2:37 P.M., the Social Worker (SW) said the BIMS and Mood interviews should have been attempted as required with Resident #61 for the comprehensive MDS assessment dated [DATE], but this was not done.

Based on observation, policy review and interview, the facility failed to: 1) ensure that its staff stored and prepared foods under sanitary conditions in the kitchen and, 2) failed to properly store food brought in by visitors on one out of three unit kitchenettes. Findings include: 1. The facility staff failed to properly store foods in the freezer and maintain a sanitary environment in the kitchen area. Review of a facility policy titled Food Storage Cold Foods, revised 4/2018, included but was not limited to the following: -All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. -All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. On 7/13/22 at 8:00 A.M., during an initial tour of the kitchen during the breakfast tray service, the surveyor observed the following concerns: a) A square vent located near the cooking area had a black, speckled, mildew like substance built up in the corners of the vent. b) A large rectangular vent near the tray line was caked with dust. c) There were black layers of dirt on the dish room floor around the plumbing and sanitizer buckets. d) There was water leaking on the floor around the plumbing below the three-compartment-sink and tiles had fallen off the wall. e) There was water leaking on the floor and layers of dirt built up around the plumbing near the oven and tiles had fallen off the wall. f) There were layers of dirt built up around the plumbing below the tray line. g) There were opened, undated, bags of frozen burger patties and fish fillets in the freezer. h) There was an undated bag of tater tots and an undated bag of ravioli in the freezer. On 7/15/22 at 8:55 A.M., during a follow up tour of the kitchen with the Food Service Director (FSD), the surveyor and FSD observed the following concerns: a) A square vent located near the cooking area had a black, speckled, mildew like substance built up in the corners of the vent. b)A large rectangular vent near the tray line was caked with dust. c) There were black layers of dirt on the dish room floor around the plumbing and sanitizer buckets. d) There was water leaking on the floor around the plumbing below the three-compartment-sink and tiles had fallen off the wall. e) There was water leaking on the floor and layers of dirt built up around the plumbing near the oven and tiles had fallen off the wall. f) There were layers of dirt built up around the plumbing below the tray line. g) There were opened, undated, bags of hamburger patties, tater tots and fish fillets in the freezer. h) There was an undated bag of hotdogs that was open to air in the freezer. During an interview on 7/15/22 at 9:20 A.M.with the FSD, she said all items in the freezer should be dated when opened and no items should have been left open to air. The FSD said the maintenance department was responsible for cleaning the air vents and she was not aware of the maintenance schedule for those. She further said she had been the FSD for approximately 3 months and there had been an ongoing issue with the plumbing in the dish room, three compartment sink area, under the oven and near the tray line. She said that was why there was water, built up dirt and tiles that had fallen off. She said it had been a problem for a few months and the Administrator was aware. During an interview on 7/15/22 at 9:25 A.M.with the Administrator, he said he was waiting for a contractor to fix the plumbing issues in the kitchen. He said it had been at least a few months and he had been having a hard time getting a hold of the contractor. The Administrator further said the maintenance director was on vacation and he was not aware of the maintenance schedule for cleaning the air vents in the kitchen. 2. The facility staff failed to properly label and date food brought in by visitors in the East Unit kitchenette. Review of a facility policy titled Foods Brought by Family/Visitors, revised 2014, included but was not limited to the following: -perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. -Nursing staff is responsible for discarding perishable foods on or before the use by date. On 7/15/22 at 9:52 A.M., during a tour of the East Unit kitchenette, the surveyor and Nurse #1 observed the following concerns in the refrigerator: a) A white styrofoam container of leftovers was labeled with a resident's name but was not dated. b) A plastic lidded container, containing a half eaten hamburger on a bun and a partially eaten bag of cheese flavored crackers, was not labeled or dated. During an interview on 7/15/22 at 9:55 A.M., Nurse #1 said staff should label left over food with the resident's name and date before putting it in the refrigerator. Nurse #1 further said the kitchen staff was responsible for maintaining the refrigerator on a daily basis and should have been throwing away any undated items.

Based on observation, record review and interview, the facility failed to ensure that its staff assessed five Residents (#19, #66, #193, #84 and #11) out of a total sample of 19 residents, for risk of entrapment or considered appropriate alternatives, prior to the use of bed rails. Findings include: Review of the facility Bed Safety policy, dated 2017, indicated bed rails would be used for all residents on admission and have an assessment completed quarterly. 1. Resident #19 was admitted to the facility in April 2022. Review of a Minimum Data Set (MDS) assessment, dated 4/20/22, indicated Resident #19 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15. During an observation and interview on 7/13/22 at 9:56 A.M., the surveyor observed Resident #19 in bed with two quarter (1/4) length bed rails in the upright position. The Resident said he/she used bed rails daily. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the record indicated no assessment for risk of entrapment and no evidence that alternatives had been trialed, prior to the use of bed rails. 2. Resident #66 was admitted to the facility in March 2022. Review of an MDS assessment, dated 3/22/22, indicated Resident #66 was cognitively intact as evidenced by a BIMS score of 13 out of 15. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/22 at 10:03 A.M., the surveyor observed Resident #66 in bed with two quarter bed rails in the upright position. The Resident said he/she always used bed rails when in bed. Review of the record indicated there was no assessment for risk of entrapment and no evidence that alternatives had been trialed, prior to the use of bed rails. 3. Resident #193 was admitted to the facility in July 2022. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 7/13/22 at 9:41 A.M., the surveyor observed Resident #193 in bed with the two quarter side rails in the upright position. The Resident had his/her legs out of the bed (upper torso was still in bed) and was holding on to the left rail for support. The surveyor alerted Nurse #2 that the resident was attempting to self transfer and the nurse assisted the Resident safely back into bed. Review of the record indicated there was no assessment for risk of entrapment and no evidence that alternatives had been trialed, prior to the use of bed rails. 4. Resident #84 was admitted to the facility in June 2022. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/22 at 10:15 A.M., the surveyor observed Resident #84 was fully dressed and lying in bed on top of the bed spread with two quarter bed rails in the upright position. During an interview on 7/13/22 at 10:30 A.M. with Certified Nurse Aide (CNA) #1, CNA #1 said Residents #19, #66, #193, and #84 used two quarter bed rails when in bed. Review of the record indicated there was no assessment for risk of entrapment and no evidence that alternatives had been trialed, prior to the use of bed rails. During an interview on 7/14/22 at 3:05 P.M. with the Director of Nurses (DON), the DON said there was no evidence that Residents #19, #66, #193, and #84 trialed alternatives or were assessed for entrapment prior to implementing the use of bed rails. 5. Resident #11 was admitted to the facility in October 2021. On 7//12/22 at 10:56 A.M. the surveyor observed the Resident in bed with bilateral quarter side rails up. The Resident's eyes were closed. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic health record (EHS) did not indicate an assessment for side rail use to assess for risks of entrapment, nor was there evidence to support any alternatives to side rails had been considered. During an interview on 7/14/22 at 2:05 P.M.with the DON, she said the facility does not do side rail assessments on admission, but does them quarterly per the facility policy. She said Resident #11 used side rails, but had not been assessed as yet. During an interview on 7/14/22 at 2:29 P.M., the Corporate Regional Nurse said the facility's policy needed to be updated to better reflect current regulations.

Based on record review, and interview the facility failed to ensure that its staff coordinated routine dental services to be provided for one Resident (#38) out of 19 sampled residents. Finding include: Resident #38 was admitted to the facility in August 2014. Review of a Minimum Data Set (MDS) assessment, dated, 2/16/22, indicated that Resident #38 had natural teeth. Review of the clinical record indicated that Resident #38's representative had signed a consent, dated 11/5/20, for dental services to be provided to the Resident at the facility. Review of the clinical record indicated that Resident #38 had not been seen by a dental provider. During an interview on 7/15/22, at 9:02 A.M. with Unit Manager (UM) #1, UM #1 said that Resident #38 should have been seen by the dental provider, but he/she had not been seen.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who resided on a secured unit, was severely cognitively impaired with poor safety awareness, and was assesses by nursing as being as at high risk for falls, the Facility failed to maintain Resident #1's safety and ensure his/her environment was free of hazards to prevent incident/accidents resulting in injury. - On 5/04/22 at 11:30 A.M., Resident #1 had an unwitnessed incident/accident in his/her room, when he/she stood on the bottom drawer of an unsecured freestanding wardrobe closet, to get to clothing on the top shelf. The freestanding wardrobe closet tipped over and fell on top of Resident #1, resulting in fractures to his/her right clavicle, a right second rib and sternum (the flat bone that forms the center front of the chest wall). Findings include: Review of the Facility's Policy titled, Assessing Falls and their Causes, dated 2017, indicated that: - Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. - Approximately 50% of residents fall annually and 10% result of these falls result in serious injury. - Falling may be related to environmental risk factors. - Clarify the details of the fall, when the fall occurred what was the resident trying to do at the time of the fall. - Identify causes of a fall, whether any environmental risk factors were involved such as furniture. The Consumer Product Safety Commission, dated 2006, indicated to prevent injury from tall furniture falling on people, anchor tall furniture to the wall or to the floor. Review of Resident #1's Medical Record indicated his/her diagnoses included, dementia with agitation and behaviors, a cerebro-vascular accident (stroke), [CONDITION(S)], generalized muscle weakness, and blurred vision in both eyes. Resident #1's Falls Care Plan, dated 2/20/22, indicated he/she was at risk for falling due to poor safety awareness, poor decision-making skills and was receiving anti-psychotic medications. Interventions included to keep Resident #1's personal items that were frequently used within reach. Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was severely cognitively impaired, was a one-person physical assist for dressing and toilet use, required supervision with eating, and was independent with transfers and ambulation. Resident #1's Nursing Progress Note, dated 5/04/22 at 11:48 A.M., indicated that he/she was found on the floor with a wardrobe closet on top of him/her from the chest down to his/her lower extremities. The Note indicated Housekeeper #1 yelled out for help. Resident #1 complained of chest pain and had an abrasion on his/her forehead, a skin tear to the right side of his/her neck measuring 1 centimeter (cm) by 2 cm, and a red area on the back of his/her head. Resident #1 stated he/she was climbing the wardrobe closet because he/she wanted the underwear that was on the top shelf. Resident #1's Nursing Progress Note, dated 5/04/22 at 2:31 P.M., indicated Nurse #1 was called to Resident #1's room, Housekeeper #1 said that the wardrobe closet fell on top of Resident #1 and that he picked up the closet off Resident #1 and helped him/her to sit on the bed. The Note indicated Resident #1 was assessed and transferred to the Hospital Emergency Department. Review of the Hospital Emergency Department (ED) Physician's Note, dated 5/04/22, indicated Resident #1 presented after a fall (incident) at the Facility, when he/she reached up and tried to get something out of his/her wardrobe closet, lost his/her balance, fell backwards, and the wardrobe closet fell on top of him/her. The ED Note indicated Resident #1 said the wardrobe closet fell on his/her chest, he/she had chest pain and pain along the right clavicle. The ED Note indicate Resident #1 received a Computerized Tomography (CT) scan of his/her head, neck and chest which showed a right medial clavicle fracture, a right second rib fracture, and a sternum fracture. The ED Note indicated Resident #1 was then transferred to a tertiary (third level) Hospital for trauma consultation. Review of the Tertiary Hospital's Physician Note, dated 5/04/22, indicated Resident #1 was admitted to the Trauma Service for further management of his/her injuries, pain management, and then discharged back to the facility on [DATE]. Review of the Facility's Internal Investigation, dated 5/04/22, indicated that on 5/04/22 at 11:30 A.M., staff heard a loud noise coming from Resident #1's room, went his/her room and found Resident #1 on the floor with his/her freestanding wardrobe closet on top of him/her. The wardrobe closet was immediately lifted off him/her, a nurse assessed Resident #1, and 911 was activated. The Investigation indicated that the wardrobe closet had two side by side doors on the top section, with two drawers on the bottom section. The Investigation indicated Resident #1 said he/she pulled out the bottom drawer and climbed into the drawer to reach clothing on the top shelf. The Investigation indicated Resident #1's weight pulled the wardrobe closet forward, causing it to be pulled forward and land on top of him/her. The Facility's Investigation findings indicated that Resident #1 had a freestanding wardrobe closet, and the intervention was to secure all freestanding wardrobe closets to prevent them from tipping over. The Investigation indicated that after the fall (incident) Resident #1's wardrobe closet had brackets applied to secure it to the wall. Review of Housekeepers #1's Written Witness Statement, dated 5/04/22, indicated he was in the hallway and heard a loud noise coming from Resident #1's room and found Resident #1 on the floor with the wardrobe closet on top of him/her. The Statement indicated he (Housekeeper #1) immediately took the closet off him/her and called to the nurse for assistance. During an interview on 5/25/22 at 12:07 P.M., Housekeeper #1 said on 5/04/22 at 11:30 A.M., he was in the hallway just outside of Resident #1's room, when he heard a loud banging noise, followed by Resident #1 yelling, help me, help me in a muffled voice Housekeeper #1 said Resident #1's whole body was pinned under the freestanding wardrobe closet. Housekeeper #1 said he lifted the wardrobe closet off Resident #1, and that Resident #1 said words to the effect, I was looking for underwear on the top shelf of the closet. Housekeeper #1 said that Resident #1's disposable briefs were stored on the top shelf of the wardrobe closet. During an interview on 5/25/22 at 11:40 P.M., the Director of Maintenance said he did not have any safety instructions for use for the freestanding wardrobe closets, or the name of the manufacturer of the wardrobe closets. The Director of Maintenance said the wardrobe closets were prefabricated, were 10 to [AGE] years old, and said they were heavy so he did not think they could topple over. The Director of Maintenance said that in hindsight, the freestanding wardrobe closets should have been secured to the wall. During an interview on 5/25/22 at 9:07 A.M., Unit Manager #1 said all freestanding closets should be secured to the wall for the resident's safety.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy, the Facility failed to ensure Resident #1's Health Care Agent (HCA) was immediately notified of a change in his/her condition, when on 5/04/22 after he/she was found on the floor in his/her room with a (stand-alone) wardrobe closet on top of him/her, was transferred to the Hospital Emergency Department for evaluation, and diagnosed with multiples fractures from the incident, his/her HCA was not notified of the full extent of his/her injuries until 5 days later. Findings include: Review of the Facility Policy titled Change in a Resident's Condition, dated 2018 indicated that the facility shall promptly notify the resident's responsible representative of any changes in the resident's medical condition or status. The Policy indicated that the nurse will notify the resident's responsible party when the resident is involved in any accident that results in injury. Review of Resident #1's Medical Record indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Health Care Proxy Form, dated 2/17/22, indicated his/her Health Care Proxy was activated, secondary to advanced dementia. Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was severely cognitively impaired, and had an invoked Health Care Proxy (HCP). Resident #1's Nursing Progress Note, dated 5/04/22 at 2:31 P.M., indicated Nurse #1 was called to Resident #1's room, Housekeeper #1 said that the wardrobe closet fell on top of Resident #1 and that Housekeeper #1 picked the wardrobe closet up off Resident #1 and helped him/her to sit on the bed. Resident #1 was assessed and transferred to the Hospital Emergency Department. Review of the Facility's Internal Investigation, dated 5/04/22, indicated that on 5/04/22 at 11:30 A.M., staff heard a loud noise coming from Resident #1's room, went his/her room and found Resident #1 on the floor with his/her stand-alone wardrobe closet on top of him/her. The Investigation indicated the (stand-alone) wardrobe closet was immediately lifted off him/her, a Nurse assessed Resident #1 and 911 was activated. Resident #1's Nursing Progress Note, dated 5/05/22, indicated that he/she had returned to the Facility from the Hospital at 6:30 P.M., he/she had sustained a right medial clavicle fracture, a right sternal fracture and a right second rib fracture due to a fall (incident) at the Facility (on 5/04/22). During an interview on 5/25/22 at 12:25 P.M., Resident #1's HCA said she was not aware of the extent of Resident #1's injuries from his/her fall (incident) at the Facility on 5/04/22, until approximately five days later. The HCA said on 5/09/22, the Unit Manager called her regarding Resident #1's appointment with a Thoracic Surgeon for his/her trauma and the multiple fractures. The HCA said that was when she was notified that Resident #1's injuries consisted of multiple fractures, including a right medial clavicle fracture, right sternal fracture and right second rib fractures. Review of Resident #1's Medical Record indicated there was no documentation to support that prior to 5/09/22, that the HCA was informed by the facility of his/her multiple fractures. During an interview on 5/25/22 at 12:50 P.M., the Director of Social Services said HCA's are informed of a residents injuries as soon as the Facility is informed of injuries, and said they facility will relay the information to the HCA. Resident #1's Nursing Progress Note, dated 5/09/22, indicated that the HCA was updated with Resident #1's thoracic appointment on 5/17/22. During an interview on 5/25/22 at 1:30 P.M., Unit Manager #1 said she had called the HCA on 5/09/22 to inform her of Resident #1's Thoracic Surgery appointment. Unit Manager #1 said when she spoke to the HCA about the appointment, said that the HCA was unaware Resident #1 had sustained multiple fractures from the fall (incident) on 5/04/22. Unit Manager #1 said her expectation was that the HCA should have been informed of Resident #1's multiple fractures as soon as the Facility was aware of the injuries on 5/05/22.

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1), who had a change in mental status and increased difficulty with eating, the Facility failed to ensure the Physician was immediately notified when on [DATE] and [DATE], Resident #1 was noted to be lethargic with restlessness, and had a congested cough after food and fluid intake. On [DATE], Resident #1's condition continued to deteriorate and he/she was transferred to the Hospital Emergency Department where he/she was diagnosed with [CONDITION(S)] (a blood infection) due to pneumonia, severe malnutrition, and dehydration. Findings include: The Facility's Policy, Change in Resident's Condition or Status and Notification, dated [DATE], indicated that the physician will be promptly notified of changes in the resident's medical or mental condition. The Nursing Supervisor will be notified of a change in a resident's condition, that may serve as an early warning sign of clinical events, this may include a significant change, deterioration in the resident's physical condition, respiratory difficulties, elevated or a change in vital signs, or a need to transfer. The Nursing Supervisor will then conduct an assessment and notify the Physician promptly. Resident #1 was admitted to the Facility in August of 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) Form, dated [DATE], indicated that his/her code status was Do Not Resuscitate in the event of a cardiac or respiratory arrest, no cardio-pulmonary resuscitation (CPR) for a respiratory arrest, do not insert a endotracheal tube (a breathing tube) or use a ventilator, and if needed may use a non-invasive method of ventilation and transfer to the hospital if it is needed. The Health Care Proxy Activation Form, dated [DATE], indicated Resident #1 did not have the capacity to make or communicate health care decisions due to advanced dementia. Review of Resident #1's Physician Orders, dated [DATE] indicated his/her Health Care Proxy was invoked. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was independent with eating and required set up only, he/she was independent with ambulation and had no behaviors for rejection of care. Review of the MDS indicated there was no documented admission weight for him/her. During an interview on [DATE] at 11:45 A.M., Resident #1's Health Care Agent (HCA) said on Friday, [DATE] at approximately 4:00 P.M., she told one of the Nurses on Resident #1's unit, that he/she was not acting right, he/she was excessively drowsy and not responding to her (HCA). The HCA said this was a change in Resident #1's condition, and said she told the Nurse she wanted to have the Physician evaluate him/her. The HCA said the Nurse told her that a Physician was not available, that it would be on-call Physician covering for the holiday weekend, and since they would not know Resident #1, it would be better to wait until Tuesday ([DATE]). The HCA said she was displeased with this response. The HCA said she spoke to that same Nurse again on [DATE](the next day) and repeated her concerns about Resident #1's condition and wanting Resident #1 to be seen by the Physician. The HCA said the Nurse repeated her disagreement with the HCA, saying that the on-call Physician would not know Resident #1. Review of Resident #1's Medical Record indicated there was no documentation to support that the Physician was notified of the changes in Resident #1, even after multiple requests by the HCA to have him/her seen. Review of Resident #1's Nursing Progress Notes, dated [DATE], indicated there was no documentation to support that Resident #1 was assessed and monitored after the Health Care Agent reported a decline in his/her condition. Review of Nurse #1's Nursing Progress Note, dated [DATE], indicated Resident #1 had episodes of lethargy, restlessness, an occasional congested cough after fluids and food with a weak cough reflex. The Note indicated Resident #1 was taking thickened fluids with assistance, and that he/she had a poor appetite. During an interview on [DATE] at 2:15 P.M., Nurse #1 said she should have called Resident #1's Physician on [DATE] due to his/her change in mental status and respiratory congestion. Review of the Nursing Progress Note, dated [DATE], indicated Resident #1 had episodes of lethargy, restlessness, an occasional congested cough after fluids and food with a weak cough reflex. The Note indicated he/she was taking honey thickened fluids with assistance, and he/she had a fair appetite. Review of Resident #1's Weight and Vital Signs Summary, dated [DATE], [DATE] and [DATE], indicated there was no documentation to support that Resident #1 vital signs were assessed to evaluate a clinical decline in his/her condition. During an interview on [DATE] at 1:30 P.M., the Nurse Practitioner said that, although Resident #1 had advanced dementia, said they (Physician or Nurse Practitioner) were not notified of Resident #1's change in mental status and respiratory congestion after eating, and said that they should have been notified. Review of the Nursing Progress Note, dated [DATE], indicated Resident #1 had upper airway congestion which became progressively worse with an oxygen saturation level (the amount of oxygen in the body, normal is 95% or greater) of 83% (abnormally low) on room air. Resident #1 was using ancillary muscles to breath (an indication of respiratory distress). Vital signs were, a temperature of 98.3 (normal 97.6 to 98.6), heart rate 136 (excessively rapid, normal 50 to 100), respiratory rate of 26 (a fast rate, normal 12 to 20), and a blood pressure of ,d+[DATE] (normal ,d+[DATE]). Review of the Ambulance Run Report, dated [DATE] indicated the following: - [DATE] at 4:43 A.M., Emergency Medical Services (EMS) was dispatched to the Facility for Resident #1 who had a breathing problem, was congested, and had low oxygen saturation levels. - Nurse at the bedside said Resident #1 had difficulty with oral secretions, and low oxygen saturations levels that started on [DATE], during the 3:00 P.M. to 11:00 P.M. shift. - EMS found Resident #1 to be in acute distress, he/she was hypoxic (lack of oxygen), had a fever of 101.1 and was [CONDITION(S)] (heart rate greater than 100, normal 50 to 100). - Resident #1 was treated with oxygen and intravenous fluids and was transferred to the Hospital. The Hospital Physician's Admission history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] .M., indicated that Resident #1 had [CONDITION(S)] due to aspiration pneumonia and acute respiratory failure, severe malnutrition, and dehydration. Resident #1's white blood cell count was 30,000 (a laboratory value for the degree of infection, excessively high, normal is 5,000 to 10,000). The Note indicated he/she was treated with antibiotics, fluid hydration without improvement, the Physician had discussions with the Health Care Agent regarding Resident #1's poor prognosis, he/she was then made comfort care on [DATE], and all interventions were discontinued.

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1), the Facility failed to ensure staff provided care and services that met professional standards of practice, when on 9/04/21 and 9/05/21, Resident #1 who had mental status changes, was lethargic with restlessness, had a congested cough after food and fluid intake, the Physician was not notified at the request of the Health Care Agent, and his/her vital signs were not monitored to identify the early signs of a clinical decline. Findings include: The American Journal of Nursing: Volume 110 - Issue 5 - indicated that vital sign monitoring is a fundamental component of nursing care. Obtaining a resident's pulse, respirations, blood pressure, and body temperature are essential in identifying clinical deterioration and these parameters must be measured consistently and recorded accurately. Abundant research indicates that lapses in monitoring vital signs interferes with appropriate and timely interventions for deteriorating patients. During an interview on 1/21/22 at 11:25 A.M., the Director of Nurses said the Facility did not have a policy for monitoring vital signs. Resident #1 was admitted to the Facility in August of 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Nurse #1's Nursing Progress Note, dated 9/04/21, indicated Resident #1 had episodes of lethargy, restlessness, occasional congested cough after fluids and food intake with a weak cough reflex. The Note indicated Resident #1 was taking thickened fluids with assistance, and that he/she had a poor appetite. Review of the Nursing Progress Note, dated 9/05/21, indicated Resident #1 had episodes of lethargy, restlessness, occasional congested cough after fluids and food intake with a weak cough reflex. The Note indicated Resident #1 was taking honey thickened fluids with assistance, and that he/she had a fair appetite. Review of Resident #1's Weight and Vital Signs Summary, indicated for 9/04/21 and 9/05/21, there was no documentation to support that Resident #1 vital signs were assessed to evaluate for a clinical decline in his/her condition. Review of the Nursing Progress Note, dated 9/06/21, indicated Resident #1 had upper airway congestion which became progressively worse with an oxygen saturation level (the amount of oxygen in the body, normal is 95% or greater) of 83% (abnormally low) on room air. Resident #1 was using ancillary muscles to breath (an indication of respiratory distress). Vital signs were, a temperature of 98.3 (normal 97.6 to 98.6), heart rate 136 (excessively rapid, normal 50 to 100), respiratory rate of 26 (a fast rate, normal 12 to 20), and a blood pressure of 124/79 (normal 120/80). During an interview on 1/21/22 at 2:15 P.M., Nurse #1 said she should have called Resident #1's Physician due to his/her change in mental status and respiratory congestion. Nurse #1 said she did not assess Resident #1's vital signs to monitor for a decline in his/her condition. Nurse #1 said because Resident #1 was having increased difficulty swallowing, she administered thickened liquids to him/her which were not prescribed on his/her diet, instead of the prescribed thin liquids. Nurse #1 said there was no Facility protocol regarding changing the consistency of resident's diets without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Ambulance Run Report, dated 9/06/21 indicated the following: - 9/06/21 at 4:43 A.M., Emergency Medical Services (EMS) was dispatched to the Facility for Resident #1 who had a breathing problem, was congested, and had low oxygen saturation levels. - Nurse at the bedside said Resident #1 had difficulty with oral secretions, and low oxygen saturations levels that started on 9/05/21, during the 3:00 P.M. to 11:00 P.M. shift. - EMS found Resident #1 to be in acute distress, he/she was hypoxic (lack of oxygen), had a fever of 101.1 and was [CONDITION(S)] (heart rate greater than 100, normal 50 to 100). - Resident #1 was treated with oxygen and intravenous fluids and was transferred to the Hospital. The Hospital Physician's Admission history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] .M., indicated that Resident #1 had [CONDITION(S)] due to aspiration pneumonia and acute respiratory failure, severe malnutrition, and dehydration. Resident #1's white blood cell count was 30,000 (a laboratory value for the degree of infection, excessively high, normal is 5,000 to 10,000). The Note indicated he/she was treated with antibiotics, fluid hydration without improvement, the Physician had discussions with the Health Care Agent regarding Resident #1's poor prognosis, he/she was then made comfort care on 9/07/21, and all interventions were discontinued.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose medical history included dysphagia (difficulty swallowing) and required a mechanically altered diet, the Facility failed to ensure Resident #1 nutritional status remained stable during his/her stay in the Facility. Resident #1's initial admission assessment did not include a baseline weight, and based on his/her hospital discharge weight, he/she experienced an unplanned and undesired significant weight loss of 17% of his/her body weight (18.6 lbs) within three weeks of being admitted to the Facility. Findings include: The Facility Policy titled, Weight Assessment and Intervention, dated 2017, indicated the following: - Staff will measure resident's weight on admission, the next day and weekly for two weeks, weights will be measured monthly thereafter. - Weights will be recorded in the resident's medical record. - The Dietician will review and follow individual weight trends over time. - Assessment information shall be analyzed by the multidisciplinary team regarding the resident's current food and fluid intake. - Approximate calorie, protein and other nutrient needs are compared to the resident's current intake. The Facility Policy titled, Resident Hydration and Prevention of Dehydration, dated 2017, indicated the following: - Minimal fluid needs will be calculated and documented on initial, annual, and significant change assessments. - Nursing will assess for signs and symptoms of dehydration during daily care. - Resident intake will be documented in the medical record, Certified Nurse Aides will report fluid intake of less than 1,200 milliliters per day to the nursing staff. - If potential inadequate intake or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated. Resident #1 was admitted to the Facility in August of 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Hospital Emergency Triage Assessment, dated 8/10/21 (before transfer to the Facility), indicated Resident #1 was 5 feet, 5 inches tall and weighed 107.8 pounds (lbs). The Hospital Discharge Summary, dated 8/13/21, indicated Resident #1 had an approximate three-day admission to the Hospital for acute mental status changes with abnormal lactic acidosis (when there is a build up of acid in the bloodstream produced when there are low oxygen levels in the cells) levels, a urinary tract infection, and had been admitted from an assisted living facility. The Summary indicated Resident #1's baseline blood laboratory work completed on 8/10/21, indicated that his/her [MEDICATION(S)] level (a marker that reflects rapid changes in nutritional status) was normal at 4.0 g/dl (grams per deciliter, normal range 2.9 to 4.7), blood urea nitrogen (BUN, an indicator of fluid balance and kidney function) was normal at 11 milligrams per deciliter (mg/dl, normal range 9-16) and creatinine level (an indicator of fluid balance and kidney function) was normal at 0.75 mg/dl, (normal range 0.5- 1.4), and serum sodium (an electrolyte elevated with dehydration) was normal at 140 meq/DL (normal range 135 -145). Review of Resident #1's Nursing Admission Assessment, dated 8/13/21, indicated there was no documentation to support that Resident #1 was weighed upon admission to the Facility. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated an admission weight was not documented. Review of the Facility's Internal Investigation, dated 9/01/21, indicated on 8/31/21 at 12:33 P.M., staff witnessed that Resident #1 had food in his/her mouth, was gasping for air, was unable to speak or cough, and abdominal thrusts (a hands-on maneuver to remove food with the force of the hands to the abdomen) were performed and the food was dislodged. The Investigation indicated predisposing factor was that Resident #1 was chewing a large piece of tough pork that the Kitchen served for lunch. Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Speech Language Pathology Evaluation and Plan, dated 9/01/21, indicated the following: - Resident #1 was evaluated following a choking episode at mealtime on 8/31/21. - Diet was downgraded from a regular diet consistency with thin liquids to a puree diet consistency with thin liquids. - Bedside assessment of his/her swallowing needs recommended that Resident #1 required thin liquids as part of the dysphagia diet treatment. Review of Resident ##1's Admission Nutritional Assessment, dated 9/03/21, indicated that his/her weight had not been documented, and the Dietician was unable to calculate his/her ideal body weight and nutritional needs, the assessment indicated Resident #1's intakes were variable, 0 - 100% (of meal intake), and fluids may not be adequate if he/she eats less than 50% of meals. The Assessment indicated to continue to monitor oral intakes and need for nutrition supplementation. During an interview on 1/21/22 at 12:30 P.M., the Dietician said staff did not obtain four weights for Resident #1 as per their policy. The Dietician said the Facility Policy required a resident to be weighed upon admission to the Facility, weighed again the day after admission, weekly weights for the next two weeks, and required for the minimal assessment of his/her nutritional status and needs. The Dietician said that without adequate monitoring of weights and meal intake for comparisons, weight loss could not be detected during his/her admission, since there was no baseline weight on admission and subsequent weights were not obtained for a timely comparison. Review of Resident #1's Nutritional Care Plan, dated 9/03/21, indicated he/she was at nutritional risk due to dementia, and history of dysphagia, a mechanically altered diet, with the goal of Resident #1's meal intakes should be greater than 75% at most meals. The Care Plan indicated nutritional interventions included to monitor and record his/her weight, notify the Physician and the Dietician of significant weight changes, monitor and record intake at meals, and encourage oral intake of food and fluids and provide snacks as needed. Review of Resident #1's Certified Nurse Aide (CNA) Flow Sheet, dated 9/04/21, for eating breakfast and lunch, indicated there was no documentation for the level of support provided (these two meals were left blank). Review of Resident #1's CNA Flow Sheet, dated 9/05/21, for eating breakfast and lunch, indicated there was no documentation for the level of support provided (these two meals were left blank). - For Resident #1's Meals from 8/29/21 through 9/04/21, 6 out of 21 meals were not documented; for the 15 meals that were documented (with percent intake of meal consumed), approximately 67% (10 meals) were marked 25% intake or lower. Specifically: - approximately 33% (5 meals) were marked at 25% intake, - approximately 13% (2 meals) were marked at 10% intake, - approximately 7% (1 meal) was marked at 5% intake, - approximately 13% (2 meals) were marked at 0% intake. Review of the Facility's Weights and Vital Signs Report, dated 8/13/21 through 9/06/21, indicated, Resident #1's first weight was recorded on 9/02/21 as 89.2 lbs., which represented an unplanned significant weight loss of 17% of his/her body weight (18.6 lbs), during the approximate three weeks he/she was at the Facility. Review of the Hospital Emergency Department Admission Note, dated 9/06/21, on the day of Resident #1's discharge from the Facility, indicated his/her [MEDICATION(S)] level had decreased to 1.3 g/dl, abnormally low (normal range 2.9 to 4.7) and he/she was found to have severe malnutrition and dehydration. However the Hospital Discharge Summary, dated 8/13/21, indicated Resident #1's [MEDICATION(S)] level was within normal limits at 4.0 g/dl upon discharge from the Hospital prior to his/her transfer to the Facility. Review of Resident #1's Medical Record indicated there was no documentation to support that supplements or additional nutritional interventions were ordered or recommended. During an interview on 1/21/22 at 12:30 P.M., the Dietician said she was not informed of Resident #1's decreased meal intake, otherwise she would have recommended a supplement to prevent weight loss and malnutrition. Review of Resident #1's laboratory work and meal intake with the Dietician, indicated Resident #1's Hospital [MEDICATION(S)] level on 9/06/21, of 1.3 g/dl, the Dietician said that is and indicator of malnourishment, the Dietician said if there was adequate monitoring of meal intakes and weights at the Facility, then this downward trend would have been detected and supplements would have been added right away, but were not. Review of Resident #1's baseline laboratory work at the Facility, indicated the following: - On 8/23/21, blood urea nitrogen of 16 mg/d (normal 9-16), creatinine 0.58 mg/dl (normal 0.5- 1.4), and serum sodium 142 MEQ/L (normal 135- 145). - On 8/31/21, blood urea nitrogen of 38 mg/dl (elevated), creatinine 0.72 mg/dl (still within normal limits, however was increased) and serum sodium 143 MEQ/L. Review of the Nursing Progress Note, dated 9/06/21, indicated Resident #1 had upper airway congestion which became progressively worse, (a change from three days ago) with an oxygen saturation level of 83% (abnormally low, normal 90-95%) on room air. Resident #1 was using ancillary muscles to breath (a indication of respiratory distress). Vital signs were, a temperature of 98.3 (normal 97.6 to 98.6), heart rate 136 (excessively rapid, normal 50 to 100), respiratory rate of 26 (a fast rate, normal 12 to 20), and a blood pressure of 124/79 (normal 120/80). The Physician's Hospital Admission history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] .M., indicated that Resident #1 had [CONDITION(S)] due to aspiration pneumonia and acute respiratory failure, severe malnutrition, and dehydration. Review of Resident #1's Hospital blood laboratory work, obtained on 9/06/21, indicated the following: - blood urea nitrogen of 45 mg/dl, (BUN, an indicator of fluid balance and kidney function, normal range 9-16) - serum sodium 156 MEQ/L (an electrolyte elevated with dehydration, normal range 135 -145 MEQ/L) Both of these blood laboratory values are indicators for dehydration. During an interview on 1/18/22 at 11:45 A.M., the Health Care Agent said on 9/06/21, she was told by the Hospital Physician that Resident #1 arrived in poor health, and that he/she was severely malnourished with a low weight. During an interview on 1/21/22 at 12:30 P.M., the Dietician said that she would usually determine and document Resident #1's minimal fluid requirements, although there was no documented height and weight to make this fluid intake determination. The Dietician said she estimated minimal fluid intake for Resident #1 would be 1,500 milliliters per day, and when his/her meal intake trends towards below 50%, intake and output monitoring would be ordered for a more accurate determination of his/her fluid needs, which was not performed. The Dietician said from 8/30/21 to 9/05/21 Resident #1's intake had declined, and she was not notified of the decline in his/her meal intake and there were no documented interventions to address his/her sub-optimal intake.

Based on records reviewed and interviews, for one of three sampled Residents, (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when there were numerous data entry omissions for his/her weights and on Certified Nurse Aide flow sheets for the percentage of his/her meal intake, which were left blank. Findings include: The Facility Policy titled, Weight Assessment and Intervention, dated 2017, indicated the following: - Staff will measure resident's weight on admission, the next day and weekly for two weeks, weights will be measured monthly thereafter. - Weights will be recorded in the resident's medical record. - Assessment information shall be analyzed by the multidisciplinary team regarding the resident's current food and fluid intake. Resident #1 was admitted to the Facility in August of 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A. Review of Resident #1's Certified Nurse Aide (CNA) meal intake (percent consumed) flow sheets, for the four weeks dated 8/15/21 through 9/11/21, indicated that: - Meals 8/15/21 through 8/21/21, approximately 81% of the meals were not documented, for 17 meals out of 21 meals, the flow sheet was left blank. - Meals 8/22/21 through 8/28/21, approximately 90% of the meals were not documented, for 19 meals out of 21 meals, the flow sheet was left blank. - Meals 8/29/21 through 9/04/21, approximately 28% of the meals were not documented, for 6 meals out of 21 meals, the flow sheet was left blank. - Meals 9/05/21 through 9/11/21, approximately 67% of the meals were not documented, for 2 meals out of 3 meals (for one day, discharged to the hospital 9/06/21), the flow sheet was left blank. - Meals 8/29/21 through 9/04/21, 6 out of 21 meals were not documented, for the 15 meals that were documented (with percent intake of meal consumed), approximately 67% (10 meals) were marked 25% intake or lower. Specifically: - approximately 33% (5 meals) were marked at 25% intake, - approximately 13% (2 meals) were marked at 10% intake, - approximately 7% (1 meal) was marked at 5% intake, - approximately 13% (2 meals) were marked at 0% intake. Review of Resident #1's CNA Flow Sheet, dated 9/04/21, for eating breakfast and lunch, indicated there was no documentation for the level of support provided (these two meals were left blank). Review of Resident #1's CNA Flow Sheet, dated 9/05/21, for eating breakfast and lunch, indicated there was no documentation for the level of support provided (these two meals were left blank). B. Review of the Nursing Admission Assessment, for the admission of 08/13/21, indicated there was no documentation to support that Resident #1 was weighed on admission to the Facility. During an interview on 1/21/22 at 12:30 P.M., the Dietician said staff did not obtain four weights for Resident #1 as per the Facility Policy, which requires a weight upon admission to the Facility, a weight the day after admission, then weekly weights for the next two weeks, which were required for the minimal assessment of his/her nutritional status and needs. Review of the Facility's Weights and Vital Signs Report, dated 8/13/21 through 9/06/21, indicated, the first weight was recorded for Resident #1 on 9/02/21, approximately three weeks after he/she was admitted , there was no documentation to support the Facility obtained weights or monitored changes in weights, and according to their policy. During an interview on 1/21/22 at 12:40 P.M., Nurse #2 said that the meal percent intake for Resident #1's was incomplete and inaccurate. During an interview on 1/21/22 at 12:30 P.M., the Dietitian said the weight monitoring and documentation was not performed to accurately detect weight loss and dehydration.

Based on document reviews, observations and interviews, the facility failed to follow their policies, as required, and failed to implement proper infection control practices. Specifically, the facility failed to; (A.) ensure staff use appropriate Protective Personal Equipment (PPE) while providing high contact care to residents on two of three units, and (B.) properly screen visitors for COVID-19 symptoms prior to entering the facility. Findings include: A. Review of the facility policy, Providing Care to Residents in Long-Term Care Policy, updated 10/4/21, indicated that when residents or staff cases are identified as being positive for COVID-19 within the last 14 days on the unit, full PPE to include facemask, face shield/goggles, gown and gloves were to be worn. Gowns and gloves must be changed between residents. Gown use can be prioritized for high-contact resident care activities. High-contact resident care activities include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care: any skin opening requiring a dressing. During an interview on 10/28/21 at 8:00 A.M., Nurse #2 said the facility currently had three residents and four staff members that were positive for COVID-19 infection. She said the latest staff member that tested positive for COVID-19 was on 10/28/21 and the latest resident that tested positive was on 10/21/21. She further said all staff were required to wear a facemask and eye protection throughout the facility. 1. During an observation of the East Unit on 10/28/21 at 10:00 A.M. with Nurse #2, Certified Nursing Aide (CNA) #1 was observed in the hallway. She was not wearing any eye protection. During an interview at 10:02 A.M., CNA #1 said she was from a staffing agency and there were no goggles available in the facility. Nurse #2 handed CNA #1 a faceshield that was in a PPE compartment located in the hallway. Nurse #2 said faceshields were readily available throughout the facility. 2. During an observation on the East Unit with Nurse #2 at 10:10 A.M., a resident was observed with his/her upper body resting in bed with his/her legs swung over the bed. Nurse #2 entered the resident's room and repositioned the resident by picking up the resident's legs and placing them in the bed and readjusted the bed linen. She did not don a gown or wear gloves when providing the high-contact resident care. During an interview at 10:12 A.M., Nurse #2 said she did not wear the gown and gloves when she provided the high-contact care to the resident, as required. 3. During an observation on the South Unit on 10/28/21 at 10:15 A.M. with Nurse #2, a Wound Consultant was standing outside a resident room and was not wearing eye protection. During an interview at 10:10:16 A.M., the Wound Consultant said he was not aware he needed to wear eye protection. 4. During an observation on the South Unit at 10:20 A.M. with Nurse #2, CNA #2 was observed in a resident room and was providing personal care. Her goggles were on top of her forehead and she was not wearing a gown or gloves. Nurse #2 approached CNA #2 and instructed her to wear a gown and gloves. Nurse #2 lowered CNA #2 goggles so that they were covering her eyes. Nurse #2 did not properly clean the goggles before lowering them onto the CNA's face. During an interview at 10:22 A.M., Nurse #2 said CNA #2 did not wear the required PPE when she was providing high contact care to the resident. 5. During an observation on the South Unit at 10:25 A.M. CNA #3 and CNA #4 completed a transfer of a resident from the bed to a shower chair via a sit to stand lift (an assistive device that allows residents to be transferred between a bed and a chair using electrical or hydraulic power). Both CNAs were not wearing gowns. CNA #4 then removed her gloves and took the lift and brought it to the adjacent unit. She did not sanitize her hands when she removed her gloves and did not sanitize the lift prior to removing it from the resident room. During an interview at 10:28 A.M., CNA #3 and CNA #4 said they did not wear gowns for the transfer, as required. CNA #4 said she did not sanitize her hands after she removed her gloves and did not sanitize the lift prior to bringing it to another unit, as required. 6. During an observation on the East Unit at 11:14 A.M., CNA #5 and CNA #6 had completed personal care in a resident room and were not wearing gowns. During an interview upon them exiting the resident room, both said they were not aware gowns were needed to be worn when providing personal care. They further said they were told by the charge nurses that only gloves were needed when providing care to residents . During an interview with Nurse #2 at 11:16 A.M., she said CNA #5 and CNA #6 should have worn gowns when providing personal care, as required. 7. During an observation on South Unit on 10/28/21 at 3:20 P.M., a Housekeeper was standing in the unit Activity/Dining Room and was observing three residents that were seated in the room. She was wearing a facemask and had a pair of goggles hanging on her shirt. She was not wearing any eye protection. During an interview at 3:22 P.M., the Housekeeper said she did not have the goggles on her face, as required. B. Review of the facility policy, Screening of All Individuals Policy, updated 10/4/21, indicated long-term care facilities should be screening all individuals entering the facility, including healthcare personnel and visitors, for symptoms. 1. Upon entering the facility on 10/28/21 at 7:10 A.M., the surveyor was greeted by a staff member who was exiting the facility and indicated for the surveyor to enter a nursing unit. There was no staff member present at the entrance to screen the surveyor. During an interview on 10/28/21 at 7:40 A.M., Nurse #1 said the screener was not present at the entrance to the facility when the surveyor entered the facility, as required. 2. During a tour of the South Unit on 10/28/21 at 10:15 A.M., a visiting Wound Consultant was observed exiting a resident room. During a review of the [NAME] COVID-19 Employees/Vendor/Permitted Visitor Symptoms Check Line Listing log sheet, dated 10/28/21, indicated the Wound Consultant's name was not documented on the log sheet and had not been screened for signs and symptoms of Covid-19. During an interview on 10/28/21 at 12:15 P.M., Nurse #2 said the Wound Consultant was not listed on the [NAME] COVID-19 Employees/Vendor/Permitted Visitor Symptoms Check Line Listing line log sheet, dated 10/28/21, which indicated he was not screened, as required.

Based on policy review, record review and interview, the facility failed to maintain a complete and accurately documented clinical record for six Residents (#2, #125, #58, #32, #22 and #47) in a total sample of six residents reviewed as part of the infection control survey for COVID-19. Findings include: Review of the facility policy titled COVID-19, Providing Care to Residents in Long Term Care, updated 6/18/21, indicated that residents should be asked about COVID-19 symptoms and must have their temperatures checked a minimum of one time per day. 1. Resident #2 was admitted to the facility in October of 2018. Review of the Weights and Vitals Summary in the electronic health record (EHR) indicated the Resident did not have his/her temperature taken from 7/2/21 to 7/7/21 or from 7/9/21 to 7/26/21. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #125 was admitted to the facility in September of 2020. Review of the Weights and Vitals Summary in the EHR indicated that from 7/1/21 through 7/26/21 the Resident did not have his/her temperature taken. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #58 was admitted to the facility in April of 2020. Review of the Weights and Vitals Summary in the EHR indicated that the Resident did not have his/her temperature taken on 8 dates: 7/5/21, 7/6/21, 7/16/21, 7/17/21, 7/19/21, 7/20/21, 7/22/21 or 7/24/21. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident #32 was admitted to the facility in September of 2020. Review of the Weights and Vitals Summary in the EHR indicated the Resident did not have his/her temperature taken at any time in July of 2021. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Resident #22 was admitted to the facility in February of 2014. Review of the Weights and Vitals Summary in the EHR indicated the Resident did not have his/her temperature taken from 6/30/21 to 7/26/21. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Resident #47 was admitted to the facility in January of 2018. Review of the Weights and Vitals Summary in the EHR indicated the Resident did not have his/her temperature taken from 6/30/21 to 7/26/21. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/27/21 at 4:33 P.M., the Director of Nurses and the Clinical Care Coordinator said the temperature readings omitted from the Weights and Vital Summary in the EHR were not done. During an interview on 7/28/21 at 12:11 P.M., Unit Manager #1 said the temperatures were not taken for the residents on the days they were omitted from the EHR and said the nurses should not have signed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Refer to F880

Based on interview and record review, for three of four sampled residents (Residents #1, #2 and #4), the Facility failed to ensure care plan interventions, for managing behavioral symptoms, were implemented. -For Resident #1, on 1/30/14 and 6/7/14, a care plan which identified and addressed Resident #1's vulnerability to aggression by other residents, was not implemented, and Resident #1 was kicked and pushed. -For Resident #4, on 1/30/14, a care plan which identified and addressed Resident #4's potential for unprovoked aggression toward residents was not implemented, and Resident #4 kicked Resident #1. -For Resident #2, on 6/7/14, a care plan which identified and addressed Resident #2's potential for aggression toward residents was not implemented, and Resident #2 pushed Resident #1 into a chair. Resident #1 sustained a fractured left hip as a result. Finding include: 1. Resident #1's Quarterly Minimum Data Set (MDS) Assessment Form, completed 4/25/14, indicated that his/her short and long term memory skills were impaired and Resident #1 exhibited behavioral symptoms, which included occasional physical and verbal abuse and daily socially inappropriate behavior. The MDS indicated Resident #1 required supervision when ambulating. Resident #1's care plan concern, initiated 8/10/12 and most recently reviewed 5/7/14, indicated that Resident #1's behavioral symptoms included verbal abuse, wandering, restlessness and intrusiveness. The care plan indicated Resident #1's behavioral symptoms put him/her at risk for being the victim of other residents' aggression, and documented previous incidents of negative interactions with other residents. The Facility Internal Investigation Reports for these prior incidents, dated 2/26/13 and 3/24/13, indicated that Resident #1 was grabbed and slapped by other residents. The care plan interventions included monitoring Resident #1's whereabouts, avoiding crowding, avoiding loud, aggressive residents, and removing Resident #1 from other residents' rooms and/or unsafe situations The Facility Internal Investigation report, dated 1/31/14, indicated that on 1/30/14, Resident #4 kicked Resident #1 while in the day room. The Surveyor interviewed CNA #2 at 1:45 P.M. on 7/24/14 and CNA #3 at 1:10 P.M. on 7/24/14. CNA #2 and CNA #3 said that on 1/30/14, they fed residents lunch in the day room. CNA #2 and CNA #3 said Resident #1 was standing and wandering in the area of the wide entrance way into the day room in a manner that was typical of him/her. CNA #2 and CNA #3 said Resident #1 wandered without purpose, was always in other residents way, was intrusive and was unaware when he/she invaded other residents' personal space. CNA #2 and CNA #3 said Resident #1's behavioral symptoms often provoked other residents who did not understand his/her confusion, and staff members supervised him/her and distracted him/her away from residents who were bothered by his/her behavior. CNA #2 said she was assigned to be Resident #4's one-to-one close supervisor during the 7:00 A.M. to 3:00 P.M. shift on 1/30/14, following his/her return from a hospitalization after an episode of unprovoked aggression toward a resident. CNA #2 said she fed another resident in the day room while Resident #4 ate. CNA #2 and CNA #3 said Resident #4 jumped up without warning, and moved to exit the day room through the wide entrance way where Resident #1 stood. CNA #2 said, although she moved quickly to follow Resident #4, Resident #4 reached Resident #1 before CNA #2 could get between them. CNA #3 said Resident #4 kicked Resident #1 in the back of his/her leg, three times quickly. CNA #2 said she escorted Resident #4 away from the day room, and he/she said Resident #1 was in his/her way. 2. Resident #2's Quarterly MDS Assessment Form, completed 5/16/14, indicated that his/her short and long term memory skills were impaired and his/her decision making skills were severely impaired. The MDS indicated that Resident #2 wandered and required supervision when he/she ambulated. Resident #2's care plan concern, initiated 4/22/14 and most recently updated 5/27/14, indicated Resident #2 posed a risk to his/herself and other residents because of hitting, wandering, and paranoia. Resident #2's care plan interventions included assessing whether Resident #2's behavior endangered others, staff were to intervene as necessary; avoid noise, crowding, and aggressive residents. The Facility Internal Investigation Report indicated around 6:00 P.M. on 6/7/14, Resident #2 pushed Resident #1 into a chair. The Surveyor interviewed CNA #4 at 3:30 P.M. on 7/24/14. CNA #4 said that, around 6:00 P.M. on 6/7/14, he supervised 6 or 7 residents in the day room. CNA #4 said Resident #2 sat in a chair and Resident #1 stood nearby. CNA #4 said Resident #1 needed to be redirected away from other residents often because he/she intruded on other residents' space, including tapping or touching them to get their attention. CNA #4 said that, on 6/7/14, he redirected Resident #1 away from Resident #2 a couple of times, but because Resident #1 walked independently, he/she continued to get up and approach Resident #2. CNA #4 said that, at one point, he exited the day room and walked about ten feet away to a wall mounted computer across the hall from the day room. CNA #4 said that, while he was at the computer, Resident #1 approached Resident #2 and Resident #2 pushed Resident #1. CNA #2 said that Resident #1 landed in a chair and he called for help. 3. Resident #4's Quarterly MDS Assessment Form, completed 1/24/14, indicated that his/her cognitive patterns were moderately impaired. The MDS indicated Resident #4 required supervision when ambulating. A Facility Internal Investigation Report, dated 1/10/14, indicated that around 7:00 A.M. on 1/8/14, Resident #4 placed his/her hands around another resident's neck and shook the other resident's head back and forth. The Report indicated Resident #4 told the other resident that he/she was sick of him/her. The Report indicated Resident #4 was hospitalized , and placed on one-to-one close supervision when he/she returned to the Facility. Resident #4's a care plan concern, initiated 1/15/14, indicated he/she exhibited episodes of physical abuse (aggression) toward other residents, and the care plan interventions included distance in seating from other residents, providing one-on-one close observation, and seating Resident #4 where constant or near constant, observation was possible.

Based on interview and record review, the Facility failed to prevent Resident #2 from pushing Resident #1 into a chair, on 6/7/14, and Resident #1 sustained a fractured left hip. Resident #2's plan of care indicated he/she posed a risk to others due to hitting, wandering, and paranoia. Resident #1's plan of care indicated Resident #1's behaviors put him/her at risk for being the victim of other residents' aggression, and documented previous incidents of negative interactions by other residents. On 6/7/14, CNA #4 was assigned to supervise 6 to 7 residents the day room, including Resident #1 and Resident #2. CNA #4 said he exited the day room to use a computer across the hall, and while out of the room, Resident #2 pushed Resident #1, who landed in a chair, and when evaluated was determined to have sustained a fractured left hip. Findings include: Resident #1's Quarterly Minimum Data Set (MDS) Assessment Form, completed 4/25/14, indicated that his/her short and long term memory skills were impaired and his/her decision making skills were severely impaired. The MDS indicated Resident #1 exhibited indictors of delirium which included inattention and disorganized thinking and behavioral symptoms which included occasional physical and verbal abuse and daily socially inappropriate behavior. The MDS indicated Resident #1 required supervision when ambulating. Resident #1's care plan concern, initiated 8/10/12 and most recently reviewed 5/7/14, indicated that Resident #1's behavioral symptoms included verbal abuse, wandering, restlessness and intrusiveness. The care plan indicated Resident #1's behaviors put him/her at risk for being the victim of other residents' aggression and documented previous incidents of negative interactions by other residents. The Facility Internal Investigation Reports of these previous incidents, dated 2/26/13, 3/24/13 and 1/30/14 indicated that Resident #1 was grabbed, slapped and kicked by other residents. The care plan interventions included monitoring Resident #1's whereabouts, avoiding crowding, avoiding loud aggressive residents, and removing Resident #1 from other residents' rooms and/or unsafe situations Resident #2's Quarterly MDS Assessment Form, completed 5/16/14, indicated that his/her short and long term memory skills were impaired and his/her decision making skills were severely impaired. The MDS indicated that Resident #2 wandered and required supervision when he/she ambulated. Resident #2's care plan concern, initiated 4/22/14 and most recently updated 5/27/14, indicated Resident #2 posed a risk to his/herself and other residents because of hitting, wandering and paranoia. Resident #2's care plan interventions included assessing whether Resident #2's behavior endangers others, intervene as necessary and avoid noise, crowding and aggressive residents. The Facility Internal Investigation Report indicated that, around 6:00 P.M. on 6/7/14, Resident #2 pushed Resident #1 and Resident #1 fell into a chair and sustained a fractured hip. The Surveyor interviewed CNA #4 at 3:30 P.M. on 7/24/14. CNA #4 said that, around 6:00 P.M. on 6/7/14, he supervised 6 or 7 residents in the day room. CNA #4 said Resident #2 sat in a chair and Resident #1 stood nearby. CNA #4 said Resident #1 needed to be redirected away from other residents often because he/she intruded on other residents' space, including tapping or touching them to get their attention. CNA #4 said that, on 6/7/14, he redirected Resident #1 away from Resident #2 a couple of times, but because Resident #1 walked independently, he/she continued to get up and approach Resident #2. CNA #4 said that, at one point, he exited the day room and walked about ten feet away to a wall mounted computer across the hall from the day room. CNA #4 said that, while he was at the computer, Resident #1 approached Resident #2 and Resident #2 pushed Resident #1. CNA #4 said that Resident #1 landed in a chair and CNA #4 called for help. The Facility Internal Investigation Report indicated that Resident #1 was assessed, complained of pain, was sent to the hospital and was diagnosed with [REDACTED].

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed develop a comprehensive care plan for Resident #1, who was at risk of dehydration, ensure Resident #1 received adequate fluids to prevent dehydration, and failed to follow the Facility Hydration policy, when Resident #1's fluid intake was less than 1500 cubic centimeters (cc) for over three days and the Physician was not notified. On 9/14/12 Resident #1 was hospitalized with dehydration. Findings include: The Resident Admission Record indicated Resident #1 was admitted to the Facility in August, 2012 with [DIAGNOSES REDACTED]. The Facility Hydration Policy indicated licensed nurses assess the hydration status of residents on admission, quarterly and with a change in condition. The policy indicated new admissions are placed on intake and output monitoring for the first 72 hours and if intake is inadequate, the monitoring is continued until it is no longer a concern. The policy indicated that an intake of less than 1500 cc, consistently for 3 days will be reported to the physician. The Dehydration Risk assessment, dated 8/1/12, indicated Resident #1 was at risk for dehydration. The Admission Interim Care Plan, dated 8/1/12, indicated care planning was done to address Resident #1's risk for dehydration secondary to refusal of intake. The care plan intervention was to monitor intake and output. The Intake and Output record for Resident #1, dated 8/1/12 to 8/6/12, indicated Resident #1's daily fluid intake ranged from 360 cubic centimeters (cc) to 1020 cc's. Nurse's Notes, dated 8/1/12 to 8/6/12, did not indicate the Physician was notified of Resident #1's decreased fluid intake per the Facility policy. The Social Worker Progress note, dated 8/6/12, indicated Resident #1 was hospitalized following a resident to resident altercation. The Progress note indicated Resident #1's family agreed to a 10 day bed hold. The Dehydration Risk assessment, dated 8/16/12, when Resident #1 returned to the Facility indicated Resident #1 was at risk for dehydration. There was no comprehensive care plan found relative to a risk for dehydration. The physician progress notes [REDACTED]. The progress note indicated Resident #1 exhibited an elevated BUN (blood urea nitrogen) level and creatinine level (indicators of kidney disease and dehydration). The progress note indicated Resident #1 had chronic renal (kidney) disease and laboratory blood tests would be monitored. Laboratory blood test results, dated 8/16/12, indicated Resident #1's BUN level was elevated at 39 (normal range 5-25) and the Creatinine level was elevated at 1.55 (normal range 0.5 -1.1). The Nutritional Assessment, dated 8/17/12, indicated Resident #1's daily fluid requirements were 1350 cc's to 1980 cc's. The Cognitive Pattern assessment, dated 8/22/12, indicated Resident #1 had difficulty with short and long term memory and was severely impaired for decision making. The Nutritional Progress note, dated 8/24/12, indicated Resident #1's meal intake varied from 50% to 100%. The admission Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #1 was severely impaired for decision making and exhibited physically and verbally abusive behaviors. Care plans, dated 8/28/12, were developed to address Resident #1's incontinence, risk for skin breakdown and self care deficit, based on MDS results. There was no comprehensive care plan which addressed Resident #1's risk for dehydration as assessed on 8/16/12. The Care Plan Conference Sheet, dated 9/5/12, indicated Resident #1 exhibited resistiveness to care and abusive behaviors toward staff. The conference sheet indicated Resident #1's intake was frequently low. Fluid intake records, dated from 9/9/12 to 9/13/12, indicated the following fluid intake for Resident #1: -9/9/12: 240 cubic centimeters (cc) -9/10/12: 440 cc -9/11/12: 600 cc -9/12/12: 420 cc -9/13/12: 480 cc There was no documentation to indicate the Physician was notified of Resident #1's continued poor fluid intake. The Hospital Discharge Summary, dated 9/21/12, indicated Resident #1 was admitted to the hospital on [DATE], and diagnosed with [REDACTED]. The Surveyor interviewed Nurse Practitioner (NP) #1, on 2/5/13 at 4:00 P.M. NP #1 said Resident #1 did not eat or drink well and was known to refuse to eat or drink. NP #1 said staff did not notify her that Resident #1's intake was poor. The Surveyor interviewed the Dietician on 3/5/13 at 10:15 A.M. The Dietician said that it was the responsibility of the nursing staff to develop the comprehensive care plan relative to risk of dehydration. The Dietician said she did not recall if she was notified that Resident #1's fluid intake was less than 1500 cc for more than 3 days. The Surveyor interviewed Family Member #1 on 1/31/13 at 12:00 P.M. Family Member #1 said on the day Resident #1 left the Facility, he/she exhibited drooping lips and an inability to swallow. Family Member #1 said Resident #1 was lethargic. Family Member #1 said Resident #1 was transferred to the Hospital shortly after arriving at another facility. The Surveyor interviewed the Assistant Director of Nursing (ADON) on 1/30/13 at 3:35 P.M.and again on 3/5/13 at 9:40 A.M. The ADON said when a resident is assessed for a risk of dehydration on admission, an interim care plan is developed. The ADON said the Dietician determines a resident's fluid requirements. The ADON said nursing staff on the 3:00 P.M. to 11:00 P.M. shift is responsible for totaling resident intake and output, and Unit Managers are responsible to check the intake and output totals and assess for any further action. The ADON said the Facility Dietician is only at the Facility two days per week so the responsibility for monitoring hydration status is the responsibility of nursing. The ADON said that if a resident is assessed at risk for dehydration a care plan is developed by nursing. The ADON said the Dietician evaluates a residents hydration and nutritional status and will address it if there is a problem. The Surveyor interviewed the Director of Nursing (DON), on 1/30/13 at 8:00 A.M. The DON said Resident #1 had a history of [REDACTED]. The DON was not employed at the Facility at the time of the incident. The Surveyor interviewed the Social Worker, on 1/30/13 at 2:10 P.M. The Social Worker said on the day of discharge, Resident #1 was alert and he/she was fine. The Surveyor interviewed Certified Nurse Aide (CNA) #1, on 1/30/13 at 2:30 P.M. CNA #1 said Resident #1 required assistance to eat his/her meals. CNA #1 said Resident #1 ate and drank poorly.

Based on record review, observation, and interview, the facility failed to follow the plan of care for 3 sampled residents (#1, #3, and #13), out of a total sample of 20 residents. Findings include: 1. For Resident #3, the facility failed to follow the Physician's recommendations regarding the treatment to the left and right heel ulcers which impeded the healing process of both heels and caused a decline to the left heel ulcer. Resident #3 was admitted to the facility in 4/12, discharged to the hospital, then readmitted to the facility in 5/12. Pertinent [DIAGNOSES REDACTED]. Review of the May 2012 Treatment Records indicated that the Resident had a treatment for [REDACTED]. During interview with Unit Manager (UM) #1 on 8/15/12 at 11:30 A.M., she stated this order ended on 5/30/12 without being re-evaluated and the resident's heels remained slightly red. Review of a nursing note of 6/24/12 indicated that the Resident was complaining of sore heels. The resident had gone 23 days without receiving the skin prep to his/her heels, a total of 46 applications as the order was for twice daily. The nurse assessed the Resident's heels which were found to be red and tender to touch. A new order was obtained for Skin Prep to the right and left heel twice daily and Heelbos (heel protectors) to bilateral heels while in bed. Review of the 7/12 Treatment Record indicated the Skin Prep order to the Right and Left Heels twice daily x (times) 30 days (completed by 7/27/12). Review of the evaluation by the Wound Physician completed on 7/9/12 indicated to continue the Skin Prep to bilateral heels twice daily and a Sponge cradle boot/left heel while in bed to off-load wound. During interview on 8/15/12 at 8:40 A.M., UM #1 stated that she never saw any of the consults/wound evaluations completed by the Wound Physician, therefore, the Sponge cradle boot was not applied to off-load pressure to the heel as recommended. The Wound Physician evaluated Resident #3's heels on 7/23/12. Recommendations included to continue with the Skin Prep twice daily and that he would follow-up within 7 days. Review of the July 2012 TAR (Treatment Administration Record) indicated that the Skin Prep to both the left and right heels was discontinued on 7/28/12; despite the Wound Physician's recommendations to continue with the Skin Prep twice daily. During interview on 8/15/12 at 11:30 A.M., UM #1 stated that the Skin Prep was discontinued in error. Review of the evaluation by the Wound Physician on 7/30/12 (2 days after the discontinuation of the Skin Prep to bilateral heels), indicated recommendations to apply Skin Prep twice daily to both heels. During interview on 8/15/12 at 11:30 A.M., UM #1 stated the Skin Prep had been discontinued in error, and Resident #3 should have continued to receive it to his/her bilateral heels. The consult indicated the wound care Physician would follow-up within 7 days. Review of the evaluation by the Wound Physician on 8/6/12, (9 days without the Skin Prep to bilateral heels) indicated recommendations to continue to apply Skin Prep twice daily to both heels, and to change the off-loading device to a Heel Cradle. The consult indicated the wound care Physician would follow-up within 7 days. During interview on 8/15/12 at 10:00 A.M., UM #1 stated the resident had never had a heel cradle on the bed as recommended by the Wound Physician on 8/6/12, and she never saw the recommendation for it. UM #1 also said that the Wound Physician was in on 8/13/12 but had not seen Resident #3, therefore the Wound Physician did not follow up in 7 days as planned. On 8/14/12 at 9:00 A.M., the surveyor reviewed Resident #3's August, 2012 TAR which included: - Heelbos while in bed to bilateral feet - Off load heels every shift The surveyor observed the Resident lying in bed on 8/14/12 at 10:20 A.M., with both heels pressing into the mattress. Heelbos were not on the resident while in bed and pressure by off-loading heels was not provided as planned. On 8/15/12 between 7:00 A.M. and 7:15 A.M., the Surveyor observed Resident #3 lying in the bed on his/her back. The Resident's heels were directly on the bed. Heelbos were not on the resident while in bed and pressure relief by off-loading heels was not provided as planned. On 8/15/12 at 8:20 A.M., the Surveyor observed Resident #3 lying on his/her back in the bed. The right heel was directly on the bed. The left calf had a pillow under it and the left heel was elevated off of the bed. However, Heelbos were not on the resident while in bed as planned. During discussion with the Acting DON on 8/15/12 at 3:20 P.M. she said that the care plan was not followed for Resident #3 as per the Wound Physician's evaluation reports. Please refer to F314. 2. For Resident #1, the facility failed to follow the plan of care for Geri-Legs. Resident #1 was admitted to the Facility in 3/09 with [DIAGNOSES REDACTED]. Nurse's Notes of 1/7/12 indicated that Resident #1 was noted to have sustained a skin tear to the right lower leg. Physician's Interim Orders of 1/9/12 included: Geri-Legs at all times, off for care and re-apply. physician's orders [REDACTED]. On 8/13/12 from 11:00 A.M. to 12:00 P.M., Resident #1 was observed sitting in a recliner chair in the day room. Resident #1 was wearing shorts and ankle socks and not wearing Geri-Legs as planned. On 8/13/12 at 2:45 P.M., Resident #1 was observed lying in bed on left side. Resident #1 was not wearing Geri-Legs. On 8/14/12 from 8:30 A.M. to 9:15 A.M., Resident #1 was observed sitting in a recliner chair in the day room. Resident #1 was wearing long pants and ankle socks. Resident #1 was not wearing Geri-Legs as planned. On 8/14/12 at 9:15 A.M., Unit Manager #3 said there was a physician's orders [REDACTED]. 3. For Resident #13, the facility failed to ensure that the plan of care was followed related to the application of heel booties and keeping the Resident's nails trimmed. Resident #13 was admitted to the facility in 4/11. The Resident's [DIAGNOSES REDACTED]. a. The 10/11/11 (and 1/3/12) Quarterly MDS Assessments indicated that the Resident did not ambulate, received extensive assistance from staff for ADLs, had functional limitation in range of motion to one lower extremity, was at risk for pressure ulcers, and did not have pressure ulcers. The 10/13/11 nursing note indicated that the Resident's right lateral foot was reddened. The Physician was notified and an order was written for skin prep to be provided to the area for 15 days, and to apply heel booties when in bed. The 6/20/12 Quarterly MDS Assessment was essentially unchanged. Record review (on 8/15/12 at 9:10 A.M.) indicated the following entry on the 8/12 TAR (Treatment Administration Record): - Heel Booties while in bed. The initials FYI (For Your Information) were handwritten in the section where the hour/shift would have been documented. There were no initials in the dated columns to indicate that heel booties were provided, as ordered. The surveyor observed Resident #13 in bed eating breakfast on 8/15/12 from 9:10 A.M. to 9:23 A.M. Resident #13's knees were flexed and both heels pressed into the mattress. There were no heel booties applied. CNA #2 entered Resident #13's room. The surveyor asked Resident #13 if the surveyor could look at the Resident's heels and the Resident agreed. CNA #2 lifted the Resident's left heel. The posterior/lateral heel was deeply reddened (approximately 4 cm (centimeters) x 3.5 cm. CNA #2 attempted to lift the Resident's right heel and the Resident winced, and said, "my knee." CNA #2 said that Resident #13 has contracted knees. CNA #2 gently lifted the right heel slightly off the mattress. The lateral/posterior and medial right heel was deeply reddened (approximately 4.5 cm x 4 cm). CNA #2 said that she was not assigned to Resident #13 today, but was familiar with this Resident. CNA #2 said that she was not aware that Resident #13 should be wearing heel booties in bed. On 8/15/12 at 9:30 A.M., the surveyor asked UM #1 if Resident #13 had heel booties available to wear when in bed as the physician's orders [REDACTED].#13's room and in the wardrobe closet. UM #1 said that there were no heel booties available in the Resident's room. On 8/15/12 at 10:30 A.M., the surveyor observed that Resident #13 still did not have heel booties on in bed as ordered/planned. The Resident's heels continue to press into the mattress, despite the surveyor having brought it to the facility's attention. During interview with both the DON and Regional Nurse Consultant on 8/15/12 at 12:25 P.M., both the DON and Regional Nurse Consultant said that they will assess the Resident's heels and ensure that the care plan is followed regarding preventative measures for the development of pressure ulcers on this Resident's heels while in bed. b. The 4/4/12 care plan included problems such as decreased range of motion. This care plan was updated 5/30/12 with the intervention to keep the Resident's nails trimmed On 8/15/12 at 9:23 A.M., the surveyor observed Resident #13 sitting up in bed eating breakfast. CNA #2 entered Resident #13's room to inquire if Resident #13 was done with breakfast. CNA #2 removed the covers from the Resident's feet. The Resident's toenails were long and jagged. The nails were not trimmed, as planned. During interview with both the DON and the Regional Nurse Consultant on 8/15/12 at 12:40 P.M., the DON said that Resident #13's responsible party refused to pay for Podiatry care. The DON said that this Resident was very particular about their appearance and hygiene needs, required extensive assistance for all care needs, therefore, could not provide care for him/herself. The DON said that the facility had not attempted to trim the Resident's toenails and should have done something about the toenails, as planned.

Based on observation, record review, and interviews, the facility failed for 2 sampled residents (#2, and #3) of 5 applicable residents with pressure sores out of a total sample of 20 residents, to keep the resident from developing pressure sores, and also failed to ensure that necessary treatment and services were provided to promote healing. Findings include: 1. For Resident #3, the facility failed to ensure that the resident, who was admitted without heel ulcers, did not develop pressure ulcers. Resident #3 was admitted to the facility in 4/2012, and readmitted to the facility in 5/2012. Pertinent [DIAGNOSES REDACTED]. Review of a Nursing Admission Assessment, dated 5/1/12, indicated that Resident #3's skin was intact, (dry, scaling was checked on the assessment). The assessment stated no obvious skin issues - skin intact, heels intact/slight red. Review of a "Norton Plus Pressure Ulcer Scale," dated 5/1/12, indicated that the resident scored "14" (moderate risk is 11- 15). Review of an Admission MDS (Minimum Data Set) Assessment, completed on 5/7/12, indicated that the Resident had severely impaired cognition. The resident required extensive assistance for bed mobility, transfers, toilet use and walking in room and corridor, locomotion on the unit, dressing, personal hygiene, and bathing. The resident was frequently incontinent of urine, and occasionally incontinent of bowel, was at risk for Pressure Ulcers, had no Pressure Ulcers and had no foot problems. Review of the 5/2012 Treatment Records indicated that the Resident had a treatment for [REDACTED]. The treatment to the Resident's bilateral heels ended on 5/30/12, and the last description of the heels written on the back of Treatment Record on that date at 10:00 P.M. indicated, "...heels intact/sl (slight) red." During interview on 8/15/12 at 11:30 A.M., Unit Manager (UM) #1 stated that the Skin Prep treatment was never re-evaluated after the 30 days and it was no longer applied to the resident's heels. Review of a "Norton Plus Pressure Ulcer Scale," dated 5/30/12, indicated that the resident scored "13," (a point less than on admission), increasing the resident's risk for skin breakdown. Review of the 6/2012 TAR (Treatment Administration Record) indicated that on 6/24/12, the Resident had a new order for the application of Ted (compression) stockings to bilateral legs on in the A.M., off at H.S. (hour of sleep). Review of a nursing note of 6/24/12 indicated that the Resident was complaining of sore heels. The nurse assessed the Resident's heels which were found to be red and tender to touch. A new order was obtained for Skin Prep to the right and left heel twice daily and Heelbos (heel protectors) to bilateral heels while in bed. Review of the facility's Protocol For Stage I Pressure Ulcers identified: *Use heel and elbow protectors to reduce friction forces. These devices do not provide adequate pressure reduction. * Heels are extremely vulnerable and must be elevated completely off bed surface. Utilize pillows or foot splints. Review of a Nursing note of 6/28/12 indicated that the Resident was noted to have a blister to the right heel measuring 2 cm (centimeters) x (by) 3 cm, and the left heel was slightly red, soft and intact. The resident's Physician was notified and indicated to continue the Skin Prep and to leave the resident's right shoe off. Review of the 7/12 Treatment Record identified an order for [REDACTED]. Review of a "Wound Care Specialist Evaluation" completed by the facilities Wound Physician on 7/2/12, indicated that Resident #3 had a Stage II Pressure Ulcer of the right heel, which presented as a fluid filled blister measuring 2 cm long x 3 cm wide. Recommendations included to apply Skin Prep twice daily. The consult indicated the wound care Physician would follow-up within 7 days. Review of the evaluation by the Wound Physician, completed on 7/9/12, indicated that Resident #3 had a Stage II Pressure Ulcer of the right heel, dry blister, measuring 2 cm long x 3 cm wide. Recommendations included to apply Skin Prep twice daily. Assessment of the left heel revealed a Stage II Pressure Ulcer, dry blister, measuring 1.5 cm long x 2.5 cm wide. Recommendations included to apply Skin Prep twice daily, and a Sponge cradle boot to be worn in bed to off-load wound. During discussion (on 8/15/12 at 8:40 A.M.), with UM #1 and the Acting DON (Director of Nursing), UM #1 said she never saw any of the consults/wound evaluations by the Wound Physician, therefore, the recommendations for the Sponge cradle boot were not put in place for the resident. The consult indicated the wound care Physician would follow-up within 7 days. Review of the evaluation by the Wound Physician, completed on 7/16/12, indicated that Resident #3's Stage II Pressure Ulcer of the right heel remained with a dry blister. Recommendations included to continue the Skin Prep twice daily. Further assessment revealed the Stage II Pressure Ulcer of the left heel remained with a dry blister. Recommendations included to continue Skin Prep twice daily. The consult indicated the wound care Physician would follow-up within 7 days. Review of a "Norton Plus Pressure Ulcer Scale," dated 7/20/12, indicated that the resident scored "11," (down 2 points since 5/30/12), increasing the resident's risk for skin breakdown. (Moderate Risk = 11 - 15). Review of the evaluation by the Wound Physician, completed on 7/23/12, indicated that Resident #3's Stage II Pressure Ulcer of the right heel remained as a dry blister and measured 1.2 cm long x 1.3 cm wide. The Pressure Ulcer was stable, and to continue with the skin prep twice daily. Assessment of the left heel revealed a Stage II Pressure Ulcer measuring 1.3 cm long x 2.3 cm wide in stable condition, and to continue with the Skin Prep twice daily. The consult indicated the wound care Physician would follow-up within 7 days. Review of the July 2012 TAR indicated that the Skin Prep to both the left and right heels was discontinued on 7/28/12, despite the Wound Physician's recommendations. During interview on 8/15/12 at 11:30 A.M., UM #1 stated that the Skin Prep was never re-evaluated after the 30 days, and it was discontinued in error. Review of an evaluation by the Wound Physician on 7/30/12 (2 days after the discontinuation of the Skin Prep to bilateral heels), indicated that Resident #3's Stage II Pressure Ulcer of the right heel remained as a dry blister and measured 1.3 cm long x 1.4 cm wide, (had slightly increased in size), but remained stable. Assessment of the left heel indicated that the Stage II Pressure Ulcer remained stable and measured the same size as on 7/23/12 (1.3 cm long x 2.3 cm wide). Recommendations for both heels was to apply Skin Prep twice daily. However, the order had been discontinued on 7/28/12. During interview on 8/15/12 at 11:30 A.M., UM #1 stated the Skin Prep had been discontinued in error, and that Resident #3 should have continued to receive it to his/her bilateral heels. The consult indicated the wound care Physician would follow-up within 7 days. Review of the evaluation by the Wound Physician on 8/6/12, (9 days without the Skin Prep to bilateral heels), indicated that Resident #3's Stage II Pressure Ulcer of the right heel remained as a dry blister and measured 1.5 cm long x 1.5 cm wide, (and continued to increase in size). The recommendations were Skin Prep twice daily (which had been discontinued on 7/28/12). Assessment of the left heel indicated that the Stage II Pressure Ulcer had deteriorated and was now classified as Unstageable DTI (Deep Tissue Injury) of the left heel. Recommendations included Skin Prep twice daily, and to change the off-loading device to a Heel Cradle. The consult indicated the wound care Physician would follow-up within 7 days. During interview on 8/15/12 at 10:00 A.M., UM #1 stated that the resident had never had a heel cradle on the bed, as recommended by the Wound Care Physician on 8/6/12, and she had never seen the recommendation for it. During review of Resident #3's clinical record, the surveyor could not locate a wound consult from the Wound Physician as indicated after the consult of 8/6/12, "...follow-up within 7 days." It was identified during the 8/6/12 visit that the right heel remained as a dry blister and measured 1.5 cm long x 1.5 cm wide, (continued to increase in size), and the left heel indicated that the Stage II Pressure Ulcer had deteriorated and was now classified as Unstageable Deep Tissue Injury. During an interview with UM #1, she said the Wound Physician had been in on 8/13/12; however, he did not evaluate the resident. UM #1 said she would call the Wound Physician and find out why, especially since the right heel increased in size and the left heel was classified as an Unstageable Deep Tissue Injury on 8/6/12. On 8/14/12 at 9:00 A.M., the surveyor reviewed Resident #3's August TAR relative to the treatment to the resident's heels and included the following: - Heelbos while in bed to bilateral feet - Off load heels every shift On 8/14/12 at 9:30 A.M., the Surveyor asked UM #1 about the condition of Resident #3's heels, and she replied, "They are intact and (he/she) receives Skin Prep twice a day to them." The surveyor observed the Resident lying in bed on 8/14/12 at 10:20 A.M. with bare feet. Both heels pressed into the mattress as they were lying flat on the bed. The Resident had a sheet covering him/her from mid shins to chest and was sleeping. The surveyor looked around the room and there were no extra pillows, or heel protectors on the bed, or visible in the resident's bedroom. On 8/14/12 at 2:40 P.M., the Surveyor asked Nurse #1 if an assessment of Resident #3's heels could be done. Observation of the right heel revealed a 3 cm (centimeter) wide x (by) 2 cm long dark purple/black/dark brown dry hardened scabbed area. To the left perimeter of the ulcer (2 cm left circular), were three layers of thin iridescent peeling skin. The medial aspect of the left posterior heel was boggy, and light yellow in color, approximately 2 cm in length x 2 cm wide. The ball of the left heel revealed a few small, scattered, deep brownish-discolored spotted areas. On 8/15/12 between 7:00 A.M. and 7:15 A.M., the Surveyor observed Resident #3 lying in the bed on his/her back with the bed in the low position. Resident #3 had 2 upper siderails up and a house pressure reduction mattress. The Resident's heels were directly on the bed mattress and the resident had bare feet. On 8/15/12 at 8:20 A.M., the Surveyor observed Resident #3 lying on his/her back in the bed. The right heel was directly on the bed. The left calf had a pillow under it and the left heel was elevated off of the bed. On 8/15/12 at 8:40 A.M., the Surveyor observed Resident #3's heels with the Acting Director of Nursing and UM #1. Upon assessing Resident #3, both the left and the right heel were resting on the mattress. Both the Acting DON and Unit Manager #1 stated that Resident #3's heels should not be resting on the mattress. Observation of the Resident's right heel revealed the 3 cm x 2 cm dark purple/black/dark brown dry hardened scabbed area which the Acting DON stated looked the same as the last time she did rounds with the Wound Physician. During observation of the Left heel, the medial aspect of the posterior heel which had been boggy and yellow in appearance (8/14/12 at 2:40 P.M.), was now a fluid filled blister measuring approximately 2.25 cm round. The surveyor indicated the change to the Acting DON and UM #1 who stated a call would be placed to the Wound Physician. On 8/15/12 at 9:50 A.M., the Surveyor observed the Resident lying in bed on his/her back, the left heel was lying on the mattress, the right heel elevated off the mattress by a pillow under the Resident's calf. During interview on 8/15/12 at 2:00 P.M., CNA (Certified Nursing Assistant) #2 who was familiar with the Resident's care stated that the Resident never had a heel cradle, but the resident got some boots late this morning for his/her feet. The CNA stated when he/she came in this morning the Resident had no pillow to elevate his/her feet in the bed. "When I care for the Resident I use a pillow to keep the heels off the bed." During interview on 8/15/12 at 2:10 P.M., CNA #6 said that he/she was also familiar with the resident. The CNA said he/she just heard today that the Resident had a problem with his/her heels. On 8/15/12 at 3:10 P.M. Resident #3 was observed sitting in the day room with Ted stockings on and shoes on his/her feet. During discussion with the Acting DON on 8/15/12 at 3:20 P.M., she said that the Wound Physician had returned the call to Unit Manager #1, and indicated the following orders were received from the Wound Physician: 1. D/C Heelbos while in bed 2. D/C Off load heels every shift ORDERS TO READ 1. Skin Prep to Bilateral Heels twice daily 2. Air boots to bilateral feet while in bed, check for redness or skin irritation every shift 3. Pillow to be under calves to elevate and off-load pressure while in bed During further discussion with the Acting DON on 8/15/12 at 3:20 P.M., she said that the Resident's Physician should also have been contacted regarding the application of the Ted Stockings and Shoes, due to the new blister on the left heel. 2. For Resident #2, the facility failed to: - Cleanse the wound bed and space beneath the area of the Stage 4 (full thickness tissue loss) pressure ulcer; - Utilize the correct packing; - Pack the wound in order to accommodate the undermining (space beneath the surface of the wound). Resident #2 was admitted to the facility in 11/09. The Resident's pertinent [DIAGNOSES REDACTED]. The 3/6/12 and 5/29/12 Quarterly MDS Assessments indicated that the Resident had memory problems, severely impaired cognitive abilities; was dependent for bed mobility, ADLs (Activities of Daily Living) and had an unstageable pressure ulcer. Review of the "Wound Care Specialist Evaluation" report indicated that the Wound Specialist (Physician) evaluated the Resident's left hip ulcer on 8/6/12, and the Stage 4 pressure ulcer had deteriorated with undermining (space beneath the surface of the wound). Documentation on this report identified that the pressure ulcer measured 0.6 cm (centimeters) x 0.5 cm x 0.1 deep, with undermining that measured at 3.4 cm beneath the surface of the wound. The Wound Specialist indicated that the treatment would be changed to an [MEDICATION NAME] (antiseptic impregnated gauze) packing daily. The 8/6/12 Physician's Interim Order sheet indicated a new order to pack the Resident's left hip ulcer daily with [MEDICATION NAME] gauze followed by a DSD (Dry Sterile Dressing) daily. (The order did not include how the ulcer would be cleansed, or with what solution before application of the packing.) Review of the 8/12 TAR (Treatment Administration Record) identified an entry to irrigate the pressure ulcer daily with N/S (Normal Saline), pat dry with 4 x 4, pack with [MEDICATION NAME] gauze and to cover this with a DSD for the 7:00 A.M. to 3:00 P.M. shift. During the treatment observation with Nurse #1 on 8/15/12 at 7:45 A.M., Nurse #1 set up supplies on the Treatment Cart in the Resident's room as follows: - 2 N/S tubettes. - 2 stacks of clean 4 x 4 gauze pads. - 1 Bottle of Plain Packing Strip, 1/2 inch wide (not [MEDICATION NAME] Packing that was ordered). - Suture removal set (containing tweezers and scissors). - 1 Gauze pad with an adhesive border. - 2 packages of Q-Tip applicators. Resident #2 was resting on the right side in bed. The left hip dressing had a moderate amount of bloody drainage. Nurse #1 removed the old dressing, then removed the blood soaked strip packing (approximately 5 - 6 inches of strip packing was removed). The wound was a round-shaped hole. The inner wound margin had a thin layer of yellow necrotic tissue. Nurse #1 squeezed the two tubettes of N/S onto one stack of clean 4 x 4 gauze pads. Nurse #1 picked up a few of the pre-moistened 4 x 4's and wiped across the exterior of the ulcer and periphery. Nurse #1 then picked up one dry Q-Tip and swabbed the exterior of the ulcer. Nurse #1 picked up a second dry Q-Tip and swabbed the exposed inner margin of the ulcer. Nurse #1 picked up a stack of dry 4 x 4 gauze pads and patted the exterior of the ulcer dry. Nurse #1 opened the bottle of Plain Packing Strips, picked up the tweezers from the suture removal kit, and used the tweezers to grasp the end tab of the packing strip from the bottle. Nurse #1 picked up another Q-Tip and attempted to pack the ulcer. The packing strip was too wide and the end of the packing strip was folded over. Nurse #1 did not adequately pack the inside of the ulcer to accommodate the undermining. Nurse #1 placed the bottle of Plain Packing Strips on the bed pad below the Resident's buttocks, turned and retrieved the scissors from the suture removal packet, cut the strip packing and applied the outer dressing. During interview with Nurse #1, directly following the treatment on 8/6/12 at 8:00 A.M., the surveyor pointed out that the packing strip utilized was "Plain," and not the antiseptic impregnated [MEDICATION NAME] gauze that was ordered by the Physician. The surveyor identified that the interior (undermining) of the wound was not irrigated/cleansed in order to promote healing of this deteriorated pressure ulcer, the ulcer was not packed to accommodate the undermining in order to promote healing by filling in the dead air space (bacterial load and air space inside the unclean wound can cause infection and potentiate further undermining). Nurse #1 said that she did not cleanse the inside of the ulcer. Nurse #1 said that she was not aware that [MEDICATION NAME] was an impregnated antiseptic gauze. During interview with UM (Unit Manager) #1 on 8/15/12 at 8:05 A.M., UM #1 said that UM #2 documented both the 8/6/12 physician's orders [REDACTED]. UM #1 said that the undermining pressure ulcer should have been cleansed/irrigated, but that neither the physician's orders [REDACTED]. UM #1 said that [MEDICATION NAME] gauze packing was ordered, and that the [MEDICATION NAME] should have been used, not the Plain packing, and that the wound should have been packed to accommodate the wound beneath the ulcer's surface. During interview with UM #2 on 8/15/12 at 8:50 A.M., UM #2 said that she conducted rounds with the Wound Specialist on 8/6/12. UM #2 said that the Wound Specialist said to irrigate the inside of the undermining pressure ulcer with N/S, and that this had been completed on 8/6/12. UM #2 said that she should have written the 8/6/12 physician's orders [REDACTED]. UM #2 said that Nurse #1 should have used [MEDICATION NAME], and should have irrigated the inside of the ulcers in order to promote healing. During interview with the Interim DON (Director of Nursing) and the Regional Nurse Consultant on 8/15/12 at 12:20 P.M., both the DON and Regional Nurse Consultant said that the Resident's pressure ulcer should have been irrigated due to the undermining, and that the packing should have been with the antiseptic impregnated [MEDICATION NAME] gauze in order to promote healing of the deteriorating pressure ulcer. The Regional Nurse Consultant said that the Wound Specialist will be contacted, the appropriate dressing, irrigation and appropriate packing of the undermining area to the pressure ulcer would be provided for Resident #2 today. Please refer to F514.

2. For Resident #10, the facility failed to consistently use the correct catheter/balloon size for this resident with a history of urine leakage. Findings include: Resident #10 was admitted to the facility in 4/2009 with [DIAGNOSES REDACTED]. Review of the clinical record revealed that the Resident had an original order from the Physician dated 1/19/10 for a Foley Catheter #18 French and inflate the balloon with 30 cc's (cubic centimeters). The Catheter size had been increased to this size due to urinary leakage. Review of the current Plan of Care for the Foley Catheter dated 2/1/12 indicated that the Resident had a Foley Catheter related to a [DIAGNOSES REDACTED]. Interventions included: - A number 18 French Foley Catheter in place with a 10 cc balloon, replace monthly and as needed (Original order called for a 30 cc balloon which would help decrease leakage). - Administer ABT (antibiotic) for three days before Foley Catheter Change. - Assess skin with personal care every shift, notify MD (Medical Doctor) of any changes. Provide incontinent care with Foley leakage, and at times of incontinent of bowel. - Follow-up with Urologist as needed. - Irrigate Foley with 60 cc of Acetic Acid 0.25% 3 times weekly and as needed. Report evidence of mucous threads. - Monitor fluid intake every shift. - Provide Catheter care every shift with personal care. - Report output every shift and document. Notify MD if output is less than intake. Review of the 4/2012 MAR (Medication Administration Record) revealed that the resident had a standing order to receive the antibiotic medication SMZ-TMP (Bactrim) 400-80 mg (milligram) tab by mouth twice daily for three days every month on the day before, the day of, and the day after the Foley Catheter change. Review of the 4/2012 TAR (Treatment Administration Record) included the following orders regarding Resident #10's Foley Catheter: - Foley Catheter 18 French 30 cc balloon to gravity drainage. - Change Foley Catheter monthly on the 15 th on the 11-7 (11:00 P.M. - 7:00 A.M.) shift. - Acetic Acid Solution 0.25% Irrigation - Irrigate with 60 ml (milliliters) every week on Wednesday on the 11-7 shift. - Foley Catheter care every shift. - Change Foley Catheter drainage bag weekly on Wednesday on the 11-7 shift. - Irrigate Foley as needed with 60 ml of Acetic Acid. Further review of the 4/2012 TAR revealed that Resident #10's Foley Catheter was changed on 4/15/12, using a 18 French Catheter, 30 cc balloon. Review of a Quarterly MDS Assessment completed on 4/17/12 identified the resident as scoring 3 of 15 on the BIMS (Brief Interview for Mental Status), indicating short and long term memory impairment, requiring extensive assistance for bed mobility, transfer, locomotion in wheelchair on the unit, dressing, toilet use, personal hygiene, and bathing, having an indwelling catheter, being continent of bowel, and receiving an antibiotic 3 times in the past 7 days. Review of a nursing note of 4/20/12 indicated that Resident #10's Foley Catheter was leaking and the Catheter was irrigated with Acetic Acid Solution. Review of a nursing note of 4/21/12 indicated, "Resident's foley catheter leaking. Irrigated (with) Acetic acid - continued to leak. #16 Fr. (French) foley catheter (with) a 30 cc balloon inserted - no more leakage/draining clear yellow urine...". During discussion with Unit Manager #2 on 8/15/12 at 11:00 A.M., she said the physician's orders [REDACTED]. Review of the Physician order [REDACTED]. Review of a nursing note of 4/28/12 indicated that the Foley Catheter was leaking and the Catheter was irrigated without resistance with clear returns. Review of a nursing note of 5/15/12 on the 11-7 (11:00 P.M. - 7:00 A.M.) shift indicated that Resident #10's Foley Catheter was changed, and a new order was obtained to insert a Foley Catheter #18 French with a 10 cc balloon if 30 cc balloon unavailable. During discussion with Unit Manager #2 on 8/15/12 at 11:00 A.M., she said the original order was for a 30 cc balloon, and they must not have had the correct Catheter on hand in the facility, so the nurse called the Physician for a new order. Review of a nursing note of 5/15/12 on the 7-3 (7:00 A.M. - 3:00 P.M.) shift indicated that the Foley Catheter was dislodged and a new Foley Catheter was inserted and the Physician was notified. Review of a nursing note of 5/20/12 indicated that the Resident's Foley Catheter had decreased output and leakage x (times) 1 of a large amount. "Irrigated (with) 60 cc Acetic Acid (with) clear + mucous plug returns." Review of a nursing note of 5/26/12 indicated that the Resident's Foley Catheter was leaking and had to be irrigated. The result was 400 cc's of clear yellow urine return. Review of the June 2012 TAR indicated, "Foley Catheter #16 French until next change if leaking may change to #18 French." On 6/15/12, the Resident's Foley Catheter was changed according to the June TAR, and a #16 French 30 cc balloon was inserted, despite the Resident's urinary leakage. The Surveyor reviewed the TAR with Unit Manager (UM) #2 on 8/15/12 at 11:00 A.M. UM #2 could not explain where the order originated. UM #2 could not locate a Physician's telephone order, or a Physician's progress note identifying when the order for the Foley Catheter order changed to a #16 French 30 cc balloon. The surveyor reviewed the clinical record which indicated the order of 4/21/12, identical to the order that was written on the June 2012 TAR. However, the Physician had changed the order again on 5/15/12 back to an 18 French 30 cc balloon (may use 10 cc balloon if 30 cc balloon not available). Review of a nursing note of 6/15/12 indicated that the Resident's Foley Catheter was leaking and was irrigated. Nursing note of 6/16/12 indicated that there was an extra large amount of leaking from the Foley Catheter. A new Foley Catheter #18 French was inserted. Review of a Quarterly MDS Assessment completed on 7/10/12 remained basically the same. Review of the July 2012 TAR indicated: - Use 18 French F/C (Foley Catheter) for monthly change - Change Foley Catheter on the 15 th on 11-7 shift - May change F/C if leaking or out with 18 French 30 cc balloon Review of a nursing note dated 7/15/12 indicated that the Foley Catheter was changed in the A.M. The urine was cloudy, and amber in color with mucous clumps. The inner labia was bright red, macerated, and very raw. An 18 French silicone Catheter was placed with a 10 cc balloon. During interview with UM #2 on 8/15/12 at 11:00 A.M., she said the 30 cc balloon Catheter must not have been available for insertion, despite the scheduled monthly changes completed consistently on the 15th of each month. Nursing note of 7/19/12 indicated that the Resident's Foley Catheter with the 10 cc balloon had dislodged, and a new Foley Catheter #18 French 30 cc balloon was inserted. Review of the August 2012 TAR indicated that the Resident had the Foley Catheter Change with a 18 French 30 cc balloon. The surveyor observed the Resident in the room sitting in a wheelchair, catheter in place, with an over-the-bed table in front of him/her. The Resident was looking at a word search puzzle book. During interview with UM #2 on 8/15/12 at 11:20 A.M., she said after reviewing the Resident's record with the surveyor, it was apparent that the facility did not have the correct size Foley Catheters available for the Resident when the Catheter needed to be changed. Based on record review observation and interview, the facility failed to ensure that 1 of 12 applicable residents (#8) received appropriate care and services regarding bladder incontinence and received appropriate treatment and services to restore as much bladder function as possible. Additionally, the facility failed to ensure that care and services were provided for 1 of 1 (#10) applicable sampled residents with a F/C (Foley Catheter) from a total resident sample of 20. Findings include: The Facility Incontinence Management Program included the following: "The objective of this policy is to manage incontinence and in certain instances achieve control by minimizing or eliminating incontinence, by implementing an appropriate and individual program..." 1. Resident #8 was admitted to the facility in 4/12. The Resident's [DIAGNOSES REDACTED]. The 4/6/12 Initial MDS (Minimum Data Set) indicated that Resident #8 had moderately impaired cognitive abilities with a BIMS (Brief Interview for Mental Status) score of 10; received extensive assist from staff for bed mobility, transfers, dressing, hygiene, bathing and was continent of both bowel and bladder. The 4/13/12 care plan for risk for bladder incontinence indicated interventions which included: - assist of 1 for toileting. - occasionally incontinent of bladder and approach included to provide incontinent care as needed (updated 4/29/12). - Bowel and Bladder assessment per protocol. - Norton Skin Assessment (4/2/12) indicated Resident is not incontinent of bladder) According to the nursing notes (5/5 to 5/8/12), Resident #8 had increased lethargy, a low grade fever, and was started on an antibiotic for an upper respiratory infection. The Physician ordered that the Resident be sent to the Hospital and evaluated 5/8/12. The Resident returned to the facility on [DATE]. The 6/29/12 Quarterly MDS Assessment now identified that the Resident had improved cognition with a BIMS (Brief Interview for Mental Status) score of 13, which indicated that the Resident's cognitive abilities were intact. This MDS also indicated that the Resident now required only limited assist for ambulation, was now dependent on staff for dressing, hygiene, bathing, and was now always incontinent of bladder (decline since 4/12, when Resident #8 was identified as being continent). The 6/12 Norton Skin Assessment indicated that the Resident had double incontinence (bowel and bladder). The 6/12 and 7/12 Activity of Daily Living (ADL) Flow Sheets identified that Resident #8 was incontinent of bladder for all three shifts. The 6/29/12 bladder assessment indicated the following: - Incontinent of bladder - Length of time incontinent identified: "per hospital stay ?[MEDICAL CONDITION] 5/8/12." - Independent, as well as assist for ambulation. - Independent with transfers. - Use of pads or briefs for incontinence. - Unable to express need to void (urinate). - Always incontinent with no pattern (there was no bladder patterning completed, to even determine if there was a pattern. There was no bladder scan completed to determine if there was a urinary problem). The section of the bladder assessment relative to "Signs and Symptoms of Urinary Tract Problems" was not completed. - Type of Program checked on the bladder assessment that would be utilized for Resident #8 was "Prompted Voiding." Review of the Bowel and Bladder Policy identified the following for the Prompted Voiding toileting program: - "Patients are able to sense bladder fullness and also ask for assistance. They require prompting from the care giver but are functionally able to use the toilet." During the initial tour of the Resident's Unit on 8/13/12, at 9:15 A.M., Unit Manager (UM) #1 said that Resident #8 could be interviewed regarding care and services provided in the facility. The surveyor interviewed Resident #8 on 8/14/12 at 8:42 A.M.. Resident #8 said that he/she is embarrassed when he/she wets him/herself, but just can't get to the bathroom because the staff are always demanding for him/her to "sit down," or "wait for help." Resident #8 said, "I'm here for rehabilitation for the body, but I need it for the mind too." CNA (Certified Nursing Assistant) #1 interviewed on 8/14/12 at 8:48 A.M., said that she was familiar with Resident #8, and was assigned to care for this Resident today on the 7:00 A.M. to 3:00 P.M. shift. CNA #1 said that Resident #8 had been incontinent, required assist for management of incontinence, and is not on any toileting program. CNA #1 said that Resident #8 was correct when he/she said that staff instruct him/her to sit, and wait for help because they are concerned Resident #8 will fall. Review of the CNA Care Card (updated 7/4/12) indicated that the Resident was continent of bladder. The 7/12 ADL flow sheet indicated that Resident #8 was incontinent for all three shifts in the month of July, 2012. The surveyor observed Resident #8 sitting in the Unit's Activity/Dining Room on 8/14/12 at 11:08 A.M. The Resident had a wheeled walker to the right of his/her chair. Resident #8 stood and a chair alarm sounded. CNA #7 was sitting at a table nearby and said, "sit down." Resident #8 sat back in the chair and the chair alarm stopped sounding. During interview with the DON (Director of Nursing) and the Regional Nurse Consultant on 8/15/12 at 12:30 P.M., both said that the Facility's policy was to provide a bladder assessment, a bladder patterning especially when there is a dramatic change in a Resident's incontinence, then a toileting program would be developed to manage or prevent the Resident's incontinence. The DON said that a bladder scan would also be obtained after the Resident urinated (post void residual) to ascertain if there was a urinary/structural problem, such as [MEDICAL CONDITION]. The DON said that Resident #8 is "mortified" when he/she has wet him/herself. Both the DON and the Regional Nurse Consultant said that bladder patterning, a toileting program and a bladder scan were not provided in order to manage or restore as much bladder function as possible for Resident #8.

Based on record review and interview, for one of three sampled Residents (Resident #1), who received Hospice Services, Nurse #2 failed to administer pain medication when Resident #1 yelled out so loudly in pain from 11:30 P.M. to 5:00 A.M. on 1/17/12 that other residents awoke. In addition, there was no documentation that Nurse #2 assessed Resident #1 for pain, notified Hospice, or notified the physician of Resident #1's pain. Findings include: Resident #1's Admission Record indicated that the Facility admitted Resident #1 in August, 2010. A pain plan of care, dated 7/22/11, indicated Resident #1 had pain related to [MEDICAL CONDITION] disc disease, T12 compression fracture, compression deformities of L1 and L2, and spinal stenosis. The care plan goal was for Resident #1 to have an acceptable level of pain relief with scheduled medications. Care plan interventions included assessing Resident #1 for pain each shift, notifying the physician and Hospice if scheduled pain medication was insufficient, and medicating Resident #1 as scheduled. The January, 2012, physician's orders [REDACTED]. The January, 2012, physician's orders [REDACTED].M. and off at 8:00 P.M.), [MEDICATION NAME] (narcotic [MEDICATION NAME]) 5 milligrams (mg) by mouth twice daily, [MEDICATION NAME] (urinary spasmolytic) 200 mg by mouth three times daily, [MEDICATION NAME] 650 mg by mouth every 4 hours prn (as needed) for pain or increased temperature, and [MEDICATION NAME] 5 mg by mouth prn for pain every 4 hours. Resident #1 also had an order for [REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 1/6/12, indicated that Resident #1 was understood by others and usually understood others. A brief interview for mental status indicated that Resident #1 scored 3 out of 15 possible points, which was representative of severe cognitive impairment. The MDS indicated that Resident #1 required extensive staff assistance with bed mobility, transfers, ambulation, dressing, eating, and bathing. The MDS indicated that Resident #1 was totally dependent on staff for toilet use and hygiene. The MDS indicated that Resident #1 had almost constant severe pain and was on a scheduled pain regimen. A physician's orders [REDACTED]. The physician ordered Resident #1's [MEDICATION NAME] 5 mg scheduled and prn to be discontinued when the suspension was received. The physician also ordered [MEDICATION NAME] 0.25 mg by mouth at 8:00 P.M. daily. The Surveyor interviewed Unit Manager #1 at 3:30 P.M. on 1/31/12. Unit Manager #1 said Resident #1 was still able to take medication in pill form, but staff was concerned that Resident #1 would continue to decline and not be able to swallow pills, so she obtained an order for [REDACTED].#1 could still receive the [MEDICATION NAME] tablets. The Surveyor interviewed Nurse #1 at 3:10 P.M. on 1/31/12. Nurse #1 said she worked the 3:00 P.M. to 11:00 P.M. shift on 1/17/12 and at the beginning of the shift Unit Manager #1 told her about the order. Nurse #1 said at shift change, she told Nurse #2 about the order change from [MEDICATION NAME] tablets to liquid, but also told Nurse #2 that Resident #1 could have the [MEDICATION NAME] tablets until the [MEDICATION NAME] suspension arrived from the pharmacy. Nurse #1 said Nurse #2 did not question the order. Nurse #1 said there were times when Resident #1's pain was more intense and that evening (1/17/12), Resident #1 was in more pain than usual. Nurse #1 said she believed she administered prn [MEDICATION NAME] to Resident #1 at about 4:30 P.M. and she administered scheduled [MEDICATION NAME] 5 mg to Resident #1 at 8:00 P.M., and Resident #1 had no problem taking the medication. Nurse #1 said Resident #1 could still take medication in pill form, but the suspension was ordered for when Resident #1 could no longer swallow pills. Nurse #1 said Resident #1 was definitely able to make his/her needs known. The January, 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., a scheduled [MEDICATION NAME] 5 mg tablet at 8:00 P.M., and a prn [MEDICATION NAME] 0.5 mg at 4:00 P.M. on 1/17/12. The staffing sheet for the 11:00 P.M. to 7:00 A.M. shift on 1/17/12 into 1/18/12 indicated that the following staff worked on Resident #1's unit: Nurse #2, CNA #1, and CNA #2. The Surveyor interviewed CNA #1 at 8:55 A.M. on 2/1/12. CNA #1 said at the beginning of the 11:00 P.M. to 7:00 A.M. shift, Resident #1 called out for help and she checked on Resident #1. CNA #1 said Resident #1 told her that he/she was in pain. CNA #1 said she went to Nurse #2 and informed her, but Nurse #2 said Resident #1's pain medications were discontinued and he/she had to wait for liquid medications to come from the pharmacy. CNA #1 said she and CNA #2 went back to Resident #1 and tried to reposition him/her to make him/her more comfortable, but about 20 minutes later, Resident #1 yelled out in pain. CNA #1 said she and CNA #2 repositioned Resident #1 numerous times to try and make him/her more comfortable, but it really did not help very much. CNA #1 said she asked Nurse #2 several times if there was anything she could give Resident #1, and at one point Nurse #2 read the order to her that the pills had been discontinued and liquid medication was ordered, but Nurse #2 said it was not in yet. CNA #1 said she went and explained this to Resident #1 and Resident #1 said he/she was sorry for yelling, but he/she was in pain. CNA #1 said other residents complained about Resident #1 yelling out and one resident, who was hard of hearing, even complained of the yelling. CNA #1 said the resident across the hallway and Resident #1's roommate also complained about Resident #1's yelling out. CNA #1 said Resident #1 was really loud and intense and it was a very long night for Resident #1. CNA #1 said at one point about 3:00 A.M., Nurse #2 went to Resident #1's room and stood in the doorway. CNA #1 said she was not sure if Nurse #2 ever entered the room to assess Resident #1, but she told them to give Resident #1 some crackers, which Resident #1 did not eat. CNA #1 said the liquid medications finally arrived from the pharmacy about 5:00 A.M., Nurse #2 administered the medications about 5:15 A.M. or so, and Resident #1 calmed down and had stopped yelling out in pain by about 6:00 A.M. The Surveyor interviewed CNA #2 at 1:46 P.M. on 1/31/12. CNA #2 said about 11:30 P.M. Resident #1 yelled out loudly and CNA #1 went and asked Nurse #2 to administer pain medication to Resident #1. CNA #2 said Nurse #2 told CNA #1 that she could not administer any medication to Resident #1. CNA #2 said Nurse #2 said there was nothing to give Resident #1 until the pharmacy delivered medication. CNA #2 said Resident #1 complained of pain and yelled out throughout the night. CNA #2 said they repositioned Resident #1, offered fluids and cookies, but nothing helped. CNA #2 said Resident #1's face looked like he/she was in pain and Resident #1 complained of pain. CNA #2 said Nurse #2 went to the doorway of Resident #1's room once, but did not enter the room or assess Resident #1. CNA #2 said Nurse #2 commented that she wished she could give Resident #1 something, but she had to wait for the pharmacy to deliver medications. The January, 2012, MAR indicated [REDACTED]. A nurse's note, dated 1/18/12 at 6:00 A.M., indicated that Resident #1 was restless and uncomfortable secondary to pain. The nurse's note indicated that Nurse #2 awaited the delivery of [MEDICATION NAME] suspension secondary to medication changes. The nurse's note indicated Resident #1 received [MEDICATION NAME] suspension at 5:00 A.M. with full effect. The nurse's note was signed by Nurse #2. The Narcotic Administration Record indicated Nurse #1 administered Resident #1's scheduled [MEDICATION NAME] 5 mg at 8:00 P.M. on 1/17/12 and there was no further [MEDICATION NAME] administered to Resident #1 until 5:00 A.M. on 1/18/12. The Narcotic Administration Record indicated that Nurse #2 received [MEDICATION NAME] 20 mg/ml at 5:00 A.M. on 1/18/12, and Nurse #2 administered 0.5 ml of [MEDICATION NAME] to Resident #1. The Facility's Pain Management Policy indicated that the Facility respected and supported a resident's right to prompt, safe, and effective pain management. The Policy indicated pain is whatever the person experiencing it says it is and the Facility believed a resident's self report of pain to be the most important factor in assessing pain. The Policy indicated that at a minimum the assessment includes the origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment. A review of Resident #1's clinical record indicated no documentation that Nurse #2 assessed Resident #1 for pain during the 11:00 P.M. to 7:00 A.M. shift on 1/17/12 into 1/18/12. The Surveyor made numerous attempts (on 1/31/12, 2/1/12, 2/8/12, and 2/9/12) to contact and interview Nurse #2 and on two occasions provided Nurse #2 with specific times to contact the Surveyor, but the attempts were unsuccessful. A review of a written statement, completed by Nurse #2 on 1/20/12, indicated she was told in report that Resident #1's pain medications were changed to suspension form, but she was not told the tablet form could be used until the suspension arrived. The written statement indicated that Resident #1 called out and was periodically checked and did not seem to be in pain. The written statement indicated that the suspension arrived, was administered, and by the end of the shift Resident #1 said he/she felt a lot better. Resident #1 was pronounced dead by RN (Registered Nurse) pronouncement at 6:35 P.M. on 1/18/12.