Every finding on record at Vantage at West Springfield LLC

Based on interview, and record review, the facility failed to determine that a significant change in status/ condition had occurred and ensure that a Significant Change in Status Minimum Data Set [MDS] Assessment (SCSA) was completed for two Residents (#105 and #52) out of a total sample of 23 residents. Specifically, the facility failed to identify and complete a SCSA:1. for Resident #105, when a significant change of functional decline in several ADL areas and bowel and bladder continence occurred for the Resident. 2. for Resident #52, when a significant change in mood, toileting, and activities of daily living (ADLs) occurred for the Resident. Findings include:Review of the facility policy titled Comprehensive Assessments, revised March 2022, indicated: -Comprehensive assessments are conducted to assist in developing person-centered care plans. -Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. -Significant change in status assessment – the SCSA is a comprehensive assessment for a resident that must be completed when the IDT [Interdisciplinary Team] has determined that a resident meets the significant change guidelines for either major improvement or decline. -A significant change is a major decline or improvement in a resident's status that: >will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. The decline is not considered self-limiting; >impacts more than one area of the resident's health status, and >requires interdisciplinary review and/or revision of the care plan. 1. Resident #105 was admitted to the facility in June 2025 with diagnoses including Vascular Dementia. Review of the admission assessment dated [DATE], indicated Resident #105: -was independent for eating -required supervision for toilet hygiene -required moderate assistance for transfers -was independent for bed mobility -required supervision for ambulation -was independent for personal hygiene -was continent of bladder -was continent of bowel Review of the Quarterly MDS assessment dated [DATE], indicated Resident #105: -required moderate assistance for eating (changed from 7/9/25 assessment) -was dependent on staff for toilet hygiene (changed from 7/9/25 assessment) -was dependent on staff for transfers (changed from 7/9/25 assessment) -was dependent on staff for bed mobility (changed from 7/9/25 assessment) -required moderate assistance from staff for ambulation (changed from 7/9/25 assessment) -was dependent on staff for personal hygiene (changed from 7/9/25 assessment) -was frequently incontinent of bladder -was occasionally incontinent of bowel Review of Resident #105's medical record failed to indicate that a SCSA had been completed after the resident had a decline in activities of daily living (ADLs) and continence that was not self-limiting from June 2025 to September 2025. During an interview on 12/10/25 at 11:32 A.M., Unit Manager (UM) #1 said that Resident #105 has had a decline since admission in June 2025 and is requiring more assistance from staff for ADLs. During an interview on 12/10/25 at 12:57 P.M., the MDS Nurse said she should have evaluated Resident #105 for a significant change when she completed the Quarterly Assessment on 9/17/25. The MDS Nurse said that a SCSA should have been completed because the Resident had a functional decline in several ADL areas and continence. 2. Review of the facility policy titled, Comprehensive Care Plan, undated, indicated but was not limited to the following: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. -Our facility's Care Planning/Interdisciplinary Team, in accordance with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. -The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. -Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Areas Assessment) before interventions are added to the care plan. -Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. -The Care Planning/Interdisciplinary Team along with the resident/representative is responsible for the review and updating of care plans: <When there has been a significant change in the resident's condition <When the desired outcome is not met <When the resident has been readmitted to the facility from a hospital stay; and <At least quarterly Review of the facility policy titled Functional Impairment Clinical Protocol, revised, September 2012, indicated but was limited to: Upon admission to the facility, at any time a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical condition and functional status. <The physician will help identify individuals who have had a recent history of functional decline and those who are at risk for additional decline. <The staff will identify individuals with a significant decline in function, including ability to perform activities of daily living (ADLs). -As appropriate, the physician and other staff will identify and evaluate the individual's co-morbidities, conditions causing functional decline, symptoms, risks, impairments, and disabilities, and investigate their causes. -The physician should order consultation and professional evaluations that are appropriate for the resident's condition. -The physician and staff will evaluate the resident for complications secondary to functional decline and/or immobility, such as: <Incontinence -The physician and staff will review the results and implications of these evaluations and use them to guide subsequent care planning. <The physician will help identify and explain medical causes of functional decline and/or why functional decline might be medically unavoidable. - The physician, nurse or therapist may initiate screening for the potential to benefit from rehabilitative services such as physical and occupational therapy. - Following the screening, the therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy (example (e.g.,) restorative nursing services that can be provided by caregivers or exercises with which family members can assist). - If a potential to benefit from rehabilitation therapies (either skilled or unskilled) is identified, the attending physician will order a relevant therapy evaluation (for example, by the physical or occupational therapist) Resident #52 was admitted to the facility in December 2024 with diagnoses including Cerebral Palsy, Acquired absence of Right Leg Below Knee, Spondylosis, Lumbar Region, Need for Assistance with Personal care and anxiety disorder. Review of Resident #52's Quarterly MDS assessment dated [DATE], indicated that the Resident: -was feeling down or depressed 2 - 6 days -total severity score of 1 for Mood -had no behaviors. -required setup or clean up assist for personal hygiene. -oral hygiene was set-up clean up assistance -was occasionally incontinent of urine. -was always continent of bowels. Review of Resident #52's Annual MDS assessment dated [DATE], indicated that the Resident: -had little interest or pleasure in doing things -was feeling down or depressed 7 – 11 days (increased from 7/23/25) -was feeling tired or having little energy -had trouble concentrating on things such as reading the newspaper or watching the television -was moving or speaking so slowly that other people could have noticed. -total severity score was 11 for Mood (increased significantly from 7/23/25 assessment) -was dependent on staff for oral hygiene. (changed from 7/23/25 assessment) -was dependent on staff for toilet hygiene. (changed from 7/23/25 assessment) -was dependent on staff for personal hygiene (changed from 7/23/25 assessment) - was always incontinent of urine (changed from 7/23/25 assessment) - was always incontinent of bowels. (changed from 7/23/25 assessment) During an interview on 12/11/25 at 12:56 P.M., the MDS Nurse said that she should have evaluated Resident #52 for a significant change when she completed the Annual assessment for 10/20/25. The MDS Nurse said that SCSA MDS Assessment should have been completed because the Resident had a functional decline in personal hygiene, bed mobility and toilet transfers. The MDS nurse said that she referred to the RAI manual for guidance. During an interview on 12/11/25 at 1:06 P.M., Unit Manager (UM) #2 said that she noticed that Resident #52 had declined in ADL care and required more assistance with care than before. UM #2 said that all care plans, care cards, and change in condition should be completed upon any change in ADL care for residents. UM #2 also said the Rehabilitation Department was notified about the change in ADL care and completed a screen requesting the Resident to be evaluated but the Rehabilitation Department had not completed an evaluation. UM #2 said she would provide evidence of the communication slip between her the Rehabilitation Department. The facility staff failed to provide any additional evidence to the surveyor at the time of survey exit.

Based on observations, interviews, and record review, the facility failed to review, revise and implement a person-centered care plan relative to assistance with Activities of Daily Living (ADLs-self-care tasks like bathing, dressing, eating, toileting, transferring and continence which are essential for independence) for one Resident (#52), out of a total sample of 23 residents. Specifically, for Resident #52, the facility failed to assess and implement the Resident's request for the use of a commode for toileting in accordance with the needs, goals of care, and preferences that addressed the identified limitations in his/her ability to perform ADL's. Findings Include: Review of the facility's policy, titled Activities of Daily Living, dated December 2020, included but was not limited to:To provide support, assistance, and encouragement to remain as independent as possible with activities of daily living, including hygiene, mobility, elimination, dining, and communication; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values, and beliefs. -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming, and personal and oral hygiene. -Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that it was unavoidable. -The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living:<Mobility-transfer and ambulation, including walking<Elimination-toileting and incontinent care Resident #52 was admitted to the facility in July 2024 with diagnoses including need for assistance with personal care, Cerebral Palsy, Major Depressive Disorder with Severe Psychotic Feature, and Acquired Absence of Right Leg Below Knee Amputation. Review of Resident #52's Occupational Therapy (OT) Discharge Summary Records dated 1/3/25, indicated the following:-Toilet transfer not attempted due to medical condition or safety concerns.-Recommendation- toileting needs to be at bed level. Requires mechanical lift transfers. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #52:-has moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of 15 -had no rejection of evaluation or care-was dependent on staff to get on and off a toilet or commode-was occasionally incontinent of bladder-was always incontinent of bowel, not on toileting program Review of Resident #52's ADL Care plan, initiated 7/17/24 and revised 7/18/25, indicated the following under Toilet Use:-Dependent on staff for toileting, revised 7/18/25-Able to use the commode in room, revised 7/18/25-Commode to be against the wall for stability, revised 7/18/25-Encourage to participate to the fullest extent possible with each interaction, revised 7/18/25-Physical Therapy (PT)/Occupational Therapy (OT) evaluation and treatment as per Medical Doctor (MD) orders. Review of Resident #52's Certified Nurse Aide (CNA) Care Card dated 12/1/25, indicated the following:-Bladder incontinent-Bowel incontinent >Toilet Use -Dependent -Briefs On 10/2/25 at 8:19 A.M., the surveyor observed Resident #52 in his/her bedroom lying in bed. During an interview at the time, the Resident said that he/she was dependent on staff for toileting needs and wishes to use the commode, but staff would always give him/her a bed pan. On 10/2/25 at 12:07 P.M., the surveyor observed Resident #52 in his/her bedroom. Resident #52 said that he/she was dependent on staff to use the bathroom, and staff typically gives him/her a bedpan. Resident #52 also said staff use a mechanical lift to transfer him/her in and out of bed and that staff were unable to assist him/her out of bed in order to use the commode, and he/she wished to use the commode instead of a bed pan. On 12/11/25 at 8:28 A.M., the surveyor observed Resident #52 lying in bed in his/her bedroom. During an interview at the time, the Resident said he/she wished to use the commode when needed, but he/she would be offered a bed pan if he/she wanted to use the bathroom and that the bed pan was uncomfortable. On 12/11/25 at 8:40 A.M., the surveyor observed CNA #9 enter Resident #52's room and closed the door behind her.During an interview on 12/11/25 at 9:02 A.M., CNA #9 said that she was unfamiliar with Resident #52 as she was agency staff. CNA #9 said that she typically asks other staff members about the type of assistance Resident #52 required for daily care. CNA #9 said Resident #52 was incontinent of bowel and bladder and used adult briefs. CNA #9 said typically staff would assist Resident #52 with toilet use by using a mechanical lift to transfer the Resident to bed to provide incontinent care and then assist the Resident back to his/her wheelchair using the mechanical lift. CNA #9 also said that Resident #52 was dependent on staff for care. CNA #9 said that she provided ADL care for the Resident because the Resident had an appointment. During an interview on 12/11/25 at 9:15 A.M., Unit Manager (UM) #2 said that Resident #52 was dependent on staff for care. UM #2 said Resident #52 required a mechanical lift and two staff assist for transfers. UM #2 also said that staff should transfer the Resident to the bathroom for toilet use. UM #2 further said that Resident #52 would at times be transferred to bed for incontinent care. During an interview on 12/11/25 at 9:45 A.M., the Rehabilitation Service Director said Resident #52 had not used a commode since he/she had right below the knee amputation surgery in December 2024. The Rehabilitation Service Director said the department attempted the use of a slide board transfer to the chair in January 2025 after the surgery and was unsuccessful. The Rehabilitation Service Director said Resident #52's care plan had not been updated to reflect the Resident's status and should have been. The Rehabilitation Service Director further said that she was unaware Resident #52 had made requests to use the commode. The Rehabilitation Service Director said that the therapy department and/or the Physician were not aware of Resident #52's inability to use the commode and had not attempted to evaluate or assess the Resident's desire to be transferred to a commode for him/her to be able to move his/bowels. During an interview on 12/11/25 at 10:03 A.M., the MDS Nurse said Resident #52 was able to use the commode previously that is why he/she was care planned to use the commode. The MDS Nurse said Resident #52 should have been assessed after his/her amputation by the interdisciplinary team (IDT) but had not done so. The MDS Nurse further said that unit managers were responsible for updating and revising the care plans. During an interview on 12/11/25 at 10:35 A.M., the Resident's Healthcare Proxy (HCP) said that Resident #52 had expressed the wish to use the commode to him/her. The HCP said that the IDT had informed him/her that the Resident required a mechanical lift for transfers and that they could not provide a commode for the Resident's use. The HCP further said that the facility had not discussed any attempts that they had evaluated or attempted to assist the Resident to use the commode. During an interview on 12/11/25 at 1:06 P.M., UM #2 said that she noticed that Resident #52 had declined in ADL care and required more assistance with care than he/she was before. UM #2 further said the Resident was being provided with a brief to defecate or urinate on him/herself so that he/she would call and be cleaned. During an interview on 12/11/25 at 1:33 P.M., the Rehabilitation Service Director said that the department would complete a screen when the department receives notice of a change in function for a Resident. The Rehabilitation Service Director said that therapy should have done an assessment to determine the Resident's functional ability, but they did not.

Based on observation, record review, and interview, the facility failed to ensure that one Resident (#23), out of total sample of 23 residents was provided assistance with personal hygiene. Specifically, for Resident #23, the facility failed to ensure that the Resident, who required ADL assistance was offered and/or provided with grooming assistance for the removal of unwanted facial hair. Findings include:Review of the facility's policy titled, Activities of Daily Living (ADLs), revised December 2022, indicated:-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.-The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.-The facility will provide care and services for the following activities of daily living:<hygiene, bathing, dressing, grooming and oral care. Resident #23 was admitted to the facility in November 2024 with diagnoses including Unspecified Dementia and Anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #23:-had moderate cognitive impairment impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 9 out of a possible score of 15.-required assistance with personal hygiene. Review of Resident #23's Certified Nurse Aide (CNA)'s Care Card (identifies the care to be provided to residents), indicated that the Resident needed physical assistance for grooming. Review of Resident #23's Activities of Daily Living (ADLs) Flow Sheet documentation for December 2025 indicated that the Resident was a physical assist for grooming. Review of Resident #23's ADL Care Plan, initiated on 10/9/24, indicated the Resident required assistance with bathing, grooming, dressing, hygiene, toileting tasks, and that staff would continue to provide support/assistance needed for ADL completion. Review of Resident #23's comprehensive medical record indicated an invoked Healthcare Proxy (HCP) (a healthcare decision maker - person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) for an incapacitated person, effective 1/12/22. On 10/1/25 at 9:16 A.M., the surveyor observed Resident #23 was dressed for the day and watching television in his/her room. The surveyor observed the Resident to have approximately 1.5 inches length of facial hair spread sparsely on the upper lip and chin. During an interview at the time, Resident #23 said he/she does not like any facial hair and that he/she was waiting for family to assist with the removal of his/her unwanted facial hair. On 12/10/25 at 9:21 A.M., the surveyor observed Resident #23 was dressed for the day and reclining in his/her room. The surveyor observed that the Resident's facial hair was denser and longer than previously observed on 10/1/25 and was now covering the upper lip and the entire chin area. During an interview on 12/10/25 at 9:22 A.M., Certified Nurse Aide (CNA) #2 said she was assigned to the Resident but had not noted Resident #23's facial hair. During an interview on 12/10/25 at 9:25 A.M., Unit Manager (UM) #1 said it was his expectation that the CNAs would provide grooming to Residents which includes removing unwanted facial hair. UM #1 further said that he had not observed Resident #23 to have facial hair. During a telephone interview on 12/10/25 at 10:16 A.M., Resident #23's HCP said he/she had not visited the Resident recently but knew his/her family member would not like any facial hair. During an interview on 12/10/25 at 10:23 A.M., CNA #1 said she had provided ADL care to Resident #23 that morning but had not noticed that the Resident had facial hair. CNA #1 said she would go back to the Resident's room, observe him/her, and check back with the surveyor. During an interview on 12/10/25 at 10:40 A.M., CNA #1 said Resident #23's facial hair was gross. CNA #1 said she had only provided bathing and dressing for Resident #23 that morning and that the Resident was on CNA #2's assignment. During an interview on 12/10/25 at 10:53 A.M., the Director of Nursing (DON) said it was her expectation for all residents to receive the necessary care. The DON further said Resident #23 should have been assisted with his/her facial hair removal but was not.

Based on observations, interviews and record reviews, the facility failed to ensure that controlled medication (medication that fall under the United States Drug Enforcement Administration (DEA) Schedules II-V, and have a potential for abuse) records were accurately maintained for a Controlled Substance Book on one unit (Unit Two) out of four units Controlled Substance Books reviewed.Specifically, the facility failed to accurately document the transfer, destruction, and removal of controlled substance medications (Oxycodone and Tramadol) for four residents in the Controlled Substance Book for Unit Two. Findings include:Review of the facility policy titled, Disposal of Medications and Medication-Related Supplies: Controlled Substance Disposal, effective January 2024, included but was not limited to:-Policy: Medications included in the DEA classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations.-Procedures:<Disposition is documented on the individual controlled substance Accountability Record/book.<The Administrator, nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the individual controlled substance accountability record/book:1) Date of destruction2) Resident's name3) Name and strength of medication4) Prescription number5) Amount of medication destroyed6) Signatures of witnesses On 12/11/25 at 2:08 P.M., the surveyor and Nurse #6 observed the Controlled Substance Book on Unit Two and randomly reviewed seven individual controlled substance accountability records within the Controlled Substance Book, with the following findings:-Page #49 indicated a resident had four tablets of Oxycodone (opioid/narcotic pain medication) remaining for administration. Nurse #6 was unable to locate the four tablets in the medication cart's lock box.-Page #54 indicated a resident had seven tablets of Tramadol (opioid/ analgesic pain medication) remaining for administration. Nurse #6 was unable to locate the seven tablets in the medication cart's lock box.-Page #70 indicated a resident had 27 tablets of Oxycodone remaining for administration. Nurse #6 was unable to locate the 27 tablets in the medication cart's lock box.-Page #73 indicated a resident had 27 tablets of Oxycodone remaining for administration. Nurse #6 was unable to locate the 27 tablets in the medication cart's lock box.During an interview at the time, Nurse #6 said that these four identified controlled substances should have been in the medication cart's lock box according to the documentation on the designated pages in the Controlled Substance Book, but the medications were not found in the lock box. During an interview on 12/11/25 at 2:20 P.M., Nurse #5 said that according to the Controlled Substance Book index on Unit 2, two of the four identified controlled substances had been destroyed. Nurse #5 said that the controlled substances designated pages in the Controlled Substance Book should have had documentation to reflect the destruction of these controlled substances and did not have the documentation. Nurse #5 said that two of the identified controlled substances were likely transferred to another Controlled Substance Book in the facility because the residents had moved to another unit. Nurse #5 said that when a controlled substance was destroyed, destruction was indicated in the index of the Controlled Substance Book, as well as on the controlled substance's designated page in the Controlled Substance Book. Nurse #5 said that an x was written across the entirety of the designated page, and two Nurses signed under the section titled Medication Destroyed located at the bottom of the page. During an interview on 12/11/25 at 3:15 P.M., the Director of Nursing (DON) said that an investigation had been performed to determine the status of the four identified controlled substances on Unit Two. The DON said the findings of the investigation were as follows:-The four tablets of Oxycodone on page #49 had been destroyed on 9/24/25.-The seven tablets of Tramadol on page #54 had been destroyed on 9/24/25.-The 27 tablets of Oxycodone on page #70 had been transferred to another medication cart's lock box.-The 27 tablets of Oxycodone on page #73 had been removed from the medication cart's lock box for destruction.The DON further said documentation was not completed for the four identified controlled substances on the designated pages in the Controlled Substance Book and should have been completed. The DON said the expectation was that when a controlled substance was removed from the medication cart's lock box, both the index and the designated page in the Controlled Substance Book were updated to reflect whether the controlled substance had been removed from the medication cart's lock box or destroyed. The DON said the documentation on the designated page in the Controlled Substance Book should have included the date of the removal or destruction, along with two Nurses' signatures.

Based on observation and interview, the facility failed to ensure that medications were labeled and stored in accordance with currently accepted professional principles on one unit medication cart (Unit 4) out of a total of four medication carts reviewed. Specifically, the facility failed to ensure that four pre-poured medication tablets observed in a plastic medication cup and stored in the top drawer of the medication cart on Unit 4 was appropriately labeled to prevent accidental administration of the medication. Findings include: Review of the facility policy titled Storage of Medications, undated, included but was not limited to:-Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -The provider pharmacy dispenses medications in containers that meet regulatory requirements, medications are kept in these containers.-All medications dispensed by the pharmacy are stored in the container with the pharmacy label. On 10/2/25 at 8:54 A.M., the surveyor and Nurse #4 observed the following on the Unit 4 medication cart: -One plastic medication cup with 4 tablets of medications in the cup that had no name and label. During an interview at the time, Nurse #4 said a resident had refused the medications earlier. Nurse #4 said that the resident wanted her to leave the medication on his/her bedside table. Nurse #4 said that she kept the medications in the medication cart to re-administer to the resident at a later time. Nurse #4 said the medication cart was locked and it was safe to leave the pre-poured medications inside the medication cart. During an interview on 10/2/25 at 9:05 A.M., Unit Manager (UM) #2 said that the Nurse should immediately destroy the medications if the resident had refused. UM #2 said that pre-pouring medications and leaving in the medication cart would lead to medication errors. During an interview on 10/2/25 at 10:20 A.M., the Director of Nursing (DON) said that the Nurse should have destroyed the medication when the resident refused and not leave pre-poured medications inside the medication cart. The DON said Nurses are not to pre-pour medication and leave inside the medication cart to prevent medication errors.

Based on observations, and interview, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections during two medication administration observations on one unit (Unit 4) out of four total units. Specifically, failed to adhere to infection control practices when:1. Nurse #4 was observed picking up a medication tablet that was dropped on the surface of an un-sanitized medication cart with a gloved hand and administered the medication to a resident during medication administration.2. Nurse #1 was observed picking up a medication that was dropped on an un-sanitized medication cart with his ungloved/un-sanitized hands and administering the medication to a resident during medication administration. Findings include: Review of the facility's policy titled Hand Hygiene, revised 2/23/22, indicated: -Use an alcohol-based hand rub before performing an aseptic task. -Before moving from work on a soiled body site to a clean body site. -After touching a patient's immediate environment. Review of the facility's policy titled, Medication Administration – general Guidelines, undated, indicated: -The person administering medications adheres to good hand hygiene, including prior to handling any medication. -Before and after administration of medications. -No medications are kept on top of cart. 1. On 10/2/25 at 8:47 A.M., the surveyor observed a medication administration being conducted by Nurse #4. The surveyor observed the following relevant to the surface of Nurse #4's medication administration cart: -A computer mouse on the surface of the cart -A pen being used by Nurse #4 to write on the surface of the cart -Nurse #4 was leaning and resting her forearms on the surface of the medication cart -Nurse #4 dropped a tablet on the surface of the medication cart when she opened the pill pack. -Nurse #4 donned a pair of gloves, picked up the tablet that was dropped and placed the tablet in a small plastic medication cup. -Nurse #4 administered the medication picked up from the medication cart surface to a resident. During an interview on 10/2/25 at 8:56 A.M., Nurse #4 said that she picked up the tablet that had dropped on the surface of the medication cart with gloves on her hands and administered the medication because it was safe for her to administer the medication. Nurse #4 said that she cleaned the surface of the medication cart prior to starting the shift but was unsure whether the medication cart surface was dirty or clean. During an interview on 10/2/25 at 9:05 A.M., Unit Manager (UM) #2 said that Nurse #4 should not have administered the medication that was dropped on the surface of the medication cart to the resident. UM #2 said that the medication cart was contaminated and dirty. UM #2 said that Nurse #4 should have destroyed the medication and removed a new medication from the pyxis to administer to the resident. During an interview on 10/2/25 at 10:20 A.M., the Director of Nursing (DON) said Nurse #4 should have destroyed the medication that was dropped on the surface of the medication cart and not administered the medication to the resident. The DON said that the medication had been contaminated from a dirty surface at the time. 2. On 12/10/25 at 4:06 P.M., the surveyor observed a medication administration being conducted by Nurse #1. The surveyor observed the following on the surface of Nurse #1's medication administration cart: - - Finger stick glucose machine (glucometer) -Lancets - -Test strips for the glucose machine - -Portable blood pressure cuff machine - -Jug of water - -Multiple assorted juices >Nurse #1 proceeded to begin medication administration to a resident and performed the following: -obtained the resident's blood pressure using the portable blood pressure machine. -returned the portable blood pressure machine and placed the machine back on top of the medication administration cart. -did not disinfect the blood pressure machine with any cleaning agent or perform any hand hygiene. -documented the resident's blood pressure reading and placed the blood pressure machine to the right side of the medication cart surface. -opened a medication to place in a medication administration cup. -dropped the medication on the surface of the medication administration cart. -picked up the dropped medication with his fingers and placed the medication in the medication administration cup. -handed the medication cup to the resident and the resident swallowed the medication. During an interview on 12/10/25 at 4:25 P.M., Nurse #1 said he had dropped the medication and picked the medication up with his bare hands without wearing gloves or sanitizing his hands. Nurse #1 said the medication administration cart was not clean and that he had not disinfected the medication administration cart. Nurse #1 said he should not have administered the dropped medication to the resident, but he did. During an interview on 12/11/25 at 11:02 A.M., the Director of Nursing (DON) said Nurse #1 informed her of the poor infection control practice on 12/10/25. The DON said Nurse #1 should have observed infection control practices during the medication administration process. The DON further said Nurse #1 should not have administered the medication that was dropped on an un-sanitized medication cart, which he picked with his/her ungloved and un-sanitized hands.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was cognitively intact and had the potential to be verbally aggressive, the Facility failed to ensure he/she was free from physical abuse by a staff member, when on 10/02/24 at approximately 12:30 P.M. (exact time unknown), Nurse #1 engaged in a verbal altercation with Resident #1 during which she grabbed his/her chin and reprimanded him/her for his/her behavior. Nurse #1 admitted to physically touching Resident #1 during the altercation. Findings include: Review of the Facility's policy titled Abuse Prohibition, dated as revised 02/20/23, indicated residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The Policy indicated that physical abuse included hitting, slapping, pinching, scratching, spitting, holding roughly, kicking etc. The Policy indicated that physical abuse also included controlling behavior through corporal punishment. Resident #1 was admitted to the Facility in March 2023, diagnoses included Parkinsonism, bipolar disorder, anxiety disorder and major depressive disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/22/24, indicated that Resident #1 was cognitively intact, with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). The Assessment indicated Resident #1 exhibited verbal and other behaviors 4 to 6 days per week, during the assessment period. Review of Resident #1's Behavior Care Plan, reviewed and renewed with the Quarterly MDS completed 09/22/24, indicated he/she exhibits persistent requests, becomes easily anxious and easily agitated when he/she does not get immediate gratification therefore he/she can be accusatory and hypercritical of others and verbally abusive toward staff. The Care Plan interventions identified for Resident #1 included the following: -Provide one-to-one with Resident #1 and allow him/her to express his/her frustrations and fears. Let Resident #1 know if any of his/her requests are beyond the reach of the Facility and attempt to problem solve ways that would work to fulfill his/her requests. -When Resident #1 becomes agitated, intervene before agitation escalates, guide away from source of distress, and engage calmly in conversation. If the response is aggressive, staff should walk calmly away and reapproach later. Review of Resident #1's Behavioral Health Note, dated 10/01/24, indicated Resident #1 requested a medication evaluation. The Note indicated Resident #1 reported that he/she wanted his/her medication adjusted so that he/she was not so angry and verbally aggressive. The Note indicated that Resident #1 said he/she was distressed by his/her behavior. The Note indicated there was a plan to check labs and to consider continuing Depakote (anticonvulsant, used as a mood stabilizer) 500 milligrams (mg) twice a day (BID) given at 8:00 A.M. and 8:00 P.M., and add Depakote 250 mg, at 2:00 P.M. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 10/02/24, indicated that during an altercation, Nurse #1 grabbed Resident #1's chin and Resident #1 slapped her, and threw water at her. The Report indicated the Facility substantiated the allegation of abuse when Nurse #1 admitted to grabbing Resident #1 by the chin, and Nurse #1 was terminated. Review of a text message sent from Nurse #1 to Administrator #2, dated 10/02/24 at 2:53 P.M., indicated Nurse #1 admitted to grabbing Resident #1's chin [during the altercation earlier that day] and that she had resigned from her position at the Facility. During an interview on 10/15/24 at 10:35 A.M., Resident #1 said that prior to the incident on 10/02/24, he/she had recognized a change in his/her mood and said he/she had felt anger and rage at times. Resident #1 said he/she felt bad for expressing his/her anger by saying mean things to staff. Resident #1 said that on Friday [09/27/24] he/she had communicated his/her change in mood to the nursing staff. Resident #1 said his/her medications were evaluated by a Behavioral Health Practitioner [on 10/01/24, the day before the incident] and that the Practitioner had recommended adding an additional 250 mg of [Depakote] his/her mood stabilizer medication. Resident #1 said that on 10/02/24, around lunch time (exact time unknown), Nurse #1 entered his/her room to administer his/her medications and that he/she asked for a mood stabilizer. Resident #1 said that he/she yelled and swore at Nurse #1 when she told him/her that an extra dose of a mood stabilizer had not yet been approved by the physician. Resident #1 said that Nurse #1 grabbed him/her, roughly, by the chin, and yelled at him/her, in response to his/her outburst. Resident #1 said that Nurse #1 yelled and said to him/her she was sick and tired of his/her acting out when she was only trying to help him/her, and that she was trying her best. Resident #1 said that he/she responded by pushing Nurse #1's hand away from his/her chin and that he/she threw a cup of water in Nurse #1's direction, as she turned and walked away. During a telephone interview on 10/16/24 at 10:14 A.M., Nurse #1 said that she went to administer Resident #1's medication on 10/02/24 at approximately 12:30 P.M., and Resident #1 requested a mood stabilizer. Nurse #1 said that when she told Resident #1 that the physician had not yet ordered the extra dose of the mood stabilizer, he/she became angry and started yelling. Nurse #1 said that Resident #1 directed profanity at her and told her she was a lousy nurse. Nurse #1 said that Resident #1 slapped her hand and threw a cup of water at her. Nurse #1 said that as she stepped away from Resident #1, she slipped in the water and landed on the floor. Nurse #1 said that she grabbed and held Resident #1's chin as you would do to a little child to get his/her attention and told him/her that his/her behavior needed to stop, right now! During a telephone interview on 10/22/24 at 8:17 A.M., the Licensed Clinical Social Worker (LICSW) said she visited with Resident #1 at 1:00 P.M. on 10/02/24, shortly after the incident with Nurse #1. The LICSW said that when she entered Resident #1's room, he/she appeared irritated and was yelling loudly. The LICSW said that Resident #1 told her that Nurse #1 grabbed his/her face during an altercation. The LICSW said that Resident #1 told her that he/she pushed Nurse #1's hand from his/her chin, and he/she inadvertently made contact with (Nurse #1's) face, but denied intentionally slapping her. The LICSW said that Resident #1 told her that he/she threw water at Nurse #1. The LICSW said that Resident #1 usually had a good rapport with Nurse #1, and that his/her moods had been deregulated leading up to the incident, and that Behavioral Health Services had been actively involved with Resident #1's behavioral health treatment plan. Nurse #1 said that grabbing Resident #1's chin during the altercation was wrong. Nurse #1 said she reported her actions to the Social Worker, before she left the Facility to seek medical care, and that she reported her actions to the Administrator, via text message. During an interview on 10/15/24 at 12:19 P.M., the Social Worker said she first learned about the altercation between Resident #1 and Nurse #1 on 10/02/24, when she (Nurse #1) interrupted the At-Risk Meeting around 1:30 P.M., and asked to be relieved so that she could seek medical care for a fall in Resident #1's room. The Social Worker said there was no abuse allegation at that time, when she spoke with Nurse #1. The Social Worker said that around 2:00 P.M., when she returned to her office after the At-Risk Meeting, Nurse #1 told her that she had grabbed Resident #1 by the chin during the altercation. During an interview on 10/15/24 at 12:00 P.M., the Case Manager said that on 10/02/24 sometime between 1:30 and 2:00 P.M., Nurse #1 told her that Resident #1 became angry during medication pass and said that he/she (Resident #1) slapped her (Nurse #1) and threw water at her. The Case Manager said Nurse #1 told her that she grabbed Resident #1 by his/her chin to get him/her to listen. During a telephone interview on 10/16/24 at 12:47 P.M., Administrator #2 said that on 10/02/24 Nurse #1 told him that around 12:30 P.M., she slipped and fell after Resident #1 had thrown water at her. Administrator #2 said the Social Worker told him that Nurse #1 had admitted to grabbing Resident #1's chin during the altercation. The Administrator said Nurse #1 sent him a text message that said she had grabbed Resident #1's chin during the altercation and that she wished to resign from her position at the Facility. Administrator #2 said the outcome of the Facility's Internal Investigation was that the allegation of physical abuse was substantiated and that Nurse #1's last day of employment at the Facility was 10/02/24.

Based on record and policy review, and interview, the facility failed to conduct interdisciplinary care plan meetings after the Minimum Data Set (MDS) assessments were completed, and involve the Resident and/or Resident Representative in the care planning process for six Residents (#11, #1, #2, #23, #54, and #8), out of a total sample of 26 residents. Specifically, the facility failed to provide evidence of a care plan meeting being held, or that the Resident and/or Resident Representative had participated in the care planning process following the MDS assessments completed: 1. For Resident #11 on 5/20/24. 2. For Resident #1 on 3/25/24 and 6/25/24. 3. For Resident #2 on 12/22/23, 3/21/24 and 6/20/24. 4. For Resident #23 on 9/8/23, 12/1/23, 2/23/24, and 5/25/24. 5. For Resident #54 on 5/20/24 6. For Resident #8 on 8/10/23 and 2/28/24. Findings include: Review of the policy titled Comprehensive Care Plan, undated, included the following: --Our facility's Care Planning/Interdisciplinary Team (IDT) in coordination with the resident, his/her family or representative (sponsor), develops, and maintains a comprehensive care plan for each resident . -Members of the interdisciplinary team responsible for assisting the resident/representative with the development of a comprehensive care plan include but are not limited to: a. Resident/representative . -The Care Planning/Interdisciplinary Team along with the resident/representative is responsible for the review and updating of care plans: At least quarterly. Review of the facility policy titled Care Planning - Interdisciplinary Team (IDT), last revised 5/12/21 and reviewed May 2022, included the following: -The care plan is based on the resident's comprehensive assessment (and other assessments as appropriate) and is developed with the resident/representative with the Care/Planning Interdisciplinary Team. -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are invited and encouraged to participate in the development of and revisions to the resident's care plan. 1. Resident #11 was admitted to the facility in May 2024, with diagnoses including Bipolar Disorder (a mental disorder characterized by periods of depression and periods of elevated mood) and Type 2 Diabetes (DM II - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). Review of the Resident's clinical record showed evidence that an MDS Assessment had been completed on 5/20/24, and the MDS assessment indicated that the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Review of the Resident's clinical record did not provide any evidence of any involvement of the Resident and/or their Representative being involved in the care planning process or that a care plan meeting had been held following the MDS Assessment completed on 5/20/24. During an interview on 8/6/24 at 1:16 P.M., the MDS Nurse said that there had not been any care plan meetings held with the Resident and/or their Representative related to the development of the Resident's care plan since admission to the facility in May 2024. During an interview on 8/6/24 at 2:01 P.M., the Social Worker (SW) said that she was unable to provide any evidence of a care plan meeting being held or any involvement of the Resident and/or their Representative in the development of the care plan since the Resident's admission to the facility in May 2024. 50563 2. Resident #1 was admitted to the facility in April 2018, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD: a group of diseases of the lungs that cause airflow blockage and breathing-related problems), Type 2 Diabetes, Chronic Kidney Disease [CKD] Stage 4 (moderately to severely damaged kidneys causing them to no longer work as they should to filter waste from the blood), Chronic Heart Failure (CHF: a condition of the heart caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs), and Methicillin Resistant Staphylococcus Aureus (MRSA: strain of gram-positive bacteria resistant to several antibiotics, making it difficult to treat, which spreads through contact with infected individuals). Review of Resident #1's MDS Assessment, dated 6/25/24, indicated the Resident was moderately cognitively impaired as evidenced by a BIMS score of 9 out of 15. Review of Resident #1's MDS records indicated that MDS Assessments were completed on 3/25/24 and on 6/25/24. Review of Resident #1's clinical record indicated no evidence that a care plan meeting was held or that the Resident and/or their Representative were involved/offered to be involved in the review and revision of the Resident's care plan following the completion of MDS assessments on 3/25/24 and 6/25/24. During an interview on 8/6/24 at 2:01 P.M., the SW said she could not provide evidence that Resident #1 and/or their Representative were involved in/or offered involvement in the review and revision of the Resident's care plan following his/her scheduled MDS assessments on 3/25/24 and 6/25/24. 3. Resident #2 was admitted to the facility in November 2019, with diagnoses including Unspecified Cerebral Infarction (occurs when blood flow to the brain is blocked causing damage to the brain tissue), Vascular Dementia (a chronic condition that affects memory, thinking and behavior due to damage to the brain caused by restricted blood flow), and CKD Stage 2 (where the kidneys are still functioning well but there are signs of kidney damage). Review of Resident #2's MDS Assessment, dated 6/25/24, indicated the Resident was moderately cognitively impaired as evidenced by a BIMS score of 11 out of 15. Review of Resident #2's MDS records indicated that MDS Assessments were completed on 12/22/23, 3/21/24 and on 6/20/24. Review of Resident #2's clinical record indicated no evidence that a care plan meeting was held or that the Resident and/or their Representative were involved/offered to be involved in review and revision of the Resident's care plan following completion of MDS assessments on 12/22/23, 3/21/24 or 6/20/24. During an interview on 8/6/24 at 2:01 P.M., the SW said she could not provide evidence that Resident #2 and/or their Representative were involved in/or offered involvement in the review and revision of the Resident's care plan following his/her MDS assessments on 12/22/23, 3/21/24 or 6/20/24. 45435 4. Resident #23 was admitted to the facility in December 2023, with a diagnosis of Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy). Review of the MDS Assessment, dated 5/24/24, indicated that Resident #23 was severely cognitively impaired as evidenced by a BIMS score of 6 out of 15. Review of the Resident's clinical record indicated the following relative to MDS assessments: -assessment dated [DATE] was completed on 9/14/23. -assessment dated [DATE] was completed on 12/5/23. -assessment dated [DATE] was completed on 3/6/24. -assessment dated [DATE] was completed on 6/10/24. Review of Resident #23's medical record indicated no documentation that a care plan conference was held, or the Resident and/or Resident Representative was involved in the care planning process after the completion of the 9/8/23, 12/1/23, 2/23/24, and 5/25/24 MDS assessments. During an interview on 8/2/24 at 3:30 P.M., the MDS Nurse said the process for care plan meeting scheduling is that the MDS Nurse provides a list of upcoming care plan meetings to the front desk staff, and the front desk staff send out notifications to the IDT (interdisciplinary team). The MDS Nurse further said that the Social Worker schedules and holds the care plan meetings. The MDS Nurse said she could not provide documented evidence that Resident #23's care plan meetings had been held with the IDT and the Resident/Resident Representative after the completion of the 9/8/23, 12/1/23, 2/23/24, and 5/25/24 assessments. During an interview on 8/6/24 at 8:15 A.M., the SW said she could provide no documented evidence that care plan meetings had been held for Resident #23 with the IDT and the Resident/Resident Representative after the completion of the 9/8/23, 12/1/23, 2/23/24, and 5/25/24 assessments. 42741 5. Resident #54 was admitted to the facility May 2024, with diagnoses including Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), Major Depressive Disorder, and Conversion Disorder (also known as functional neurological symptom disorder [FND], is a condition where mental health issues disrupt how your brain works). During an interview on 7/31/24 at 8:23 A.M., Resident #54 said he/she had been admitted a couple of months ago and he/she had not had any care plan meetings since he/she was admitted to the facility. Review of the most recent comprehensive MDS Assessment, dated 5/20/24, indicated Resident #54 had a BIMS score of 13 out of 15, indicating that he/she was cognitively intact. Review of Resident #54's medical record indicated no documentation that a care plan meeting had been held with the Resident and/or his/her Representative to review and revise Resident #54's plan of care following the most recent comprehensive assessment on 5/20/24. During an interview on 8/5/24 at 9:22 A.M., the SW said she was responsible for documenting when care plan meetings where held. The SW further said the documentation should include who attended the meeting, any concerns regarding care that were addressed during the meeting, and the resident's goals. During an interview on 8/5/24 at 1:23 P.M., the MDS Nurse said Resident #54 did not have a care plan meeting following his/her most recent comprehensive MDS Assessment which was the Resident's admission assessment. The MDS Nurse further said the facility had not been doing care plan meetings after admission assessments were completed and the care plan meeting should have been completed by Day 21 after the MDS admission assessment was completed. 50320 6. Resident #8 was admitted to the facility in April 2021, with diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) and Chronic Obstructive Pulmonary Disease. Review of the MDS Assessment, dated 5/3/24, indicated the Resident was cognitively intact as evidenced by a BIMS score of 14 out of 15. During an interview on 7/31/24 at 10:41 A.M., the Resident said he/she does not remember being invited to or attending care plan meetings. Review of the Resident's clinical record indicated that MDS assessments had been completed on 8/10/23 and 2/28/24. Further review of Resident #8's clinical record did not indicate any evidence that the facility held a care plan meeting and/or involved the Resident and/or their Representative in reviewing the care plan after the MDS assessments were completed on 8/10/23 and 2/28/24. During an interview on 8/1/24 on 1:26 P.M., the MDS Nurse said she makes the list of care plan meeting dates and distributes them to the staff. The MDS Nurse said she completes the care plan meeting invitations and that the front desk secretary mails them to the appropriate person. The MDS Nurse further said the SW was responsible for planning and hosting the care plan meetings. During an interview on 8/2/24 at 8:39 A.M., the MDS Nurse said she could not find any evidence the IDT held a meeting or the Resident/ Resident Representative had participated in care plan meetings for the 8/10/23 and 2/28/24 Assessments. During an interview on 8/2/24 at 1:32 P.M., the SW said the MDS Nurse was responsible for making the list of residents who were due for care plans and sending the letters to Residents/Resident Representatives. The SW said she would then facilitate putting the meetings together with Residents/Representatives and hold the meetings. The SW said she did not use an attendance sheet when the care plan meeting was completed. the SW further said there was an additional SW who no longer works in the building, and was previously responsible for Resident #8's care plan meetings. The SW said since the previous SW left in September 2023, she was now responsible for planning the care plan meetings for all the residents in the facility. The SW said she does not have any evidence IDT care plan meetings were held for Resident #8 following the 8/10/23 and 2/28/24 Assessments.

Based on observation, interview, and policy review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections within the facility on two units (Unit One and Unit Four) out of a total of four units. Specially, the facility failed to ensure: 1. On Unit One, that staff wore required Personal Protective Equipment (PPE-clothing and equipment that is worn or used in order to provide protection against hazardous substances or environments) while caring for a resident on Enhanced Barrier Precautions (EBP), placing him/her at increased risk of infection. 2. On Unit Four, that a staff member wore a fit tested N95 mask appropriately. 3. On Unit Four, that staff correctly utilized and/or discarded/ disinfected the required PPE while caring for residents diagnosed with COVID-19 (a highly contagious respiratory infection) placing residents at risk of contracting the disease. 4. On Unit Four, that staff wore the required and appropriate PPE when assisting a COVID-19 positive resident. Findings include: Review of the Occupational Safety and Health Administration (OSHA) form, titled Seven Steps to Correctly Wear a Respirator at Work, OSHA 4015-05 2020, indicated the following: -Cover your mouth and nose with the respirator and make sure there are no gaps (e.g. facial hair, hair, and glasses) between your face and the respirator. Review of the facility policy titled Transmission Based Precautions (TBP) with PPE Grid for Covid 19 Endemic, revised January 2024, indicated but was not limited to: -Covid-19 Positive Residents - recommended Staff PPE: >Fit tested N95 respirator (mask). -In addition to Standard Precautions, Enhanced Barrier Precautions (EBP) will be implemented for residents with active or colonized MDRO (Multi-Drug Resistant Organisms: bacteria that are resistant to antibiotic medications which treat bacterial infections) infections, those with indwelling devices, or chronic wounds. -In addition to wearing a gown as outlined for Standard Precautions, gowns are to be worn for high contact care activities (dressing, bathing, transferring, providing hygiene, changing linens, changing briefs/assisting with toileting), indwelling device care, wound care. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Infection Control Guidance: SARS-CoV-2 (COVID-19), updated 6/24/24, included the following: -Health Care Personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). -All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. 1. On 8/6/24 at 9:46 A.M., the surveyor observed Certified Nurses Aide (CNA) #4 in a resident room on Unit One with a sign at the doorway indicating that the resident in the room was on EBP. The surveyor observed that CNA #4 was shaving the resident and wearing gloves but was not wearing a gown as required. During an interview on 8/6/24 at 12:03 P.M., the surveyor and CNA #4 reviewed the EBP signage at the resident's door. CNA #4 said the sign indicated a gown should be worn for high contact care which would include hygiene activities like shaving. CNA #4 further said she did not wear a gown for the care but should have worn a gown. 42741 2. On 7/31/24 at 8:42 A.M., the surveyor observed Certified Nurses Aide (CNA) #3 enter the room of a COVID-19 positive resident, located on Unit Four. The surveyor observed that CNA #3 was wearing a surgical mask underneath an N95 mask (a mask that reduces a wearers exposure to small aerosol particles and large droplet particles). During an interview on 7/31/24 at 8:45 A.M., following the observation, CNA #3 said she thought having the surgical mask on under the N95 mask would provide more protection and that she had not been educated that wearing a surgical mask under an N95 mask was not good practice. Review of the facility Employee Fit Test Log, undated, indicated CNA #3 was not fit tested (procedure used to ensure that an N95 mask is the correct size and properly fits the face of the person who wears it) until 8/4/24. During an interview on 8/6/24 at 10:33 A.M., with the Corporate Infection Control Nurse and the facility's Infection Preventionist (IP), the Corporate Infection Control Nurse said wearing a surgical mask under an N95 mask should not be done as it compromises the fit of the N95 mask. During an interview on 8/6/24 at 1:35 P.M., the Corporate Infection Control Nurse said CNA #3 had not been fit tested for the use of an N95 mask until 8/4/24 after the surveyor had brought the concern to the facility's attention. 37400 3. On 7/31/24 on 9:14 A.M., the surveyor observed CNA #1 assisting a resident in their room with breakfast. The surveyor observed the signage posted outside of the resident's room indicated the following: -that it was COVID-19 positive room. -STOP. Isolation in addition to Standard Precautions. -Staff and Providers MUST: >clean hands when entering and exiting, >gown- change between each resident, >N 95 respirator, >eye protection (goggles or face shield) and >gloves-change between each resident. The surveyor observed a bin containing N95 and surgical masks, gowns, gloves and eye protection was located outside of the resident's room but there was no disinfectant in the vicinity. The surveyor observed that CNA #1 was wearing a surgical mask (not an N95 mask), gown, and eye protection. CNA #1 was not wearing gloves as required. The surveyor observed that prior to exiting the room, CNA #1 disposed of her gown and removed her eye protection (goggles) and placed them in her shirt pocket. CNA #1 conducted hand hygiene and exited the room, without removing her surgical mask or disinfecting her eye protection. During an interview on 7/31/24 at 9:33 A.M., CNA #1 said Resident #52 was positive for COVID-19 and staff were required to put on a gown, gloves, eye protection and an N95 mask prior to entering the room. CNA #1 said the gown and gloves should be removed upon exiting the room. CNA #1 said she should have worn an N95 mask and gloves but she did not. CNA #1 further said that reusable eye protection should be wiped down with bleach wipes upon exiting an Isolation Precautions room. CNA #1 said she did not disinfect her eye protection upon exiting the (COVID-19 positive) resident's room. The surveyor observed CNA #1 open the PPE bin located outside of the resident's room and CNA #1 said that N95 masks were available but she did not see bleach wipes. 4. On 8/1/24 at 9:03 A.M., the surveyor observed CNA #5 in the room of a COVID-19 positive resident during the breakfast meal. The surveyor observed the signage outside of the resident's room indicated that Isolation Precautions were in place. The surveyor observed that a bin was located outside of the resident's room and contained N95 masks, gowns, gloves, eye protection and surgical masks. The surveyor further observed that CNA #5 was wearing a gown and a surgical mask with an N95 mask over the surgical mask. The surveyor observed that CNA #5 was not wearing eye protection as required. During an interview at the time, the Minimum Data Set (MDS) Nurse, who was present during the observation, said CNA #5 was wearing two masks and should be wearing the N95 mask only. The MDS Nurse said CNA #5 did not have eye protection and should. During an interview on 8/1/24 at 9:35 A.M., CNA #5 said she should have worn all of the required PPE for the COVID-19 positive resident which included eye protection, gown, gloves and the N95 mask, but thought because she was in the room briefly, she did not have to wear the required PPE. CNA #5 further said that she wore the surgical mask under the N95 mask because she thought this added another layer of protection.

Based on record review and interview, the facility failed to ensure a care plan was developed to address the medical needs for one Resident (#52) out of a total sample of 26 residents. Specifically, for Resident #52, the facility failed to ensure a care plan was developed that included necessary interventions and goals relative to the care of a pressure wound (injury to the skin and underlying tissue resulting from prolonged pressure or friction). Findings include: Resident #52 was admitted to the facility in February 2022, and had a diagnosis of a Stage Two (2) pressure wound (partial thickness wound with loss of skin presenting as an open shallow ulcer) to his/her coccyx (tail bone area). Review of the Nursing Admission/Readmission Nursing Assessment, Skin Integrity, dated 5/8/24, indicated Resident #52 had been readmitted to the facility following a hospitalization and he/she had a pressure wound to his/her coccyx. Review of the most recent comprehensive MDS Assessment, dated 6/20/24, indicated that Resident #52 had an unhealed pressure wound. Review of the corresponding Care Area Assessments (CAA - responses triggered by the MDS Assessment which indicated whether the facility will proceed to creating a specific care plan for the identified concern in question) indicated a care plan related to Resident #52's pressure wound should have been created. Review of the Resident's care plan indicated that no pressure wound care plan with pressure wound interventions and/or goals for the pressure wound had been created after the MDS Assessment completion on 6/20/24. Review of the Wound Physician Note, dated 8/5/24, indicated that the Resident was still being treated for a Stage 2 pressure wound to his/her coccyx. During an interview on 8/6/24 at 12:19 P.M., the Infection Preventionist (IP), who rounded (when the medical team visits a resident to review their status and care plan) with the Wound Physician, said when Resident #52 returned from the hospitalization , upon identification of the pressure wound, a care plan should have been developed addressing the interventions and goals for the pressure wound and this was not done.

Based on interview, record review, and policy review the facility failed to maintain professional standards of practice to prevent the development and promote healing of pressure ulcers/skin injuries for one Resident (#83) out of a total sample of 26 residents. Specifically, for Resident #83 the facility failed to ensure: 1. that Physician's orders for care and treatment were in place to prevent worsening of a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) identified at the time the Resident was admitted to the facility. 2. the completion of weekly wound assessments to monitor for improvement and/or deterioration of the wound. 3. that recommended lab work was obtained. Findings include: Review of the facility policy titled Pressure Ulcer Prevention, revised 12/22/22, indicated the following: -Wounds will have weekly assessment and documentation on each area until healed. Review of the facility policy titled Wound Care, undated, indicated the following: -Verify that there is Physician's orders for this procedure. -The following information should be recorded in the resident's medical record: >All Assessment data (i.e. wound bed color, size, drainage, etc) Resident #83 was admitted to the facility in July 2024, with diagnosis of a right tibia (long bone in the lower leg) fracture. During an interview on 7/31/24 at 9:45 A.M., the surveyor observed Resident #83 lying in bed and the Resident's spouse said Resident #83 had fallen and broken his/her leg. The Resident's spouse said he/she was put into a leg immobilizer (removable splint that keeps a person from bending their knee to allow for a leg fracture to heal) at his/her previous nursing home and the immobilizer had caused a pressure area on his/her outer right leg. Resident #83's spouse said they were concerned that the area had grown, and felt when Resident #83 was first admitted to the facility that the wound dressing was not being changed regularly. Review of the Weekly Skin Assessment, dated 7/3/24 at 7:30 P.M., indicated Resident #83 had a 5 centimeter (cm) by (x) 2 cm injury to his/her right leg. Review of the Weekly Skin Assessment, dated 7/3/24 at 8:15 P.M., indicated Resident #83 had a large wound to the lower right leg that was red and open, and the Wound Physician had been notified. Further review of the Resident's medical record indicated no wound specific assessment had been completed when the wound on Resident #83's right leg was identified. Review of the most recent comprehensive Minimum Data Set (MDS) Assessment, dated 7/9/24, indicated Resident #83 had one unhealed pressure injury/ulcer. Review of the 7/8/24 Wound Physician Note indicated Resident #83 had: -an unstageable (due to necrosis [dead skin] of the right lateral [outside] calf) that measured 8 cm long x 3 cm wide and 0.1 cm deep. Further review of the 7/8/24 Wound Physician Note indicated the following treatment: -Calcium Alginate (a wound dressing used to absorb wound fluid), once daily and as needed (PRN). -Santyl (an ointment used to remove dead or damaged tissue), once daily and as needed (PRN). -Gauze roll, apply once daily and as needed (PRN). Review of the 7/8/24 Wound Physician Note also indicated a recommendation for a Prealbumin level to be drawn (lab work that assess whether a person is getting adequate nutrition in their diet). Review of the July 2024 Physician's orders from 7/3/24 through 7/9/24, indicated that no orders were in place for the care and treatment of Resident #83's wound on his/her right lower leg. Further review of the July 2024 Physician's orders indicated on 7/10/24, the orders for wound care as recommended by the Wound Physician on 7/8/24 were put into place. Further review of the Resident's medical record indicated no documentation that the facility was completing weekly wound assessments. During an interview on 8/5/24 at 8:06 A.M., the Director of Nursing (DON) said at the time Resident #83 was admitted to the facility the Resident's Primary Physician should have been consulted to obtain wound treatment orders for Resident #83's right leg wound until the Wound Physician could assess the Resident and that this was not done. The DON said recommendations for the treatment of the Resident's wound were not made until the Wound Physician saw him/her on 7/8/24. The DON further said the Wound Physician's orders should have been put into place immediately and this was not done until 7/10/24. The DON said the facility had a weekly Wound Assessment Form that should have been completed every week starting at admission when it was identified the Resident had a wound. The DON said the weekly Wound Assessment Form was not completed until the surveyor asked about the wound care for Resident #83. The DON said she would need to look into whether the lab work for the Prealbumin level was ordered per the Wound Physician's recommendation. At the time of survey exit on 8/6/24, the facility had not provided documentation that the recommended Prealbumin level had been obtained for Resident #83 as recommended by the Wound Physician.

Based on observation, interview, record and policy review, the facility failed to provide care and services for the administration of supplemental Oxygen (O2), consistent with professional standards of practice for one Resident #272, out of a total sample of 26 residents. Specifically, for Resident #272, the facility failed to ensure that Physician orders were in place for the use of Oxygen and the care and services of oxygen equipment when the Resident had pulmonary diagnoses that required safe and appropriate Oxygen administration to prevent the occurrence of adverse events. Findings include: Review of the facility policy titled Oxygen Administration Policy and Procedure, reviewed 12/6/22, indicated the following: -Oxygen is administered by Licensed Nurses with a Physician's order. -Orders should specify the oxygen equipment and flow rate or concentration required as routine or as needed (PRN). Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with physicians' orders or inadequate instruction for oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia [high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in PaCO2. -Equipment maintenance and supervision: >All oxygen delivery equipment should be checked at least once daily >Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. >should be serviced and maintained in accordance with the manufacturer specifications and consistent with all federal, state, and local laws and regulations. Resident #272 was admitted to the facility in November 2021, with diagnoses including Chronic Respiratory Failure (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue) and Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease that causes restricted airflow from the lungs and make it difficult to breathe). Review of the most recent Minimum Data Set (MDS) Assessment, dated 6/4/24, indicated Resident #272 had clear speech, was able to be understood, and understands. During an observation and interview on 7/31/24 at 8:30 A.M., the surveyor observed Resident #272 lying in bed and utilizing Oxygen via nasal cannula (tubing that supplies supplemental oxygen through the nose via nasal prongs). The surveyor observed that the Resident's oxygen concentrator (machine that delivers the supplemental oxygen) indicated the Resident was receiving O2 at 2 liters per minute (LPM - the flow rate of the oxygen). Resident #272 said he/she had been using O2 for a while and that his/her O2 should be set at 2 LPM. On 8/1/24 at 9:24 A.M., the surveyor observed Resident #272 lying in bed, utilizing O2 via nasal cannula and the oxygen concentrator was set at 3.5 LPM. Review of Resident #272's Physician's orders for July 2024 and August 2024, indicated no Physician's orders were in place for the administration of Oxygen and the care and services of oxygen equipment. Review of Resident #272's care plan titled Altered Respiratory Status/Difficulty Breathing due to COPD ., initiated 10/23/23, indicated the following intervention: -Oxygen Settings: O2 via nasal cannula as needed (PRN). Review of the most recent Physician's Visit Note, dated 7/1/24, indicated the following plan: -As needed (PRN) Oxygen During an observation and interview on 8/1/24 at 9:36 A.M., the surveyor and Nurse #3 observed Resident #272 lying in bed and utilizing Oxygen via nasal cannula set at 3.5 LPM. Nurse #3 said Resident #272's O2 should be set at 2 LPM. Nurse #3 reviewed Resident #272's Physician's orders and said Resident #272 did not have orders in place for the administration of Oxygen or for the care and services of the oxygen equipment. Nurse #3 said orders should have been put in place that included the administration of O2 and the liter flow, changing of oxygen tubing weekly, if titration (increasing or decreasing) of O2 was needed, and the goal of what Resident #272's oxygen saturation level (amount of O2 in the blood) should remain at.

Based on interview, record and policy review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were acted upon as required for one Resident (#23), of five applicable residents reviewed for unnecessary medications, out of a total sample of 26 residents. Specifically, the facility staff failed to act upon the Consultant Pharmacist recommendation dated 5/4/24, to include an evaluation date for a PRN (as needed) psychotropic (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medication. Findings include: Review of the facility policy titled Medication Regimen Review, undated, indicated the following: -The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. -The findings are phoned, faxed, or e-mailed within (24 hours) to the Director of Nurses (DON) or designee and are documented and stored with the other Consultant Pharmacist recommendation in the resident's active record. -Recommendations are acted upon and documented by the facility staff and/or the Prescriber. Resident #23 was admitted to the facility in December 2023, with a diagnosis of Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy). Review of the Physician's orders, dated August 2024, indicated the following: -Ativan (anti-anxiety medication) oral tablet 0.5 milligrams (mg), give 0.5 mg by mouth every six hours as needed (PRN) for anxiety/agitation, start date 4/19/24. Review of the Consultant Pharmacist recommendation, dated 5/4/24, indicated the following: -MD (Medical Doctor) Rec (recommendation): Please update this Resident's PRN Ativan order to include an evaluation date. Review of the July 2024 and August 2024 Medication Administration Records (MARs), indicated Resident #23 was administered the PRN Ativan 0.5 mg on the following dates/times: -7/5/24 at 8:12 A.M. -8/5/24 at 7:46 A.M. Review of the Resident's Progress Notes indicated no documented evidence the Consultant Pharmacist recommendation dated 5/4/24, had been acted upon. During an interview on 8/6/24 at 10:21 A.M., the surveyor and the Regional Nurse reviewed the Physician's orders and the Consultant Pharmacist recommendation. The Regional Nurse said the Nurses should have requested a re-evaluation date or a stop date be added to the Ativan PRN order as required. During an interview on 8/6/24 at 10:30 A.M., the Director of Nursing (DON) said the process for Medication Regimen Review (MRR) is that the Consultant Pharmacist reviews the resident records monthly and sends her (the DON) an e-mail within a day or two with the recommendations. The DON said that she prints the recommendations and gives them to the Provider (Physician/ Nurse Practitioner [NP]), the Provider addresses the recommendation and returns the completed recommendation to the DON. The DON said she had reviewed her binder of Consultant Pharmacist recommendations and she did not have the completed recommendation for Resident #23 dated 5/4/24. The DON said this recommendation had not been acted upon and should have been.

Based on record review, and interview, the facility failed to ensure that Physician orders were in place prior to laboratory testing being conducted for two Residents (#52 and #59), out of a total applicable sample of three residents. Specifically, for Residents #52 and #59, the facility failed to ensure that a Physician's order for COVID-19 testing was in place prior to the Residents being tested for COVID-19. Findings include: Review of the facility policy titled Policy and Procedure: Testing for COVID-19, updated 3/31/23, indicated the following: -Resident testing will be performed per Medical Doctor (MD) order. 1. Resident #52 was admitted to the facility in February 2022, with a diagnosis of Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language). Review of the facility's testing for COVID-19 line listing, undated, indicated Resident #52 was tested for COVID-19 every other day starting on 7/24/24 through 7/30/24, and then tested daily from 8/1/24 through 8/5/24. Review of Resident #52's July 2024 and August 2024 Physician's orders indicated there were no Physician's order for COVID-19 testing. 2. Resident #59 was admitted to the facility in March 2024, with a diagnosis of Unspecified Dementia (a mental disorder that occurs when someone has Dementia but does not have a specific diagnosis). Review of the facility testing for COVID-19 line listing, undated, indicated Resident #59 was tested for COVID-19 every other day starting on 7/24/24 through 7/30/24, and then tested daily from 8/1/24 through 8/6/24. Review of Resident #59's July 2024 and August 2024 Physician's orders indicated there were no Physician's order for COVID-19 testing. During an interview on 8/6/24 at 11:43 A.M., the Corporate Infection Control Nurse said Resident's #52 and #59 had been tested for COVID-19 in July 2024 and August 2024 and did not have a Physician's order in place for COVID-19 testing.

Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately coded for two Residents (#35, and #54) out of a total sample of 26 residents. Specifically, the facility failed to: 1. Accurately code that Resident #35 was no longer receiving an antibiotic (medication used to treat bacterial infections) medication. 2. Accurately code that Resident #54: -received Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) services. -utilized eyeglasses. Findings include: 1. Resident #35 was admitted to the facility in March 2024 with a diagnosis of Cellulitis (potentially serious bacterial infection of the skin) of the left lower limb. Review of the most recent MDS assessment dated [DATE], indicated that the Resident was currently taking an antibiotic. Review of the March 2024 through August 2024 Physician's orders indicated the Resident was prescribed the following antibiotic medications: -Cipro Oral Tablet 500 MG (Ciprofloxacin HCI) Give 500 milligrams (mg) by mouth, two times a day for Cellulitis until 3/22/24, start date 3/11/24 -Doxycycline Hyclate oral Tablet 100 MG (Doxycycline Hyclate) Give 100 mg by mouth, two times a day until 3/21/24 During an interview on 8/5/24 at 12:23 P.M., the MDS Nurse said that Resident #35 was not currently receiving antibiotics, and was not receiving antibiotics at the time of the MDS assessment dated [DATE]. The MDS Nurse said that the MDS Assessment should not have been coded that the Resident was receiving an antibiotic, as the Cipro medication was completed on 3/22/24, and the Doxycycline medication was completed on 3/21/24. 42741 2. Resident #54 was admitted to the facility in May 2024, with diagnoses including Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), and Conversion Disorder (a condition where mental health issues disrupt how the brain works). Review of the Social Work Progress Note dated 5/17/24, indicated Resident #54 signed onto Hospice Services on 5/16/24. Review of the Admission/Readmission nursing assessment dated [DATE], indicated Resident #54 used eyeglasses. Review of the most recent comprehensive MDS assessment dated [DATE], indicated Resident #54 was not receiving Hospice Services and did not use eyeglasses. During an interview on 8/5/24 at 12:20 P.M., the MDS Nurse said the 5/20/24 MDS Assessment was coded inaccurately. The MDS Nurse further said Resident #54 was on Hospice Services and used eyeglasses. The MDS Nurse said the 5/20/24 MDS Assessment would need to be modified.

Based on records reviewed and interviews, for one of four sampled residents (Resident #3), who's physician orders included the administration of an anticoagulant (prevents blood clots) medication and the administration of intravenous (IV) antibiotics which required the review of laboratory results to determine dosage amounts, the facility failed to ensure Resident #3's provider was notified when 1) the anticoagulant was unavailable and not administered, placing him/her at risk for the development of a blood clot and 2) despite being instructed by the provider to obtain Resident #3's laboratory results related to his/her IV antibiotic, nursing had not done so, which resulted in Resident #3 missing a dose of his/her IV antibiotic. Findings include: Review of the Facility's policy, Change In Resident's Condition or Status and Notification, reviewed June 2022, indicated the following: -Purpose: To ensure that the resident and/or his/her representative, and his/her attending physician/physician extender are notified of changes in the resident's medical/mental condition and/or status. -Policy: The RN Nurse Supervisor/Charge Nurse will notify the resident's Attending physician, physician extender or on-call physician when there has been a significant change in the resident's medical/mental conditions and/or status including but not limited to: A need to alter the resident's medical treatment significantly. Resident #3 was admitted to the Facility in November 2023, diagnoses included chronic osteomyelitis of left tibia and fibula, peripheral vascular disease, aftercare following joint replacement surgery, and atherosclerotic disease. 1) Review of Resident #3's Physicians Orders, for November 2023, included the administration of the following: Enoxaparin Sodium (anticoagulant) Injection 40 milligrams (mg)/0.4 milliliters (ml); inject 40 mg subcutaneously every 24 hours. Review of Resident #3's Medication Administration Record (MAR), dated November 2023, indicated the following: -11/10/23 Enoxaparin Sodium Injection 40 mg/0.4 ml inject 40 mg subcutaneously at 24 hours (time not specified on the MAR). Further review of Resident #3's MAR indicated Nurse #1 documented code 5 which indicated to hold the medication and see Nurses Note. Review of Resident #3's Nursing Progress Note, dated 11/10/23 at 20:17 (8:17 P.M. and written by Nurse #1), indicated the Enoxaparin Sodium Injection was not administered due to waiting for the pharmacy (delivery). During an interview on 12/06/23 at 2:09 P.M., Nurse #1 said that he remembered Resident #3's family member inquiring if the Enoxaparin had been administered. Nurse #1 said that if all of the medications had been delivered from the pharmacy, he would have administered the Enoxaparin as ordered, but said because he had not received the medication, he was unable to administer it. Nurse #1 said he told the on-coming nurse that the medication (Enoxaparin) had not been given but said that he did not remember notifying the Physician/Physician Assistant (PA) that the Enoxaparin was not available and therefore not administered as ordered. Review of Resident #3's medical record indicated there was no additional documentation to support that the Physician or PA were notified that the medication was not available, not administered, or that any new orders were obtained by nursing related to his/her anticoagulant medication. During an interview on 12/06/23 at 1:16 P.M. the Physician Assistant (PA) said she just found out today (12/06/23) that Resident #3 had not been administered the Enoxaparin as ordered. She said she definitely expected to be notified if the Enoxaparin had not been given. 2) Review of Resident #3's History and Physical, signed by the PA and dated 11/10/23, indicated Resident #3 was to continue with Intravenous Vancomycin 1000 mg twice daily, and that the Facility would contact the Hospital Infectious Disease Department for the Vancomycin trough (to determine therapeutic dosage of Vancomycin) goal. During an interview on 12/06/23 at 2:09 P.M., Nurse #1 said he told the PA on 11/10/23 that he was waiting for a fax or phone call from the Hospital regarding the Vancomycin trough level and goal, but that it was earlier in the shift when he notified her. Nurse #1 said that he told the Unit Manager (at the time) that he was unable to get the Vancomycin trough levels or goals from the Hospital. Review of Resident #3's medical record indicated no documentation to support that the Physician or the PA were notified that the Vancomycin trough level from Resident #3's hospital stay had not been obtained, as requested by the PA on 11/10/23. During an interview on 12/06/23 at 1:16 P.M., the Physician Assistant (PA) said that she was in the Facility on 11/10/23 to see Resident #3. The PA said she had asked nursing to call the Hospital to get the last Vancomycin trough level and that no one from nursing had notified her that they were unable to obtain the information as requested. The PA said she went to the facility on [DATE] but that Resident #3 had already been transferred to the Hospital. During an interview on 12/06/23 at 4:53 P.M., the Director of Nurses (DON) said that when residents are admitted , the nursing staff obtain and need to follow orders the physician. The DON said if the nursing staff was unable to obtain a medication, she expected nursing to inform the provider that the medication was unavailable to be administered as ordered.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure that staff implemented and followed their Abuse Policy related to the need to immediately report an allegation of neglect to the Administrator or Director of Nurses (DON). On 10/22/23, at the start of the day (7:00 A.M. - 3:00 P.M.) shift Nurse #3 was made aware of an allegation of possible resident neglect made against Certified Nurse Aide (CNA) #1, however, Facility administration was not made aware of the allegation until approximately 2:00 P.M. (several hours later), when CNA #2 reported the incident directly to the DON via telephone. Findings include: Review of the Facility's policy titled Abuse Prohibition, updated 02/20/23, indicated the following: -Allegations of abuse will be reported promptly and thoroughly investigated. -Any employee who has reasonable cause to believe a resident has been abused, mistreated, or neglected shall immediately report alleged incidents to their Supervisor, Director of Nursing Services, or Administrator. -The Shift Supervisor/Charge Nurse is identified as responsible for the immediate initiation of the reporting process. -Report the incident immediately to the Director of Nursing and or Administrator. Resident #1 was admitted to the Facility in March 2023, diagnoses included congestive heart failure, primary osteoarthritis and Parkinson's disease. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/27/23, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and that he/she required extensive assistance from staff with hygiene and bathing. During a telephone interview on 12/07/23 at 10:08 A.M., Certified Nurse Aide (CNA) #2 (which also included review of his written witness statement, undated) said on 10/22/23 he worked from 7:00 A.M. to 7:00 P.M., and started his shift that morning by doing a quick visual check on each of the residents on his assignment. CNA #2 said that when he went into Resident #1's room he noticed that he/she was crying, and his/her bed linens were saturated with urine. CNA #2 said that Resident #1 told him that CNA #1 was assigned to provide his/her care during overnight shift but that she (CNA #1) refused to touch him/her. CNA #2 said that Resident #1 told him that CNA #1 told him/her (Resident #1) that she (CNA #1) would not clean him/her up because he/she had herpes. CNA #2 said he immediately reported Resident #1's allegation to Nurse #3 on 10/22/23 and said that later during his lunch break at approximately 2:00 P.M., he and CNA #3 reported the incident, to the Director of Nurses (DON) by phone. During a telephone interview on 12/07/23 at 10:23 A.M., Nurse #3 said she was the nurse assigned to Resident #1 on 10/22/23 from 7:00 A.M. to 7:00 P.M. Nurse #3 said that on the morning of 10/22/23, CNA #2 reported to her that Resident #1 alleged that CNA #1 denied him/her care during the overnight shift because he/she had herpes. Nurse #3 said she spoke with Resident #1 and he/she told her that CNA #1 refused to touch him/her or provide incontinence care because he/she had herpes. Nurse #3 said she did not recall reporting the incident to Administration. During an interview on 12/06/23 at 3:00 P.M., the Assistant Director of Nurses (ADON), said she was the Director of Nurses (DON) at the time of the alleged incident between Resident #1 and CNA #1. The ADON said that on 10/22/23 at 2:00 P.M., CNA #2 and CNA #3 called her on the phone and reported an allegation of neglect involving Resident #1 and CNA #1. The ADON said that was the first time she had been notified of the allegation. During an interview on 12/06/23 at 3:15 P.M., the Administrator said he was not aware of the allegation of neglect involving Resident #1 and CNA #1 until the afternoon of 10/26/23, at which time he reported the incident to the Department of Public Health (DPH). The Administrator said the expectation was that the Charge Nurse should immediately alert himself and/or the DON when an allegation involving abuse, neglect or misappropriation was made.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure that after being made aware of an allegation of neglect on 10/22/23, that they reported the allegation to the Department of Public Health (DPH) within two hours, as required. On 10/22/23, the Director of Nurses (DON) was made aware of an allegation of neglect involving Resident #1 and Certified Nurse Aide (CNA) #1, the facility's report was not submitted to DPH by the facility until 10/26/23, four days after first being made aware of the allegation. Findings include: Review of the Facility's policy titled Abuse Prohibition, updated 02/20/23, indicated the Administrator and Director of Nurses are responsible for investigation and reporting. The Policy indicated that the Administrator is responsible for ensuring that there has been notification of local law enforcement and the State Survey Agency within two hours of the allegation after identification of the alleged/suspected incident. The Policy indicated that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of resident property are reported immediately but not later than two hours after the allegation is made. Resident #1 was admitted to the Facility in March 2023, diagnoses included congestive heart failure, primary osteoarthritis and Parkinson's disease. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/27/23, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and he/she required extensive assistance from staff with hygiene and bathing. During a telephone interview on 12/07/23 at 10:08 A.M., Certified Nurse Aide (CNA) #2 (which also included a review of his written witness statement, undated) said he worked from 7:00 A.M. to 7:00 P.M. on 10/22/23, and started his morning by doing a quick visual check on each of the residents on his assignment. CNA #2 said that when he went into Resident #1's room he noticed that he/she was crying, and his/her bed linens were saturated with urine. CNA #2 said that Resident #1 told him that CNA #1 was assigned to provide his/her care on the overnight shift but that she (CNA #1) refused to touch him/her. CNA #2 said that Resident #1 told him that CNA #1 told him/her (Resident #1) that she (CNA #1) would not clean him/her up because he/she had herpes. CNA #2 said he immediately reported Resident #1's allegation to Nurse #3 on 10/22/23 and said that later during his lunch break at approximately 2:00 P.M., he and CNA #3 then reported the incident to the Director of Nurses (DON) by phone. During an interview on 12/06/23 at 3:00 P.M., the Assistant Director of Nurses (ADON), said she was the Director of Nurses (DON) at the time of the alleged incident between Resident #1 and CNA #1. The ADON said that on 10/22/23, when CNA #2 and CNA #3 reported the allegation of neglect involving Resident #1 and CNA #1, she suspended CNA #1 and did not allow her to return to work, pending the results of the investigation. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 10/26/23, indicated the incident of alleged neglect, involving Resident #1 and CNA #1, was reported to DPH. However, this was four days after facility Administration had been made aware of the allegation. During an interview on 12/06/23 at 3:15 P.M., the Administrator said he was not aware of the allegation of neglect involving Resident #1 and CNA #1 until the afternoon of 10/26/23, at which time he reported the incident to DPH. The Administrator said the ADON should have reported the allegation to him immediately when it was reported to her on 10/22/23.

Based on records reviewed and interviews, for one of four sampled residents (Resident #3) who had a peripherally inserted central catheter (PICC-catheter that enters through the body through the skin and extends into the superior vena cava, to deliver medications for extended periods of time), the Facility failed to ensure physician orders for necessary care and treatment of the PICC were obtained and entered onto the Medication Administration Record (MAR) and/or Treatment Administration Record (TAR), and as a result Resident #3 went twenty-four hours without being administered flushes to the PICC line port (s) to prevent occlusion (blockage), there was no documentation to support the PICC insertion site was assessed and monitored by nursing for signs of infection, and the PICC line catheter was not measured upon admission or thereafter to ensure the catheter had not migrated (moved) out of place. Findings include: Review of the Facility policy titled PICC, dated May 1, 2022, indicated physician's orders would be obtained and include measures taken for care and maintenance of the PICC to include: - dressing changes, - measurements to be taken at the time of the dressing change, -routine flushes to the line including the solution to be used for flushing, and -all intravenous flushes, catheter dressing changes and catheter measurements, will be documented on the MAR. Resident #3 was admitted to the Facility in November 2023, diagnoses included chronic osteomyelitis of left tibia and fibula, peripheral vascular disease, aftercare following joint replacement surgery, and atherosclerotic disease. Review of Resident #3's Hospital PICC Insertion Note, dated 11/09/23, indicated a PICC was inserted into the right arm and placement in the superior vena cava (large vein carrying deoxygenated blood into the heart) was confirmed. Review of Resident #3's Hospital Discharge Summary, dated 11/09/23, indicated to administer intravenous Vancomycin 1000 milligrams (mg) twice a day with an end date of December 19, 2023. Review of Resident #3's Physician's Orders, for the Month of November 2023, indicated there were no physician's orders for the care and treatment of the PICC. Review of Resident #3's MAR and TAR, for the Month of November 2023, indicated there were no physician's orders obtained by nursing for the care and treatment of the PICC. During a telephone interview on 12/07/23 at 7:55 A.M., Nurse #6 said that she worked on 11/09/23 from 7:00 P.M. through 7:00 A.M., and helped to finish Resident #3's admission paperwork and assessments. Nurse #6 said she did not get a clinical report regarding Resident #3 from the previous shift's nurse so she did a head to toe assessment on Resident #3 and did the best she could to finish the admission paperwork. Nurse #6 said that Resident #3 had orders for intravenous Vancomycin but the medication had not been delivered and said Resident #3 did not have IV access. Nurse #6 said that she did a skin assessment on Resident #3 but he/she did not want to take his/her shirt off so she could not see what was under Resident #3's shirt. Nurse #6 said that if she had known Resident #3 had a PICC, she would have made sure that physician orders were in place for dressing changes and flushes. Nurse #6 said also that if she had known about the PICC she would have documented in Resident #3's medical record that there was a PICC in place. Nurse #6 said that while she helped to do some of Resident #3's admission assessments, she did not obtain any of the admission physician orders. During an interview on 12/06/23 at 2:09 P.M., Nurse #1 said he worked on 11/10/23 from 7:00 A.M. through 7:00 P.M. and Resident #3 was under his care. Nurse #1 said he did not see any orders for the PICC in Resident #3's Hospital Discharge Summary. Nurse #1 said he called the Hospital to request flush orders for the PICC but never received a call or fax back. Nurse #1 said he did not call the provider (Physician/Physician's Assistant) from the Facility, to request orders for the care and treatment of Resident #3's PICC. During an interview on 12/06/23 at 1:16 P.M., the Physician Assistant (PA) said that Resident #3 was admitted to the facility after 5:00 P.M. and therefore, the on-call provider would have given nursing all of the admission orders. The PA said that she did not have access to the on-call information. The PA said if things needed to be followed up on for Resident #3's admission, that the Facility was responsible to notify her. The PA said she was in the Facility on 11/10/23 and saw Resident #3. The PA said that she did not review all of the orders and thought that nursing had obtained physician orders for care and treatment of the PICC. The PA said she did not know the PICC was never flushed or assessed during Resident #3's admission until today (12/06/23). During an interview on 12/06/23 at 4:53 P.M., the Director of Nurses (DON) said that when residents are admitted , the nursing staff should do all of the assessments, including a thorough skin assessment, and obtain orders from the physician. The DON said the orders for care and treatment of a PICC should have been entered as a batch order and should have been part of Resident #3's admission orders.

Based on records reviewed and interviews, for one of four sampled residents (Resident #3), who had a recent partial hip replacement and was at risk for the development of a blood clot, and had physician's orders for the administration of an injectable anticoagulant medication that had to be ordered and delivered from the pharmacy, but was available in the Facility's emergency medication storage unit, the Facility failed to ensure all nurses (including agency nurses) had access to the Emergency medications, as a result Resident #3 missed one dose of his/her anticoagulation medication, therefore placing him/her at increased risk for the development of blood clots. Findings include: Review of the Facility policy, Medication Ordering and Receiving from Pharmacy, dated 10/01/19, indicated that emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. Review of the list of Emergency Medications available in the Facility's emergency medication storage unit, indicated Enoxaparin Injection was available in three different doses, including 40 milligrams (mg)/0.4 milliliters (ml). Resident #3 was admitted to the Facility in November 2023, diagnoses included chronic osteomyelitis of left tibia and fibula, peripheral vascular disease, aftercare following joint replacement surgery, and atherosclerotic disease. Review of Resident #3's Physicians Orders, for November 2023, included the administration of the following: Enoxaparin Sodium Injection 40mg/0.4 ml; inject 40 mg subcutaneously every 24 hours. Review of Resident #3's Medication Administration Record (MAR), dated November 2023, indicated that he/she was due to be administered the following: -11/10/23 Enoxaparin Sodium Injection 40 mg/0.4 ml inject 40 mg subcutaneously at 24 hours (time not specified on the MAR). Further review of Resident #3's MAR indicated Nurse #1 documented code 5 which indicated to hold the medication and see Nurses Note. Review of Resident #3's Nursing Progress Note, dated 11/10/23 at 20:17 (8:17 P.M. and written by Nurse #1), indicated the Enoxaparin Sodium Injection 40mg/0.4 ml was not administered due to waiting for the pharmacy (delivery). During an interview on 12/06/23 at 2:09 P.M., Nurse #1 said that he remembered Resident #3's family member inquiring if the Enoxaparin had been administered. Nurse #1 said that if all of the medications had been delivered from the pharmacy, he would have administered the Enoxaparin as ordered, but because he had not received the medication, he was unable to administer it to Resident #3. Nurse #1 said that he did not have access to the Facility's emergency medication storage unit and said the other nurse he was working with that night did not have access either. Nurse #1 said not all of the nurse managers had access and said no one he asked that night was able to access the emergency medication storage unit. During an interview on 12/06/23 at 4:53 P.M., the Director of Nurses (DON) said she was new to the facility and had recently found out that a lot of nurses did not have access to the emergency medication storage unit. The DON said that if a nurse did not have access to the emergency medication storage unit, she expected them to ask someone who did. The DON said if the nursing staff was unable to obtain the medication, she expected nursing to inform the provider that the medication was unavailable to be administered as ordered.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated that he/she required physical assistance of two staff members for bed mobility, bathing and hygiene care ( which included incontinence care), the Facility failed to ensure nursing staff implemented and followed interventions identified in his/her Plan of Care while meeting his/her care needs. On 09/05/23, Certified Nurse Aide (CNA) #1 provided Resident #1 morning care, which included incontinence and hygiene care to Resident #1 without another staff member present to assist her. During care, after CNA #1 rolled Resident #1 onto his/her left side, CNA #1 stepped away from the bed and went to the doorway to call for the nurse, leaving Resident #1 unassisted, and he/she fell off the bed on to the floor, striking the right side of his/her head. Resident #1 was transferred to the Hospital Emergency Department for evaluation and diagnosed with contusions (region of injured tissue or skin in which blood capillaries have ruptured) to his/her forehead and face, as well as a subconjunctival hemorrhage (a broken blood vessel on the white part of the eye) with an abrasion (area damaged by scraping) to the right side of his/her forehead. Findings include: Review of the Facility's Policy, titled Fall Reduction, dated as revised 6/22/22, indicated the following: -Facility would implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual resident's needs; - Residents will be identified as low, moderate, or high risk for falling based on the Fall Assessment tool; -Residents at risk, in addition to the Universal Safety Standards, will be reviewed for resident specific interventions as deemed appropriate; -The nurse will document the fall risk prevention measures that have been instituted in the Resident Care Plan and on the CNA Care Card. Resident #1 was admitted to the Facility in November 2019, diagnoses include cerebral infarction (stroke), generalized muscle weakness, abnormalities of gait and mobility, and pulmonary embolism without acute cor pulmonal (disease of the circulatory system). Resident #1's Annual Minimum Data Set (MDS) assessment, dated 8/11/23, indicated he/she was cognitively impaired, required two-person physical assist for all his/her care needs, including bed mobility, bathing, incontinent care, transfers, and was non-ambulatory. Resident #1's Care Plan titled Activities of Daily Living (ADL), reviewed and renewed with his/her August 2023 MDS, indicated to provide two-person physical assistance for bed mobility (repositioning and turning in bed), bathing, incontinence care, and hygiene related to impaired functional mobility. Resident #1's Certified Nurse Aide (CNA) Care Card, dated 5/31/23, indicated he/she was totally dependent and required the assistance of two staff members for bed mobility, bathing and toilet use, which included incontinence and hygiene care. Review of the Facility's Internal Investigation Report, dated 9/05/23, indicated that on 9/05/23 around 8:30 A.M., the CNA (later identified as CNA#1) walked away from Resident #1's bed to obtain supplies and he/she rolled out of bed onto floor. The Report indicated, staff noted swelling and discoloration to Resident #1's right forehead and facial area. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation, the ED obtained a CT scan and X-rays with negative results, and Resident #1 returned to the facility with a diagnosis of contusion to his/her forehead. Further review of the Report indicated that Resident #1 was left alone by CNA #1 and that he/she was a two person assist. Review of a Nurse Progress Note, dated 9/05/23 at 9:15 A.M., indicated that Resident #1 had a fall out of bed around 8:30 A.M., and was transferred to the Hospital Emergency Department. Review of a Hospital Emergency Department Discharge Summary, dated 9/05/23, indicated that Resident #1 sustained contusions to his/her forehead and face, an abrasion to his/her forehead and subconjunctival hemorrhage (a broken blood vessel on the white part of the eye) and CT scans of head, orbits and neck as well as x-rays of shoulders, knee and chest did not show any acute problems. Review of a Nurse Progress Note, dated 9/05/23 at 1:43 P.M., indicated that Resident #1 returned to the Facility with a diagnosis of a contusion to his/her forehead, his/her right eye was swollen and bruised and the CT scan and X-ray results were negative. Review of a Nurse Progress Note, dated 9/05/23 at 6:26 P.M., indicated that Resident #1's right orbit (cavity at socket/hole of skull in which eye is situated) area had ecchymosis (bruising) with remarkable edema (swelling) and right forehead had a large intact blister with a bandage dressing covering forehead. During an observation on 10/12/23 at 8:55 A.M., the surveyor observed Resident #1 (who was in his/her room) lying in bed and noted to have ecchymosis with a raised lump on the side of his/her right forehead. The surveyor was unable interview Resident #1 about his/her injuries, due to his/her cognitive impairment. During an interview on 10/12/23 at 9:00 A.M., Nurse #1 said that she was the nurse assigned to care for Resident #1 during the 7:00 A.M. through 3:00 P.M. shift on 9/05/23. Nurse #1 said that on 9/05/23, CNA #1 came out of Resident#1's room to get her to look at a red area that she had noticed while providing ADL care to him/her. Nurse #1 said when she went into Resident#1's room with CNA #1, they found him/her on the floor on the left side of the bed. Nurse #1 said there was no other staff member in Resident #1's room at that time. Nurse #1 said Resident #1 had bruising on the right side of his/her forehead and right lower jaw. Nurse #1 said she completed her assessment of Resident #1 and called 911. Nurse #1 said Resident #1 must have rolled out of bed. Nurse #1 said Resident #1 required two staff members to assist with his/her care needs. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, undated, indicated that on 9/05/23, she provided morning care to Resident #1 in his/her bed, had positioned him/her on his/her left side, noticed a wound that was dirty that had a patch over it, stepped to the doorway of the room ( away from the bed) to get the nurse, stepped back in the room and Resident #1 was on the floor. During a telephone interview on 10/13/23 at 10:50 A.M., CNA #1 said that she worked on 9/05/23 and that Resident #1 was assigned to her. CNA #1 said that she was bathing him/her and saw a red area on his/her bottom when she rolled him/her onto his/her left side and she stepped away from the bed, out into the doorway to call out to the nurse. CNA#1 said when she stepped back into the room, Resident #1 was on the floor by the left side of the bed. CNA #1 said that she reviewed Resident #1's CNA Care Card and was aware that he/she required two staff members to assist when providing ADL care. During a telephone interview on 10/13/23 at 10:43 A.M., CNA #2 said Resident #1 required total assistance from two staff members with care, that she was working on Resident #1's unit on 9/05/23, but CNA #1 did not ask her to assist her that day. During an interview on 10/12/23 at 12:35 P.M., CNA #3 said she was familiar with Resident #1's care, that he/she was totally dependent for care and required two staff members to assist with bathing and bed mobility. During an interview on 10/12/23 at 1:44 P.M., the Unit Manager said that CNA #1 did not follow interventions identified on Resident #1's CNA Care Card for the need for two staff members to assist during care and was by herself providing care to Resident #1. The Unit Manager said it is her expectation that staff follow the plan of care. During an interview on 10/12/23 at 2:01 P.M., the Director of Nurses (DON) said that Resident #1 required the assistance of two staff members with all ADL care. The DON said that CNA #1 provided care to Resident #1 without the assistance of another staff member and walked away from the bedside. The DON said that CNA #1 did not follow Resident #1's plan of care and said that it was her expectation that staff follow the plan of care. During an interview on 10/12/23 at 2:27 P.M., the Administrator said that the staff informed him that CNA #1 had left Resident #1 alone and turned on his/her side with the bed elevated prior to the fall. On 10/12/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) Resident #1 was immediately assessed by Nursing and was transferred to the Hospital Emergency Department for evaluation. B) On 09/05/23, Resident #1 returned to the Facility. C) 09/06/23, the Unit Manager and the DON provided Educational In-services for nursing department staff on following the plan of care for residents according to their specific care plan, CNA care card and the need to provide the required level of staff assistance. D) 09/06/23, all resident CNA Care Cards were reviewed and audited by the Unit Managers, and updated as needed. E) 10/10/23, a Mandatory staff meeting was held reviewing education on care plans and CNA care cards to ensure the correct care and level of assistance is provided by staff. Expectations of staff, documentation, and resident rounds were also reviewed at this time. F) 10/5/23, Standards of Care & Compliance Check List, with designated staff assignments for facility wide audits, review of audits was conducted by the Administrator. G) Daily Rounds are being conducted by DON and Unit Managers to ensure resident care needs identified on CNA Care Cards are being followed. H) Concierge rounds were implemented on 10/10/23, management staff are assigned 4 rooms each and check in with their assigned residents daily. I) Ongoing audits will be conducted by the DON and/or Designee until substantial compliance is achieved. J) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee at the next QAPI meeting on 10/27/23. K) 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 assessed by nursing to be at high risk for falls, and required physical assistance of two staff members for Activities of Daily Living (ADL) care, the Facility failed to ensure he/she was provided with the required level of staff assistance during care to maintain his/her safety, in an effort to prevent an accident resulting in an injury. On 09/05/23 at approximately 8:30 A.M., Certified Nurse Aide (CNA) #1 provided Resident #1 with morning care, which included assisting Resident #1 with bed mobility, as well as incontinence and hygiene care, and proceeded to do so without another staff member present to assist her. CNA #1 stepped away from the bed and out into the doorway, leaving Resident #1 in bed, which was in the raised position, on left his/her side, and unattended by a staff member. Resident #1 fell off the bed on to the floor, striking the right side of his/her head, was transferred to the Hospital Emergency Department for evaluation and diagnosed with a contusion (region of injured tissue or skin in which blood capillaries have been ruptured) to the right side his/her forehead and face, as well as a subconjunctival hemorrhage (a broken blood vessel on the white part of the eye) with an abrasion (area damaged by scraping) to the right side of his/her forehead. Findings include: Review of the Facility's Policy, titled Fall Reduction, dated as revised 6/22/22, indicated the following: -Facility would implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual resident's needs; - Residents will be identified as low, moderate, or high risk for falling based on the Fall Assessment tool; -Residents at risk, in addition to the Universal Safety Standards, will be reviewed for resident specific interventions as deemed appropriate; -The nurse will document the fall risk prevention measures that have been instituted in the Resident Care Plan and on the CNA Care Card. Review of the Facility's Internal Investigation Report, dated 9/05/23, indicated that on 9/05/23 around 8:30 A.M., the CNA( later identified as CNA #1) walked away from Resident #1's bed to obtain supplies and he/she rolled out of bed onto floor. The Report indicated, staff noted swelling and discoloration to Resident #1's right forehead and facial area. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation, the ED obtained a CT scan and X-rays with negative results, and Resident #1 returned to the facility with a diagnosis of contusion to forehead. Further review of the Report indicated that Resident #1 was left alone by CNA #1 and that he/she was a two person assist. Resident #1 was admitted in November 2019, diagnoses include cerebral infarction (stroke), generalized muscle weakness, abnormalities of gait and mobility, and pulmonary embolism without acute cor pulmonal (disease of the circulatory system). Resident #1's Certified Nurse Aide (CNA) Care Card, dated 5/31/23, indicated he/she was totally dependent and required the assistance of two staff members for bed mobility, bathing and toilet use, which included incontinence and hygiene care. Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively impaired, required two-person physical assist for all care needs, including bed mobility, bathing, incontinent care, transfers and he/she was non-ambulatory. Resident #1's Care Plan titled Activities of Daily Living (ADL), reviewed, and renewed with his/her August 2023 MDS, indicated to provide two-person physical assistance for bed mobility (repositioning and turning in bed), bathing, incontinence care and hygiene related to impaired functional mobility. Resident #1's Falls Care Plan, reviewed, and renewed with his/her August 2023 MDS, indicated he/she was at risk for falls, interventions included to follow facility policy related to fall reduction. Review of a Nurse Progress Note, dated 9/05/23 at 9:15 A.M., indicated that Resident #1 had a fall out of bed around 8:30 A.M., and was transferred to the Hospital Emergency Department. Review of a Nurse Progress Note, dated 9/05/23 at 1:43 P.M., indicated that Resident #1 returned to the Facility with a diagnosis of contusion to his/her forehead, his/her right eye was swollen and bruised and the CT scan and X-ray results were negative. Review of a Hospital Emergency Department Discharge Summary, dated 9/05/23, indicated that Resident #1 sustained contusions to his/her forehead and face, abrasion to forehead and subconjunctival hemorrhage (a broken blood vessel on the white part of the eye) and CT scans of head, orbits and neck as well as x-rays of shoulders, knee and chest did not show any acute problems. During an observation on 10/12/23 at 8:55 A.M., the surveyor observed Resident #1 (who was in his/her room) lying in bed and noted to have ecchymosis (bruising) with a raised lump on right forehead. The surveyor was unable to interview Resident #1 about his/her injuries due to his/her cognitive impairment. Review of a Nurse Progress Note, dated 9/05/23 at 6:26 P.M., indicated that Resident #1's right orbit (cavity at socket/hole of skull in which eye is situated) area had ecchymosis (bruising) with remarkable edema (swelling) and right forehead had a large intact blister with a bandage dressing covering forehead. During an interview on 10/12/23 at 9:00 A.M., Nurse #1 said that she was the nurse who was assigned to care for Resident #1 during the 7:00 A.M. through 3:00 P.M. shift on 9/05/23. Nurse #1 said that on 9/05/23, CNA #1 came out of Resident #1's room to get her to look at a red area that she noticed while providing ADL care to him/her. Nurse #1 said when she went into Resident#1's room with CNA #1, they found him/her on the floor on the left side of the bed. Nurse #1 said there was no other staff member in Resident #1's room at that time. Nurse #1 said Resident #1 had bruising on the right side of his/her forehead and right lower jaw. Nurse #1 said she completed her assessment of Resident #1 and called 911. Nurse #1 said Resident #1 must have rolled out of bed. Nurse #1 said Resident #1 required two staff members to assist with his/her care needs. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, undated, indicated that on 9/05/23, she provided morning care to Resident #1 in his/her bed, had positioned him/her on his/her left side, noticed a wound that was dirty that had a patch over it, stepped to the doorway of the room to get the nurse, stepped back in the room and Resident #1 was on the floor. During a telephone interview on 10/13/23 at 10:50 A.M., CNA #1 said that she worked on 9/05/23 and that Resident #1 was assigned to her. CNA #1 said that she was bathing him/her and saw a red area on his/her bottom when she rolled him/her onto his/her left side and stepped away to the doorway to call out to the nurse. CNA#1 said when she stepped back into the room, Resident #1 was on the floor by the left side of the bed. CNA #1 said that she reviewed Resident #1's CNA Care Card and was aware that he/she required two staff members to assist when providing care. During a telephone interview on 10/13/23 at 10:43 A.M., CNA #2 said Resident #1 required total assistance from two staff members with care, that she worked on Resident #1's unit on 9/05/23, but that CNA #1 did not ask her to assist her that day. During an interview on 10/12/23 at 12:35 P.M., CNA #3 said she was familiar with Resident #1's care, that he/she was totally dependent for care and required two staff to assist with bathing and bed mobility. During an interview on 10/12/23 at 1:44 P.M., the Unit Manager said that CNA #1 did not follow interventions identified on Resident #1's CNA Care Card for the need for two staff members to assist during care and was by herself providing care to Resident #1. The Unit Manager said it is her expectation that staff provide the appropriate level of assistance when caring for residents. During an interview on 10/12/23 at 2:01 P.M., the Director of Nurses (DON) said that Resident #1 required the assistance of two staff members with all ADL care. The DON said that CNA #1 provided care to Resident #1 without the assistance of another staff member and walked away from the bedside. The DON said that CNA #1 did not follow Resident #1's plan of care and said that it was her expectation that staff provide the necessary level of staff assistance during care. During an interview on 10/12/23 at 2:27 P.M., the Administrator said that the staff informed him that CNA #1 had left Resident #1 alone and turned on his/her side, prior to the fall. On 10/12/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) Resident #1 was immediately assessed by Nursing and was transferred to the Hospital Emergency Department for evaluation. B) On 09/05/23, Resident #1 returned to the Facility. C) 09/06/23, the Unit Manager and the DON provided Educational In-services for nursing department staff on following the plan of care for residents according to their specific care plans, CNA care cards and the need to provide the required level of staff assistance. D) 09/06/23, all resident CNA Care Cards were reviewed and audited by the Unit Managers, and updated as needed. E) 10/10/23, a Mandatory staff meeting was held reviewing the education on care plans and care cards to ensure the correct care is provided by staff. Expectations of staff, documentation, and resident rounds were also reviewed at this time. F) 10/5/23, Standards of Care & Compliance Check List, with designated staff assignments for facility wide audits, audit reviews were conducted by the Administrator. G) Daily Rounds are being conducted by DON and Unit Managers to ensure resident care needs identified on there Care Cards were being followed. H) Concierge rounds were implemented on 10/10/23, management staff are assigned 4 rooms each and check in with their assigned residents daily. I) Ongoing audits will be conducted by the DON and/or Designee until substantial compliance is achieved. J) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee at the next QAPI meeting on 10/27/23. K) The DON and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who had gastrostomy tubes (G-Tube, tube placed through the abdomen into the stomach, for feedings, liquids and medications), in place to meet their nutritional care needs, the Facility failed to ensure their nutritional status' including body weights, were adequately monitored by nursing in an effort to maintain acceptable parameters related to nutrition to prevent unplanned/undesired weight loss, when Resident #1 experienced an unplanned significant weight loss of 15% in three months, and Resident #2 experienced an unplanned significant weight loss of 20% in a six month period. Findings include: The Facility Policy titled Weight Monitoring, dated 12/22/22, indicated that the Facility will: - Ensure that residents maintain acceptable parameters of nutritional status. - The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss. - The nursing staff will measure weights on admission, and weekly for three weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria for a time period of : - One month - 5% weight loss is significant - Three months - 7.5 % weight loss is significant - Six months - 10% weight loss is significant The Facility Policy titled Intake and Output, dated 12/06/22, indicated that intake and output amounts (the measurement of the fluids that enter the body (intake) and the fluids that leave the body (output), which is essential in assessing calorie intake and fluid balance), will be performed when a resident has a tube feeding, and which will include the amount administered. 1. Resident #1 was admitted to the Facility in August 2022, diagnoses included acute respiratory failure, pneumonia, asthma, a cerebrovascular accident with dysarthria (difficulty speaking), and dysphagia (difficulty swallowing). Resident #1's Nutrition Care Plan, dated 9/02/22, indicated he/she was at risk for unintended weight changes due to medical co-morbidities of dysarthria, dysphagia and diuretic usage. Nutrition interventions included to tolerate diet texture without difficulty, he/she will have an oral intake of 50% or more. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, required supervision with eating, did not have malnutrition, and had generalized muscle weakness. The MDS indicated Resident #1 weighed 146 lbs., had no weight loss, was treated with a mechanically altered diet, and did not have a feeding tube. During an interview on 3/08/23 at 1:55 P.M., the Dietician said she had identified on 9/09/22, that Resident #1 had been assessed as being at risk for weight loss, that weekly weights should have been obtained by nursing to help monitor and identify any weight loss, but that weights were not being obtained consistently. Review of Resident #1's medical record indicated that based on blood laboratory work his/her baseline albumin levels (an indicator of nutritional status, normal range 3.2 to 5 g/dl) were 3.1 grams/deciliter (g/dl) on 8/31/22 and 3.3 g/dl on 9/08/22, both of which were within normal limits. Review of Resident #1's Comprehensive Nutrition Assessment, dated 9/09/22, indicated that his/her admission weight was 146.2 lbs., with a Body Mass index (BMI - weight in kilograms divided by height squared, an indication of body fat & to identify weight problems) of 26.7. The Assessment indicated an identified risk factor for weight loss, was a BMI between 18 to 26, and no unplanned weight loss was desired for him/her. The Assessment indicated Resident #1's food intake was less than 50% of his/her required need, and that Resident #1 had swallowing and chewing difficulties. The Assessment indicated Speech Language Pathologist recommended he/she required puree consistency (foods that have soft pudding like consistency/nectar) with thickened liquids (a thick liquid), that both were needed for residents with swallowing problems to prevent the liquids from entering the lungs. The Assessment indicated Resident #1 had failed a modified barium swallow (a type of X-ray to evaluate swallowing problems), indicating he/she was unable to adequately swallow. Review of Resident #1's Comprehensive Nutrition Assessment, dated 12/19/22, indicated he/she weighed 124.6 lbs. on 12/07/22 (a significant weight loss of 22 lbs. in 3 months), and he/she had a BMI of 22.8 (previously 26.7, a 14.6 % decrease in BMI). The Assessment indicated Resident #1's appetite had been poor, he/she was not eating meals consistently, insertion of a G-tube had been discussed with Resident #1, and was being placed 12/20/22. Review of Resident #1's Weights and Vital Sign Summary indicated his/her weights were recorded as follows: - 8/30/22 documented as 146.2 lbs. - 11/02/22 documented as 140.8 lbs. - 12/07/22 documented as 124.6 lbs. There was no documentation to support Resident #1's weekly weight was obtained on: 11/09/22, 11/16/22, 11/23/22, or 11/30/22. Review of Resident #1's Nursing Progress Note, dated 12/20/22, indicated he/she returned from a Gastrointestinal appointment with the placement of a G-tube. Review of Resident #1's Physician's Order, dated 12/21/22, indicated to maintain the G-tube feeding at 85 milliliters (ml) an hour continuously with water flushes 85 ml every four hours. Review of Resident #1's Nursing Progress Note, dated 12/26/22, indicated that Resident #1's continuous G-tube feeding had been disconnected at 9:00 P.M., without an order for the tube feeding to be stopped. The Note indicated that the nurse who found the disconnected tube feeding attempted to flush his/her G-tube and found that it was clogged. The Note indicated the Physician Assistant was notified and Resident #1 was sent to the Hospital to have his/her G-tube unclogged. Review of Resident #1's Significant Change Minimum Data Set (MDS), dated [DATE], he/she weighed 124 lbs. (a significant weight loss of 15% of body weight over the past 3 months, a weight loss of 22 lbs.). The MDS indicated his/her percent intake by a tube feeding or parenteral route was 51% or more. Review of Resident #1's Weights and Vital Sign Summary indicated that on 1/18/23, he/she weighed 118 lbs. There was no documentation to support Resident #1's week weight was obtained on 12/14/22, 12/21/22, 12/28/22, 1/04/23, and 1/11/23. During an interview on 3/08/23 at 10:20 A.M., the Director of Nursing said nursing had not obtained weekly weights for Resident #1, as required. Review of Resident #1's Nutritional Care Plan, updated, 1/16/23, after he/she had a G-tube placed indicated interventions included, to monitor the intake and output and record each meal. However, Resident #1's G-tube feedings started on 12/21/22, and Intake and Output should have monitored and documented affective 12/21/22, per facility policy. During an interview on 3/07/23 at 11:10 A.M., Nurse #1 said during the 11:00 P.M. to 7:00 A.M. shift, when the G-tube feeding bottles needed to be replaced with a new bottle, the nurses on that shift, were not consistently hanging a new bottle, and that nurses needed to know how to manage and care for residents with tube feedings. Nurse #1 said the nurses were also not consistently flushing the G-tube, which resulted in the G-tubes becoming frequently clogged, the G-tube feedings not being delivered, and the residents' not receiving adequate hydration and nutritional intake. Review of Resident #1's Social Service Note, dated 1/09/23, a late entry for 1/08/23, indicated Resident #1 was transferred to the Hospital on 1/08/23, after not receiving his/her G-tube feeding back to 1/05/23 (1/06/23 at 2:10 P.M. until 1/8/23 at 2:10 P.M.). Review of Resident #1's Nursing Progress Note, dated 1/08/23, indicated Resident #1's G-tube feeding bottle, dated 1/05/23 (indicating when it was first hung for administration, and should be removed 24 hours later, on 1/06/23 at 2:10 P.M., and replaced with a new tube feeding bottle) was empty and still attached to the G-tube. Resident #1 was transferred to the Emergency Department for a (clogged) G-tube. Review of Resident #1's Dietary Nutrition Note, dated 1/30/23, indicated that the Nurse Progress Note on 1/08/23 indicated the tube feed bottle from 1/05/23 was still hanging (it was empty), he/she was sent out to the hospital. Review of Resident #1's Hospital blood laboratory work, dated 1/08/23, indicated that his/her albumin level (a marker that reflects malnutrition) was low at 2.5 g/dl (normal range 3.2 to 5.0 g/dl) Review of Resident #1's Facility Physician Progress Note, dated 1/12/23, indicated he/she was alert, oriented to person, place and situation, was thin cachectic (wasting of the body) with severe dysarthria, and dysphagia with severe malnutrition. Review of Resident #1's medical record, from December 2022 through March 2023 (up to and including the dates of this survey) indicated there was no documentation to support intake and output was monitored or recorded by nursing regarding his/her continuous G-tube feedings. Review of Resident #1's Physician Progress Note, dated 1/19/23, indicated a G-tube insertion was recently performed due to his/her malnutrition and dysphagia, continue tube feedings, with dietary services to follow for adequate nutrition. Review of Resident #1's Dietary Nutrition Note, dated 1/30/23, indicated that per the Nursing staff, it was reported that Resident #1 did not receive 100% of his/her nutrition on 1/18/23 and 1/19/23. The Note also indicated that staff said that Resident #1's tube feeding bottle was not replaced on the overnight shift the previous night on 1/17/23 into 1/18/23. The Note indicated that on 01/19/23, both Resident #1 and Resident #4 (Resident #1's roommate) reported that the feeding tube machine was beeping all night, indicating there was an issue with the tube feeding, such as being empty or occluded (blocked) G-tube. The Dietary Note indicated a new tube feeding bottle was hung on 1/20/23 at the start of the 7:00 A.M. to 3:00 P.M. shift. The Dietary Note indicated there were no nurse progress notes reporting issues with the tube feeding on either occasion (as required for accurate documentation of changes in intake). The Note indicated Resident #1 continued documented weight loss even with multiple increases in tube feed rates and volumes to provide gradual weight gain. Review of Resident #1's blood laboratory work, dated 1/30/23, indicated he/she had a severely low albumin level of 1.9 g/dl (indicative of severe malnutrition). During an interview on 3/08/23 at 1:30 P.M., the Dietician said in January 2022, Resident #1's oral intake was not significant, that he/she took in only a cup of coffee or ginger ale for pleasure, his/her primary intake was the G-tube feedings. The Dietician said Resident #1 had severe weight loss of 11.5% in a month from November 2022 to December 2022. The Dietician said she was concerned that Resident #1 was not getting his/her tube feeds and informed the Director of Nurses. 2. Resident #2 was admitted to the Facility in June 2022, diagnoses included a cerebrovascular accident with hemiplegia (paralysis on one side of the body) with severe aphasia, dysphagia and congestive heart failure. Resident #2's Nutrition Care Plan, dated 6/20/22, indicated he/she required tube feedings, secondary to dysphagia, and was at risk of malnutrition, and to maintain stable weights. The Care Plan indicated interventions included he/she was dependent with G-tube feedings and required water flushes (for maintaining patency & hydration) and to obtain weights as ordered. Administer continuous G-tube feedings, with G-tube flushes of water flushes every 4 hours. Review of Resident #2's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was moderately cognitively impaired, and with eating he/she required extensive assist of one person. The MDS indicated Resident #2 had a feeding tube and the percent of intake by a tube feeding or parenteral route was 51% or more. Review of Resident #2's Weights and Vital Sign Summary indicated his/her weights were recorded as follows: - 7/19/22 documented as 265.7 lbs. - 8/14/22 documented as 256 lbs. - 9/10/22 documented as 240.5 lbs. - 10/05/22 documented as 230.4 lbs. Review of Resident #2's Quarterly MDS, dated [DATE], he/she weighed 211 lbs., had a 5% of body weight loss or greater while not on a physician prescribed diet for a weight loss. Review of Resident #2's Physician's Orders, dated 11/21/22, indicated his/her diet order was for NPO (nothing by mouth), with continuous enteral G-tube feedings Glucerna 1.2, run at 75 milliliters rate per hour. Further review of Resident #2's Weights and Vital Sign Summary indicated his/her weights were recorded as follows: - 12/25/22 documented as 209.5 lbs. - 01/09/23 documented as 212 lbs. - 02/13/23 documented as 204 lbs. - 03/06/23 documented as 200.2 lbs. Further review of Resident #2's Weights and Vital Sign Summary indicated he/she had a 20% weight loss over 6 months (between 7/19/22 to 1/09/23), a total of 53.7 lbs. weight loss. Review of Resident #2's Comprehensive Nutrition Assessment, dated 2/13/23, indicated that he/she weighed 204 lbs. on 2/13/23, which was a significant weight loss. During an interview on 3/08/23 at 2:10 P.M., the Dietician said Resident #2 had significant unintentional weight loss of greater than 7.5% in three months. Review of Resident #2's medical record, from November 2022 through March 2023 (up to and including the dates of this survey) indicated there was no documentation to support intake and output was monitored or recorded by nursing regarding his/her continuous G-tube feedings. During an interview on 3/08/23 at 10:10 A.M., the Director of Nurses said Resident #1's weights should have been obtained and recorded as ordered by the Physician. The DON said that Resident #1 and Resident #2 would not have experienced significant weight loss while receiving nutrition via G-tubes.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who had gastrostomy tubes (G-tube, placed through the abdomen into the stomach, for feedings, liquids and medications) in place to meet their nutritional and fluid intake needs, and whose physician's orders included parameters for daily administration of formula feeds and water flushes, the Facility failed to ensure that Resident #1 and Resident #2 were provided with appropriate treatment and services in an effort to prevent potential complications associated with G-tubes (such as clogged G-tubes, dehydration, aspiration pneumonia, diarrhea, vomiting, metabolic abnormalities). Resident #1 experienced multiple complications associated with having a G-tube including dehydration, clogged G-tube, weight loss, and required transfer and admission to the Hospital. Resident #2 experienced multiple complications associated with having a G-tube including dehydration, clogged G-tube, vomiting, diarrhea, and also required transfer and admission to the Hospital. Findings include: The Facility Policy titled Enteral Feedings (nutrition administered via the gastrointestinal tract), dated 12/06/22, indicated that the Facility was to ensure the following: - Safe administration of enteral nutrition - Closed system enteral nutrition formulas have a hang time of 24-48 hours, per manufacturer's instructions. - Administer only full-strength feeding tube formulas. - Always elevate the head of the bed at least 30 to 45 degrees during tube feeding. - Recognize the risk factors for aspiration, including being in a supine position, and vomiting. The Facility Policy titled Intake and Output, dated 2/06/22, indicated that the Facility will implement intake and output measurements of the tube feeding amounts and water flushes administered. The nursing staff are to observe for fluid deficits, use an intake and output record to track resident's fluid intake and write each resident's fluid recommendations. Nursing Assistants will utilize intake and output worksheets and will total the amount of intake at the end of each shift. 1. Resident #1 was admitted to the Facility in August 2022, diagnoses included acute respiratory failure, pneumonia, asthma, a cerebrovascular accident with dysarthria (difficulty speaking), and dysphagia (difficulty swallowing). Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, required supervision with eating, did not have malnutrition, had generalized muscle weakness. The MDS indicated Resident #1 had no weight loss, was treated with a mechanically altered diet and did not have a feeding tube. Review of Resident #1's Comprehensive Nutrition Assessment, dated 12/19/22, indicated he/she required an estimated minimum of fluid intake of 1,403 milliliters (ml) daily. Review of Resident #1's Nursing Progress Note, dated 12/20/22, indicated he/she returned from a Gastrointestinal appointment, with the placement of a G-tube (secondary to severe dysphagia). Review of Resident #1's Physician's Order, dated 12/21/22, indicated to maintain the G-tube feeding at 85 ml an hour continuously with water flushes of 85 ml every four hours. Review of Resident #1's Physician's Order, dated 12/22/22, indicated he/she was to receive nothing by mouth (NPO). Review of the Physician's Order, dated 12/26/22, indicated to administer Osmolite 1.2 via a tube feed continuously, at 54 ml an hour. Review of Resident #1's Nursing Progress Note, dated 12/26/22, indicated that Resident #1's continuous feeding had been disconnected at 9:00 P.M., without an order for the tube feeding to be stopped. The Note indicated that the nurse who found the disconnected tube feeding, attempted to flush his/her G-tube and it was clogged. The Note indicated the Physician Assistant was notified and Resident #1 was sent to the Hospital to have his/her G-tube unclogged, and he/she was transferred back to the Facility. Review of Resident #1's Dietician's Recommendations, dated 1/06/23, indicated to increase Osmolite 1.2 continuous tube feed to 64 ml an hour, with water flushes increased to 90 ml an hour, six times a day. Further review of the Dietician's Recommendations indicated that the Nursing Supervisor verified the recommendations by signing it, and the new order was supposed to be transferred to the electronic order entry system. Review of Resident #1's Physician's Order, dated 1/06/23, indicated the following; - the previous physician's orders for Osomolite 54 ml an hour and water flushes were discontinued. - however, although there were new orders for Osmolite 1.2 tube feeding to be administered continuously at an increased rate of 64 ml an hour and water flushes of 90 ml six times a day, the new orders had not been not activated. Review of Resident #1's Nursing Progress Note, dated 1/08/23, indicated Resident #1's G-tube feeding bottle, dated 1/05/23 (indicating when it was first hung for administration, and should be removed 24 hours later, on 1/06/23 at 2:10 P.M., and replaced with a new tube feeding bottle) was empty and still attached to the G-tube. Resident #1 was transferred to the Emergency Department for a (clogged) G-tube. Review of Resident #1's medical record from December 2022 through March 2023 (up through and including the dates of this survey) indicated there was no documentation to support that his/her intake and output was monitored or recorded by nursing for his/her continuous G-tube feeding and water flushes. Review of Resident #1's Hospital Emergency Department Physician's Progress Note, dated 1/08/23, indicated he/she was evaluated for a clogged G-tube which resolved with warm saline flushes. The Emergency Medical Staff reported that Resident #1 has not had a G-tube feeding for the last two days. The Note indicated Resident #1's physical examination indicated he/she had dry oral mucosa (an indicator of dehydration) and an elevated BUN of 32 mg/dl (which is an indicator of inadequate hydration). Review of Resident #1's laboratory work at the Facility, indicated his/her 10/25/22 and 11/15/22 baseline blood urea nitrogen (BUN, indicator of kidney function, normal range 5 milligrams/deciliter, mg/dl) ) on 10/25/22 was 11 mg/dl and on 11/15/22 it was 12 mg/dl, both of which were within normal limits. Review of Resident #1's Blood Laboratory work on 1/09/23, (completed at the facility) indicated his/her BUN remained elevated at 34 mg/dl. During an interview on 3/07/23 at 11:10 A.M., Nurse #1 said during the 11:00 P.M. to 7:00 A.M. shift, when the G-tube feeding bottles needed to be replaced with a new bottle, the nurses on that shift, were not consistently hanging a new bottle, and that nurses needed to know how to manage and care for residents with tube feedings. Nurse #1 said the nurses were also not consistently flushing the G-tube, which resulted in the G-tubes becoming frequently clogged, the G-tube feedings not being delivered, and the residents' not receiving adequate hydration and nutritional intake. During an interview on 3/07/23 at 1:45 P.M., Resident #4 said he/she was Resident #1's roommate and that there were issues with Resident #1's tube feedings, due to Resident #1's feeding pump alarming frequently for approximately two hours during the evening and night shifts, before Resident #1's tube feeding alarm was addressed by the nursing staff. Review of the Facility Investigation, dated 1/08/23, indicated that Nurse #4 found Resident #1's G-tube feeding empty, and dated 1/05/23 at 2:10 P.M. (indicating when this feeding bottle was hung), and to be administered for the next 24 hours (until 1/06/23 at 2:10 P.M.), with no new tube feeding hung on 1/06/23 or on 1/07/23. The Investigation indicated that for these two days (1/06/23 and 1/07/23) Resident #1 was not administered a tube feeding. The Investigation indicated that on 1/06/23 at 5:00 P.M., the Dietician recommended to increase the rate of the Resident #1's Osmolite 1.2 tube feeding from 54 ml an hour to 64 ml an hour. During an interview on 3/08/23 at 10:08 A.M., the Director of Nurses (DON) said that when the Dietician recommended to increase both Resident #1's tube feed rate and water flushes, the old order was discontinued. The DON said that the nurse did not confirm the new G-tube order to activate this order in the Medication Administration Record (MAR) and Treatment Administration Record (TAR), and that were no active orders on his/her MAR or TAR as a result. Review of Resident #1's Dietary Nutrition Note, dated 1/30/23, indicated that per Nursing staff, during the 7:00 A.M. to 3:00 P.M. shift, Resident #1's tube feeding bottle was found completely empty from the 11:00 P.M. to 7:00 A.M. shift, and the Dietician was unsure as to what time Resident #1's G-tube feeding bottle ran out. Review of Resident #1's MAR, dated January 2023, indicated the Osmolite 1.2 continuous G-tube feeding at 54 ml per hour was not administered on: - 1/06/23 during the 3:00 P.M. to 11:00 P.M. shift - 1/07/23 during the 7:00 A.M. to 3:00 P.M. shift - 1/07/23 during the 3:00 P.M. to 11:00 P.M. shift - 1/07/23 during the 11:00 P.M. to 7:00 A.M. shift - 1/08/23 during the early morning of the 7:00 A.M. to 3:00 P.M. shift Review of Resident #1's MAR, dated January 2023, indicated the G-tube flushes of 85 ml ordered to be administered six times a day were not administered on: - 1/06/23 at 8:00 P.M. - 1/07/23 at 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and at 8:00 P.M. During an interview on 3/07/23 at 1:20 P.M., the Director of Nurses (DON) said Resident #1's continuous tube feed that was hung on 1/05/23 at 2:10 P.M. would have finished infusing at 1/06/23 at 2:10 P.M., so from 1/06/23 at 2:10 P.M. until 1/08/23 in the morning, approximately for 42 hours there was no intake for Resident #1 (a deficit of 2,268 ml of feeding formula). The DON said that Resident #1 had not received his/her water flushes of 85 ml six times per day (a deficient 765 ml of water). Review of Resident #1's Physician's Order, dated 1/10/23, indicated to administer intravenous fluids (IV), Normal Saline 0.9% a 500 ml bag at a rate of 60 ml an hour for hydration. The Intravenous Nurse Form, dated 1/10/23, indicated a single lumen catheter was started for the administration of intravenous fluids, due to Resident #1's dehydration. Review of Resident #1's Nursing Progress Note, dated 1/30/23 at 7:35 A.M., indicated this Nurse found that his/her G-tube feeding bottle Osmolite 1.2, was empty (this was a continuous feeding), this Nurse was not sure how long the feeding bottle was empty. The Note indicated the Physician Assistant was notified due to Resident #1 having chest pain and he/she was transferred to the Hospital. The surveyors requested to review Physician Assistant #1's Progress Notes and Resident #1's blood laboratory work from January 2023, that were not located or accessible in the medical record, however despite multiple request made by the surveyors, the documentation was not provided. Review of Resident #1's Blood Laboratory values provided by the Dietician, dated 1/30/23 indicated his/her albumin level (indicator of liver and kidney functions, normal range 3.4 to 5.4 grams per deciliter, g/dl) was severely low at 1.9 grams per deciliter (g/dl), which is indicative of severe malnutrition, and Resident #1's BUN remained elevated at 40 mg/dl, which was indicative of dehydration. Review of Resident #1's Hospital Emergency Department Physician's Progress Note, dated 1/30/23, indicated he/she was in respiratory failure, sepsis and was quite dehydrated, on physical examination had dry mucous membranes, an elevated BUN of 44 mg/dl (indicative of dehydration) and was treated with intravenous fluids. His/her albumin level was extremely low 2.1 g/dl, (indicative of severe malnutrition). Resident #1's CT scans demonstrate atelectasis (a lung condition that happens when the tiny sacs of the lungs don't expand) versus pneumonia, although based on his/her presentation, probably pneumonia, treated with intravenous antibiotics. Resident #1 had hypercapnia (excessive carbon dioxide retention), he/she was offered and declined BiPAP (a non-invasive form of ventilation). Resident #1 also had a sacral wound with sacrococcygeal osteomyelitis (a pressure sore with an underlying bone infection of the sacrum and coccyx). Resident #1 was admitted to the Hospital, and discussion with Resident's and Health Care Agent indicated that if his/he condition declined, they wanted no aggressive therapy, and he/she was treated with comfort care. 2A. Resident #2 was admitted to the Facility in June 2022, diagnoses included a cerebrovascular accident with hemiplegia (paralysis on one side of the body) with severe aphasia, dysphagia and congestive heart failure. Review of Resident #2's Comprehensive Nutrition Assessment, dated 6/16/22, indicated he/she required an estimated minimum of fluid intake of 1,929 milliliters (ml) daily. Review of Resident #2's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was moderately cognitively impaired, required an extensive assist with one person with eating, had a feeding tube, with an average intake by the tube feeding was 501 ml or more per day. Review of Resident #2's Physician's Order, dated 8/21/22, indicated he/she was NPO, and to administer Glucerna 1.2, at a rate of 75 ml per hour every 24 hours continuously via a G-tube, and ensure the feeding is running properly. Review of Resident #2's Physician Orders, dated 9/27/22, indicated for his/her G-tube water flushes to administer 120 ml three times a day. Review of Resident #2's dysphagia and tube feeding care plan, with a revision date of 10/15/22, indicated the goal was for him/her to maintain adequate hydration status, interventions included, administer tube feedings and water flushes as ordered, since he/she was dependent. Ensure that Resident #2's head of the bed is elevated at least 45 degrees during and thirty minutes after the tube feeding. Review of Resident #2's Nursing Progress Note, dated 10/19/22 indicated he/she was readmitted from the Hospital with diagnoses of hypernatremia (an elevated sodium level), acute kidney injury and poor hydration. Review of Resident #2 Physician Orders, dated 10/28/22, indicated for his/her G-tube feeding to administer Glucerca 1.2 at a rate of 90 ml an hour for 14 hours (an overnight feeding). During an interview on 3/08/23 at 1:30 P.M., the Dietician said that Resident #2's oral intake was less than 50 ml per meal, he/she was not eating enough orally. Review of Resident #2's medical record, from November 2022 through March 2023 (up to and including the dates of this survey) indicated there was no documentation to support intake and output (performed to determine fluid deficits, is an essential component in resident assessments inadequate amounts are an indicator of dehydration) was monitored or recorded by nursing regarding his/her continuous G-tube feedings. Review of Resident #2's Blood Laboratory work indicated the following: -8/16/22, sodium level (indicator of hydration, normal range 135 to 145 Milliequivalents per deciliter, MEq/dl) was 138 mEq/dl, and within normal limits. -11/14/22, BUN level (normal range 5 mg/dl to 25 mg/dl) was elevated at 44 mg/dl -11/14/22, his/her sodium level was elevated at 149 mg/dl, -both of which were indicators of dehydration Review of Resident #2's Nursing Progress Note, dated 11/15/22, indicated there was a change in Resident #2's condition, he/she was transferred to the Hospital for abnormal laboratory work, high sodium and (BUN) creatinine levels (both are indicators of dehydration). Review of Resident #2's Hospital Emergency Department Physician's Progress Note, dated 11/15/22, indicated Resident #2 was G-tube dependent for nutrition and presented with abnormal laboratory work, he/she had an elevated sodium level of 149 mg/dl, an elevate BUN level of 45 mg/dl, and an elevated creatinine level of 3.76 (an indication of dehydration and kidney function). The Note indicated Resident #2 was having diarrhea during transport, and physical examination indicated he/she had moderately dry oral mucosa and was hypotensive with systolic blood pressures in the 60's and 90's (normal greater than 100). The Note indicated he/she had a severe acute kidney injury (which can occur from dehydration), he/she was treated and responsive to intravenous fluid resuscitation. The Note indicated Resident #2's hypotension and elevated laboratory work were a concern for significant dehydration. 2B. Review of Resident #2's Physician Order, dated January 2023, indicated water flushes of 120 ml four times a day via the G-tube, and were to be administered starting from 1/01/23 at 5:00 A.M. until 1/22/23 at 6:00 A.M. Review of Resident #2 medical record indicated he/she was hospitalized on [DATE] secondary to vomiting, discharged [DATE] and readmitted to the Facility. Review of Resident #2's Physician's Order, dated 1/24/23, indicated to increase the water flushes, nursing to administer 240 milliliters of water six times a day for four days, via the G-tube for hydration and patency. Review of Resident #2's MAR, dated January 2023, indicated the increased G-tube water flushes of 240 milliliters, six times a day for four days, to be administered from 1/24/23 at 10:00 P.M. until 1/28/23 at 7:00 A.M., as ordered. Further review of Resident #2's MAR for G-tube water flushes, indicated that after being administered additional water flushes for four days as ordered until 1/28/23, his/her previous water flush order for 120 milliliters of water every 6 hours, was not resumed by nursing. Therefore, three water flushes (a total of 360 ml water) were not administered (for hydration and G-tube patency). Review of Resident #2's Nurses Note, dated 1/29/23 at 8:00 A.M., indicated during medication pass, his/her G-tube was clogged, the Nurse unclogged the G-tube with warm water and the tube was flushed. Review of Resident #2's Dietary Note, dated 2/13/23, indicated that Resident #2 was hospitalized for a diagnosis of vomiting (he/she had a history of a neurogenic sigmoid) from 1/21/23 through 1/24/23. He/she was transferred back to the Facility with an order for increased water flushes for four days. The water flushes were not resumed in the physician orders when the increased water flushes were discontinued after four days. During an interview on 3/08/23 at 2:50 P.M., the Director of Nurses said she expected that Resident #2's G-tube flushes of 120 cc every six hours should have been resumed, but three doses (for a total of 360 ml of water) were not administered. 2C. Review of the Nurses Progress Note, dated 1/26/23 at 4:48 P.M., indicated the nurse found Resident #2 vomiting on him/herself, Resident #2's head of the bed was not elevated appropriately, the Nurse reminded the Certified Nurse Aides to keep the head of the bed elevated at 30 degrees, when his/her G-tube feeding was running. During an interview on 3/07/23 at 2:50 P.M., the DON said Resident #2 had his/her tube feeding running when the head of the bed was not elevated, and the staff have been educated regarding appropriately raising the head of the bed greater than 30 degrees. Review of the Educational Records for three Nurses (Nurse #4, Nurse #5 and Nurse #6) who worked the 11 P.M. to 7:00 A.M. shift on Resident #1's and Resident #2's Unit, indicated they did not have education or training with G-tube feedings or hydration. During an interview on 3/07/23 at 1:50 P.M., the Director of Nurses (DON) said that there was a problem with enteral feedings not being administered continuously and water flushes not being administered as ordered. During an interview on 3/08/23 at 10:15 A.M. during review of the audit results, the Director of Nurses said that monitoring resident intake and output was not recognized by the Nursing Supervisor who performed the audit as being needed for G-tube feedings, and that the intake and output documentation had not been performed for the residents with G-tubes.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission to the Facility in August 2022, had no areas of skin breakdown, the Facility failed to ensure he/she was provided with care and services that met professional standards of practice in an effort to prevent the development of a pressure injury, when several months after his/her admission Resident #1 developed a pressure injury to his/her coccyx which continued to worsen and progressed to an unstageable area. Findings include: The Facility Policy titled, Pressure Ulcer Prevention, dated 12/22/22, indicated that the Facility will provide the appropriate care and services to residents to assist in the prevention of pressure injuries and to promote optimal healing. Change the resident's position in bed or chair as needed at a minimum of every 2 hours or as tolerated. The Facility Policy titled, Skin Body Audit, dated 5/09/22, indicated that the skin body assessments should identify changes in skin integrity through weekly skin audits (head to toe) on all residents. Nurses will perform skin body audits on a weekly basis. The Nurse assesses the surfaces of the skin that come in contact with the bed and the chair, bony prominence's such as the tailbone, observing for redness, open areas, any significant abnormal finding will be reported to the resident's physician. Resident #1 was admitted to the Facility in 8/2022, diagnoses included acute respiratory failure, pneumonia, asthma, a cerebrovascular accident with dysarthria (difficulty speaking), and dysphagia (difficulty swallowing). Review of Resident #1's Nursing Admission Assessment, dated 8/30/22, indicated Resident #1 had no pressure injuries on admission, and no skin issues were noted. Review of Resident #1's Norton Scale (a pressure injury risk assessment scale), dated 8/30/22, indicated he/she was not at high risk for pressure injury, due to being alert, ambulatory, fully mobile, continent and in fair physical condition. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated that Resident #1, was cognitively intact, was an extensive assist of two staff persons for bed mobility, limited assist with one staff person for transfers and ambulation, was continent of bowel and bladder, had no unhealed pressure injuries, or other wounds or skin problems and was at risk for development of pressure injuries. Review of Resident #1's Care Plan related to Skin Integrity, dated 9/07/22, indicated, interventions included to keep skin clean and dry, apply a lotion to dry areas, and perform weekly skin checks. Review of the MDS, Care Area Assessment, dated 9/12/22, indicated pressure injury triggered as an area of concern for Resident #1 and to address the pressure injury risk with a care plan. Review of Resident's Weekly Skin Checks for November 2022, indicated that there was no documentation to support that the weekly skin checks were performed by nursing on: - 11/10/22 and 11/17/22. Review of Resident #1's Nursing Progress Note, dated 11/20/22, indicated he/she had a new pressure injury on the coccyx measuring 1.2 centimeters (cm) in length by 0.5 cm in width and 0.2 cm in depth., the wound bed was pink with a small amount of slough (dead tissue). Review of Resident #1's Physician Order, dated 11/20/22, indicated treatment to the new pressure injury on the coccyx; wash with normal saline, apply a border foam dressing, change daily and as needed. Review of Resident #1's Skin Integrity Care Plan, updated on 11/21/22, indicated the staff were to provide the wound treatment as ordered. Review of Resident #1's Physician Order, dated 12/20/22, indicated treatment to the pressure injury on the coccyx (tail bone), wash with normal saline, apply a border foam dressing, change daily and as needed. Review of Resident #1's Nursing Progress Note, dated 12/03/22, indicated he/she had a small pressure injury on his/her coccyx, which was covered with triad cream (a zinc oxide base wound treatment). Review of Resident's Weekly Skin Checks, for December 2022, indicated that there was no documentation to support that the weekly skin checks were performed by nursing on: - 12/01/22 and 12/29/22 Review of Resident #1's Treatment Administration Record (TAR), for December 2022, indicated there was no documentation to support that nursing completed his/her coccyx dressing changes on 12/7/22, 12/11/22, 12/12/22, 12/16/22, 12/21/22, 12/25/22, and 12/28/22. Review of Resident #1's Nursing Progress Note, dated 1/01/23, indicated his/her pressure injury on the coccyx was worsening. The Note indicated the wound was irregular in shape and measured 1.5 cm in length by 1.8 cm in width by 0.2 cm in depth. The Note indicated the wound bed was red in color with light yellow slough (dead tissue), with a small amount of serosanguineous drainage (secreted by an open wound in response to tissue damage). Review of Resident'#1's Weekly Skin Checks, for January 2023, indicated that there was no documentation to support that the weekly skin checks were performed by nursing on: - 1/12/23 and 1/26/23 Review of Resident #1's Wound Physician Notes, dated 1/05/23, indicated he/she had a coccyx pressure injury, staged as unstageable (full thickness tissue loss) due to necrosis (death of most or all cells in tissue), the open wound measured 1 cm in length by 1.5 cm in width, and 0.2 cm in depth with the wound bed containing 100% epithelial (an indicator of healing tissue). The Note indicated around this wound was Deep Tissue Injury measuring 8 cm in length by 6 cm in width (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing (friction that abrades the skin). The Physician's plan included turning and repositioning per facility protocol and optimize nutrition. Review of Resident #1's Physician Order, dated 1/05/23, indicated to cleanse the coccyx wound with a wound cleaner, pat dry, apply calcium alginate (an absorbent dressing) to fit in the wound bed, and cover with a foam dressing every other day, and to start the dressing change on 1/07/23. Review of Resident #1's Treatment Administration Record (TAR), for January 2023, indicated there was no documentation to support that dressing changes were performed by nursing on 1/07/23, and 1/19/23. Review of Resident #1's Documentation Flow Sheets for Turning and Repositioning (completed by the Certified Nurse Aides), dated November 2022, indicated that he/she required staff to physically turn and reposition him/her every 2 hours. Further review of Resident #1's repositioning sheets for November 2022, indicated there was insufficient documentation to support he/she was repositioned as needed by nursing staff and the following dates and times were left blank: Flow sheet documentation on the Day shift (7:00 A.M. to 3:00 P.M.) on the following dates and times were left blank; - 11/01/22, at 2:00 P.M., left blank - 11/06/22, the entire shift - 11/11/22, the entire shift - 11/21/22, the entire shift - 11/22/22, the entire shift - 11/25/22, the entire shift - 11/28/22, the entire shift Flow sheet documentation for Evening shift (3:00 P.M. to 11:00 P.M.) on the following dates and times were left blank; - 11/03/22, the entire shift - 11/04/22, the entire shift - 11/05/22, the entire shift - 11/06/22, at 8:00 P.M. and 10:00 P.M. - 11/07/22, the entire shift - 11/09/22, at 6:00 P.M. and 8:00 P.M. - 11/10/22, the entire shift - 11/11/22, the entire shift - 11/12/22, the entire shift - 11/13/22, the entire shift - 11/15/22, at 6:00 P.M., 8:00 P.M., and 10:00 P.M. - 11/16/22, the entire shift - 11/17/22, the entire shift - 11/18/22, the entire shift - 11/19/22, at 8:00 P.M. and 10:00 P.M. - 11/20/22, at 8:00 P.M. and 10:00 P.M. - 11/21/22, the entire shift - 11/22/22, the entire shift - 11/23/22, the entire shift - 11/24/22, at 4:00 P.M. and 6:00 P.M. - 11/26/22, the entire shift - 11/27/22, the entire shift - 11/29/22, at 6:00 P.M., 8:00 P.M., and 10:00 P.M. - 11/30/22, the entire shift Flow sheet documentation for the Night shift (11:00 P.M. to 7:00 A.M.) on the following dates and times were left blank; - 11/01/22, the entire shift - 11/03/22, at 2:00 A.M., 4:00 A.M., and 6:00 A.M. - 11/05/22, the entire shift - 11/06/22, at 2:00 A.M. and 6:00 A.M. - 11/11/22, at 2:00 A.M., 4:00 A.M., and 6:00 A.M. - 11/12/22, at 6:00 A.M. - 11/13/22, the entire shift - 11/14/22, at 2:00 A.M., 4:00 A.M., and 6:00 A.M. - 11/16/22, at 6:00 A.M. - 11/18/22, at 2:00 A.M., 4:00 A.M., and 6:00 A.M. - 11/19/22, the entire shift - 11/20/22, the entire shift - 11/21/22, the entire shift - 11/22/22, the entire shift - 11/23/22, the entire shift - 11/24/22, at 6:00 A.M. - 11/25/22, at 6:00 A.M. - 11/26/22, at 6:00 A.M. - 11/27/22, the entire shift - 11/28/22, the entire shift Review of Resident #1's Documentation Flow Sheets for Turning and Repositioning, dated December 2022, indicated he/she was not consistently turned and repositioned by nursing staff and the following dates and times were left blank: Flow sheet documentation on the Day shift (7:00 A.M. to 3:00 P.M.) on the following dates and times was left blank; - 12/01/22, the entire shift - 12/02/22, the entire shift - 12/11/22, the entire shift - 12/18/22, the entire shift - 12/22/22, the entire shift - 12/23/22, the entire shift - 12/26/22, the entire shift - 12/27/22, the entire shift - 12/28/22, at 2:00 P.M. - 12/30/22, the entire shift Flow sheet Documentation on Evening shift (3:00 P.M. to 11:00 P.M.) on the following dates and times were left blank; - 12/01/22, the entire shift - 12/02/22, the entire shift - 12/03/22, the entire shift - 12/04/22, at 8:00 P.M. and 10:00 P.M. - 12/05/22, the entire shift - 12/06/22, the entire shift - 12/07/22, the entire shift - 12/08/22, the entire shift - 12/09/22, the entire shift - 12/10/22, the entire shift - 12/11/22, the entire shift - 12/13/22, at 10:00 P.M. - 12/14/22, the entire shift - 12/15/22, the entire shift - 12/16/22, the entire shift - 12/17/22, at 8:00 P.M. and 10:00 P.M. - 12/18/22, the entire shift - 12/19/22, at 4:00 P.M. and 6:00 P.M. - 12/20/22, at 4:00 P.M., 6:00 P.M., and 8:00 P.M. - 12/21/22, the entire shift - 12/22/22, the entire shift - 12/23/22, the entire shift - 12/24/22, at 4:00 P.M. and 6:00 P.M. - 12/26/22, the entire shift - 12/27/22, the entire shift - 12/28/22, at 4:00 P.M. and 6:00 P.M. - 12/29/22, at 4:00 P.M. and 6:00 P.M. - 12/30/22, the entire shift - 12/31/22, the entire shift Flow sheet documentation for Night shift (11:00 P.M. to 7:00 A.M.) on the following dates and times was left blank; - 12/01/22, at 6:00 A.M. - 12/02/22, the entire shift - 12/03/22, the entire shift - 12/04/22, the entire shift - 12/05/22, the entire shift - 12/06/22, the entire shift - 12/07/22, the entire shift - 12/10/22, the entire shift - 12/11/22, the entire shift - 12/12/22, the entire shift - 12/15/22, at 12:00 A.M., 2:00 A.M., and 4:00 A.M. - 12/16/22, the entire shift - 12/20/22, at 4:00 A.M. and 6:00 A.M. - 12/21/22, the entire shift - 12/26/22, the entire shift - 12/27/22, the entire shift - 12/28/22, the entire shift - 12/31/22, the entire shift Review of the Medical Record indicated Resident #1 was transferred to the hospital three different times during January 2023, therefore there he/she was only in the facility for 22 full days that month. Review of Resident #1's Documentation Flow Sheets for Turning and Repositioning, for January 2023, indicated he/she was not consistently turned and repositioned by nursing staff and the following dates and times were left blank: . Flow sheet documentation for the Day shift (7:00 A.M. to 3:00 P.M.) for the following dates and times were left blank; - 01/03/23, the entire shift - 01/06/23, the entire shift - 01/12/23, the entire shift - 01/13/23, the entire shift - 01/14/23, the entire shift - 01/16/23, the entire shift - 01/19/23, the entire shift - 01/20/23, the entire shift - 01/23/23, the entire shift - 01/29/23, the entire shift On the Evening shift (3:00 P.M. to 11:00 P.M.), only the 4:00 P.M. Turning & Positioning Flow Sheet, was made available to the Surveyor for January 2023. The remaining flow sheets for January 2023 Evening shift times of 6:00 P.M., 8:00 P.M. and 10:00 P.M. were not made available to the surveyor. Flow sheet documentation for the Evening shift (for 4:00 P.M.) on the following dates were left blank; - 01/01/23 through 01/07/23 - 01/10/23 through 01/16/23 - 01/18/23 through 01/23/23 Flow sheet documentation for Night shift (11:00 P.M. to 7:00 A.M.)for the following dates and times were left blank; - 01/01/23, the entire shift - 01/04/23, the entire shift - 01/06/23, the entire shift - 01/14/23, the entire shift - 01/19/23, the entire shift - 01/20/23, the entire shift - 01/22/23, at 6:00 A.M. - 01/23/23, at 6:00 A.M. Review of Resident #1's Skin Integrity Care Plan, updated on 1/11/23, indicated a new intervention included, an air mattress was applied to his/her bed, for the open area on the coccyx. Review of Resident #1's Wound Physician Notes, dated 1/12/23, indicated he/she had a coccyx pressure injury, staged as unstageable (full thickness tissue loss) due to necrosis (death of most or all cells in tissue), the open wound measured 2 cm in length by 2 cm in width, and 0.8 cm in depth, with the wound bed containing 100% slough (dead tissue). The Note indicated around this wound was Deep Tissue Injury measuring 5 cm in length by 10 cm. in width, with tunneling which measured 0.2 cm at 10 and 11 o'clock. The Physician's plan included turning and repositioning per facility protocol and to optimize nutrition. The Note indicated this wound was worsening with increased necrosis and increased size. Review of Resident #1's Wound Physician Notes, dated 1/19/23, indicated he/she had a coccyx pressure injury, staged as Deep Tissue Injury, open wound measured 2 cm in length by 2.2 cm in width, and 1 cm in depth, with the wound bed containing 90% eschar (dried dark dead skin ). The Note indicated around this wound was Deep Tissue Injury measuring 9 cm in length by 10 cm. in width, with tunneling which measured 0.3 cm. The Note indicated this was a worsening pressure injury, with increased necrosis and increased size. The Physician's plan included turning and repositioning per facility protocol and to optimize nutrition. Resident #1's Hospital Emergency Department (ED) Physician's Progress Note, dated 1/30/23, indicated Resident #1 had a sacral pressure injury with tunneling, which had purulent drainage with redness, measuring approximately 2 cm in length by 2 cm in width. A Computerized Scan (CT) of the pelvis and sacral pressure injury indicated there was sacrococcygeal (of the sacral and coccyx bone) osteomyelitis (a bone infection) with soft tissue infection. During an interview on 3/07/23 at 3:25 P.M., the Nursing Supervisor said Resident #1 developed a Facility acquired pressure injury three months after his/her admission, and that the Facility expectation was that nurses would complete weekly skin checks and wound treatments as ordered, and nurses also were responsible for making sure Certified Nurse Aides had turned and repositioned him/her, per the Plan of Care in an effort to prevent skin breakdown.

Based on observation, records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at an increased risk for falls and who required hands on assistance of one staff member for safe transfers, the Facility failed to ensure staff consistently implemented and followed interventions from his/her plan of care related to his/her individual safety needs related to transfers and mobility. On 12/07/22 during the overnight shift, a Certified Nurse Aide left Resident #1 standing alone in front of the toilet, while she went to get an incontinence brief. Resident #1 lost his/her balance and fell . Resident #1 was later transferred to the Hospital Emergency Department where he/she was diagnosed with a right femur (thigh bone) fracture and was admitted for further treatment. Findings include: Review of the Facility's Policy, titled Fall Reduction, dated as revised 07/26/21, indicated the Facility would implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual's needs. Review of the Facility's Policy, titled Comprehensive Care Plan, undated, indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes. Resident #1 was admitted to the facility in October 2022, diagnoses included syncope (fainting) and collapse, Meniere's disease (disorder of the inner ear that can lead to dizzy spells and hearing loss), osteoarthritis, hypertension, unspecified fall, and personal history of healed traumatic fracture. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 10/31/22, indicated that his/her cognitive patterns were intact, with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #1 required extensive physical assistance from one staff member for toileting, transfers, and ambulation. Review of Resident #1's Alteration in Ability to Complete Activities of Daily Living (ADL) Care Plan, dated as revised 11/01/22, indicated he/she required use of a rolling walker and assistance of two staff members for toileting, when ambulating and/or transferring. Review of Resident #1's At Risk for Falls Care Plan, dated as revised 11/15/22, indicated he/she was at risk for falls due to deconditioning, gait and balance problems, vision and hearing problems, and a history of falls prior to admission. The Care Plan indicated the goal was for Resident #1 to remain free from falls through 01/30/23. Review of Resident #1's Physical Therapy (PT) Discharge Summary, dated 12/07/22, indicated Resident #1 required contact guard to moderate assistance from one staff member for all functional transfers. Review of the Facility's Incident Report, dated 12/07/22, indicated that Certified Nurse Aide (CNA) #1 called out for help because Resident #1 had fallen in the bathroom. The Report indicated CNA #1 had Resident #1 stand up at the toilet, when suddenly he/she fell in the opposite direction and CNA #1 could not reach over the walker to grab him/her. During an interview on 01/03/23 at 2:57 P.M., Nurse #1 said that CNA #1 called her into Resident #1's room and told her that Resident #1 stood and fell , while she (CNA #1) had gone to get a brief. Nurse #1 said CNA #1 told her she tried to grab Resident #1 to prevent the fall, but that he/she was too heavy, and fell in the opposite direction. Nurse #1 said she assessed Resident #1 and noted his/her right leg was rotated and appeared to be fractured, and he/she was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge Summary, dated 12/16/22, indicated Resident #1 was admitted to the Hospital on 12/07/22 and diagnosed with a right femur fracture for which he/she underwent surgical repair. The Summary Indicated Resident #1's hospital stay was further complicated by hemorrhagic blood loss, likely due to surgery, requiring six units of blood. During an interview on 01/03/23 at 11:30 A.M., Resident #1 said he/she had a fall at the beginning of December that resulted in a broken hip, when a female CNA (later identified as CNA #1) walked him/her to the toilet with his/her walker and said the CNA #1 left the bathroom while he/she stood at the walker unassisted, and tried to pull down his/her brief. Resident #1 said CNA #1 was not in the bathroom with him/her, that CNA #1 was in his/her room near the foot of his/her bed, when he/she lost his/her balance and fell . Resident #1 said CNA #1 could not have reached him/her to prevent the fall, because she (CNA #1) was not even in the bathroom. During an interview on 01/03/23 at 2:35 P.M., Certified Nurse Aide (CNA) #1 said that during her overnight shift on 12/07/22, Resident #1 required toileting every 30 to 45 minutes and said that was unusual. CNA #1 said that she got Resident #1 up from bed around 5:00 A.M. to take him/her to the bathroom and that Resident #1 got dizzy while transferring out of the bed. CNA #1 said she then ambulated Resident #1 to the bathroom with his/her rolling walker and positioned him/her in front of the toilet. CNA #1 said that while Resident #1 stood at the walker and pulled down his/her clothing, she went to a get a clean brief from a dresser (in Resident #1's room ) that was just outside the bathroom door. CNA #1 said she did not provide hands on assistance while Resident #1 stood at the walker in the bathroom and managed his/her clothing. CNA #1 said that in the time it took her to turn around and leave the bathroom to get a brief, said Resident #1 lost his/her balance while trying to sit down on the toilet. CNA #1 said she tried to stop the fall, but Resident #1's walker was in the way, and she only got a hold of Resident #1's hospital gown. On 01/03/23 at 11:30 AM, the surveyor observed that Resident #1's bathroom was located directly across from the foot of his/her bed and a dresser was positioned outside of the bathroom door. During an interview on 01/03/22 at 3:15 P.M., the Director of Rehabilitation (DOR) said that Resident #1 was on PT and OT services prior to the fall and required varying levels of staff assistance with transfers and toileting. The DOR said Resident #1 required minimal assistance of one staff member for ambulation, transfers and toileting with a rolling walker. The DOR said Resident #1 had not been deemed safe for independent or supervised functional transfers and that Resident #1 would be unsafe if hands on assistance was not provided while standing. During an interview on 01/03/23 at 4:40 P.M., the Corporate Director of Clinical Services said Resident #1's ADL Care Plan, that was in effect at the time of the 12/07/22 fall, indicated he/she required physical assistance from two staff members with transfers and toileting. The Corporate Clinical Specialist said the Care Plan should have been updated to reflect the PT recommendations for assistance of one staff member for transfers as recommended by therapy. During the interview the Corporate Clinical Specialist was made aware that both Resident #1 and CNA #1, said in their interviews with the surveyor, that Resident #1 was left standing alone in the bathroom with his/her walker at the toilet, while CNA #1 went to get a brief from the dresser in the room, and that was when Resident #1 lost his/her balance and fell . The Corporate Clinical Specialist said the Care Plan and the PT recommendations indicated hands on assistance was required for safe transfers, therefore the Care Plan interventions were not implemented by CNA #1, when she left Resident #1 standing alone in the bathroom on 12/07/22, resulting in a fall with a fracture.

Based on observation, records reviewed and interviews for one of three sampled residents (Resident #1), who required hands on assistance of one staff member during transfers and ambulation, the Facility failed to ensure staff provided adequate assistance during a transfer to maintain his/her safety in an effort to prevent an incident and/or accident resulting in an injury, when on 12/07/22 during the overnight shift, a Certified Nurse Aide (CNA) left Resident #1 standing alone, unassisted, in front of the toilet, and left the bathroom to get an incontinence brief. Resident #1 lost his/her balance and fell while the CNA had stepped away. Resident #1 was later transferred to the Hospital Emergency Department where he/she was diagnosed with a right femur (thigh bone) fracture, he/she was admitted and required surgical intervention to repair the fracture. Findings include: Review of the Facility's Policy, titled Fall Reduction, dated as revised 07/26/21, indicated the Facility would implement interventions to minimize and/or eliminate contributing factors for falls for residents at risk based on the individual's needs. Resident #1 was admitted to the facility in October 2022, diagnoses included syncope (fainting) and collapse, Meniere's disease (disorder of the inner ear that can lead to dizzy spells and hearing loss), osteoarthritis, hypertension, unspecified fall, and personal history of healed traumatic fracture. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 10/31/22, indicated that his/her cognitive patterns were intact, with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #1 required extensive physical assistance from one staff member for toileting, transfers, and ambulation. Review of Resident #1's Alteration in Ability to Complete Activities of Daily Living (ADL) Care Plan, dated as revised 11/01/22, indicated he/she required a rolling walker and assistance of two staff for toileting, when ambulating and/or transferring. Review of Resident #1's At Risk for Falls Care Plan, dated as revised 11/15/22, indicated he/she was at risk for falls due to deconditioning, gait and balance problems, vision and hearing problems and a history of falls prior to admission. The Care Plan indicated a goal that Resident #1 would remain free from falls through 01/30/23. Review of Resident #1's Physical Therapy (PT) Discharge Summary, dated 12/07/22, indicated Resident #1 required contact guard to moderate assistance from one staff member for all functional transfers. Review of the Facility's Incident Report, dated 12/07/22, indicated that Certified Nurse Aide (CNA) #1 called out for help because Resident #1 had fallen in the bathroom. The Report indicated CNA #1 had Resident #1 stand up at the toilet, when suddenly he/she fell in the opposite direction and CNA #1 could not reach over the walker to grab him/her. During an interview on 01/03/23 at 2:57 P.M., Nurse #1 said that CNA #1 called her into Resident #1's room and said that Resident #1 stood and fell , while she had gone to get a brief. Nurse #1 said CNA #1 told her she tried to grab Resident #1 to prevent the fall, but he/she was too heavy and fell in the opposite direction. Nurse #1 said she assessed Resident #1, noted his/her right leg was rotated and appeared to be fractured, and he/she was transferred to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge Summary, dated 12/16/22, indicated Resident #1 was admitted to the Hospital on 12/07/22 and diagnosed with a right femur fracture for which he/she underwent surgical repair. The Summary Indicated Resident #1's hospital stay was further complicated by hemorrhagic blood loss, likely due to surgery, requiring six units of blood. During an interview on 01/03/23 at 11:30 A.M., Resident #1 said he/she had a fall at the beginning of December that resulted in a broken hip, when a female CNA (later identified as CNA #1) walked him/her to the toilet with his/her walker and CNA #1 left the bathroom while he/she stood at the walker unassisted, and tried to pull down his/her brief. Resident #1 said CNA #1 was not in the bathroom with him/her, that CNA #1 was in his/her room near the foot of his/her bed, when he/she lost his/her balance and fell . Resident #1 said CNA #1 could not have reached him/her to prevent the fall, because she (CNA #1) was not even in the bathroom. During an interview on 01/03/23 at 2:35 P.M., Certified Nurse Aide (CNA) #1 said that during her overnight shift on 12/07/22, Resident #1 required toileting every 30 to 45 minutes and said that was unusual. CNA #1 said that she got Resident #1 up from bed around 5:00 A.M. to take him/her to the bathroom and that Resident #1 got dizzy transferring out of the bed. CNA #1 said she then ambulated Resident #1 to the bathroom with his/her rolling walker and positioned him/her in front of the toilet. CNA #1 said that while Resident #1 stood at the walker and pulled down his/her clothing, she went to a get a clean brief, from a dresser that was just outside the bathroom door. CNA #1 said she did not provide hands on assistance while Resident #1 stood at the walker and managed his/her clothing. CNA #1 said that in the time it took her to turn around and leave the bathroom, Resident #1 lost his/her balance while trying to sit down on the toilet. CNA #1 said she tried to stop the fall, but said the walker was in the way, and she only got a hold of Resident #1's hospital gown. On 01/03/23 at 11:30 AM, the surveyor observed that Resident #1's bathroom was located directly across from the foot of his/her bed and a dresser was positioned outside of the bathroom door. During an interview on 01/03/22 at 3:15 P.M., the Director of Rehabilitation (DOR) said that Resident #1 was on PT and OT services prior to the fall and required varying levels of assistance with transfers and toileting. The DOR said Resident #1 required minimal assistance of one staff member for ambulation, transfers and toileting with a rolling walker. The DOR said Resident #1 had not been deemed safe for independent or supervised functional transfers and said Resident #1 would be unsafe if hands on assistance was not provided while standing. During an interview on 01/03/23 at 4:40 P.M., the Corporate Director of Clinical Services said Resident #1's ADL Care Plan, that was in effect at the time of the 12/07/22 fall, indicated he/she required assistance from two staff members with transfers and toileting. The Corporate Clinical Specialist said the Care Plan should have been updated to reflect the PT recommendations for assist of one staff member for transfers as recommended by therapy. During the interview the Corporate Clinical Specialist was made aware that both Resident #1 and CNA #1, said in their interviews with the surveyor, that Resident #1 was left standing alone in the bathroom with his/her walker at the toilet while CNA #1 went to get a brief from the dresser in the room, and that was when Resident #1 lost his/her balance and fell . The Corporate Clinical Specialist said the Care Plan and the PT recommendations indicated hands on assistance was required for safe transfers, therefore the Care Plan interventions were not implemented by CNA #1, when she left Resident #1 standing alone in the bathroom on 12/07/22, resulting in a fall with a fracture.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free physical abuse, when on 6/24/21, while providing care to Resident #1 in his/her room, Resident #1 screamed, Certified Nurse Aide (CNA) #1 in response, placed his hand over Resident #1's mouth, and Resident #1 then screamed louder, and then CNA #1 removed his hand. Resident #1 reported the incident to a staff member, and was observed to be visibly shaken up and crying after the incident occurred. Findings include: Review of the Facility Abuse Prohibition Policy, revised 11/28/16, indicated that the Facility prohibited abuse of residents/patients and designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged abuse. The Policy indicated each resident had the right to be free from abuse. Review of Resident #1's clinical record indicated that his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set assessment, dated 4/14/21, indicated that Resident #1's cognitive patterns were intact. Review of Resident #1's Verbally Abusive Behavior Care Plan, initiated 8/20/20, indicated one of his/her goals was that Resident #1 would use acceptable methods of communication. The Care Plan indicated that interventions included that if Resident #1 became agitated, staff should attempt to intervene before his/her behavior escalated by engaging calmly in conversation and, if Resident #1 responded aggressively, staff should walk calmly away and approach later. During an interview on 7/12/21 at 1:00 P.M., Resident #1 said he/she recalled an incident in which CNA #1 cared for him/her in his/her room and said when he/she screamed, CNA #1 placed his hand over his/her mouth which made him/her scream louder. During an interview on 7/22/21 at 2:11 P.M., Activities Assistant #1 said that on 6/24/21, when CNA #1 brought Resident #1 out of his/her room and into the shower room, Resident #1 pointed to CNA #1 and stated words to the effect of, that's not right, that's not right, he put his hand over my mouth. Activities Assistant #1 said Resident #1 was visibly shaken up and crying. During an interview on 7/23/21 at 12:47 P.M. CNA #1 said that he assisted Resident #1 with getting ready for a shower on 6/24/21 and, when Resident #1 screamed, he placed his hand over Resident #1's mouth. CNA #1 said that Resident #1 started to scream more and said he removed his hand.

Based on interviews and records reviewed, for one of three sampled Residents (Resident #1) the Facility failed to prevent an incident at 5:45 P.M. on [DATE] in which Nurse #1 slapped Resident #1. Findings include: On [DATE], the Facility reported an allegation that on [DATE] around 5:45 P.M., Nurse #1 slapped Resident #1's shoulder. Resident #1's most recent Admission Minimum Data Set Assessment Form, completed [DATE], indicated that his/her cognitive patterns were severely impaired. The Surveyor could not interview Resident #1 about the allegation because he/she was deceased at the time of the Survey. The Surveyor interviewed Activity Assistant #1 at 11:00 A.M. on [DATE]. Activity Assistant #1 said that Resident #1 became resistant to feeding and tried to hit her during dinner on [DATE]. Activity Assistant #1 said that she reported Resident #1's behavioral symptoms to Nurse #1 and Nurse #1 said she would come to the dining room right away. Activity Assistant #1 said that when Nurse #1 approached and tried to administer medication to Resident #1, Resident #1 spat out the medication. Activity Assistant #1 said that Nurse #1 placed a towel in front of Resident #1's mouth to catch Resident #1's spit. Activity Assistant #1 said that Nurse #1 hit Resident #1's right shoulder with a pretty good thump and told Resident #1 words to the effect of no spitting. The Surveyor interviewed Activity Assistant #2 at 10:50 A.M. on [DATE]. Activity Assistant #2 said that she was assisting with dinner in the dining room on [DATE] with Activity Assistant #1. Activity Assistant #2 said that she saw Nurse #1 smack Resident #1 in the center of the chest when Resident #1 spat out medication. The Surveyor interviewed Activity Assistant #3 at 10:15 A.M. on [DATE]. Activity Assistant #3 said that on [DATE] she and Activity Assistant #1 and Activity Assistant #2 assisted residents in the dining room with their dinner. Activity Assistant #3 said that she saw Resident #1 getting rowdy in the dining room and described that Resident #1 called out and spat. Activity Assistant #3 said that Nurse #1 approached Resident #1 and placed a towel over Resident #1's mouth. Activity Assistant #3 said that Resident #1 placed his/her hands on Nurse #1's arm which was holding the towel in front of Resident #1's mouth and Activity Assistant #3 approached Resident #1 to assist Nurse #1 to remove Resident #1's hand from Nurse #1's arm. Activity Assistant #3 said that she saw Nurse #1 slap Resident #1's right shoulder. Activity Assistant #3 said that the sound of the slap was audible. The Surveyor interviewed the former Assistant Director of Nurses at 2:50 P.M. on [DATE]. The former Assistant Director of Nurses said that on [DATE], Activity Assistant #1 told her that Nurse #1 slapped Resident #1. The former Assistant Director of Nurses said that she went to Resident #1's unit and asked Nurse #1 what happened and Nurse #1 told her that she had hit Resident #1 as a reflex. The former Assistant Director of Nurses said that Nurse #1 said that she regretted what she did and said that it was an automatic reaction when Resident #1 spit. The former Assistant Director of Nurses said and review of the Incident Report, dated [DATE], indicated that she completed a skin check for Resident #1 and identified a red area on the front of Resident #1's right shoulder in the area in which Activity Assistants #1, #2 and #3 told her that Nurse #1 hit Resident #1. The Surveyor interviewed Nurse #1 at 11:00 A.M. on [DATE]. Nurse #1 said that she smacked Resident #1's shoulder in order to try and get Resident #1 to think about what he/she was doing during the episode of agitation in which Resident #1 was spitting and biting. Nurse #1's written statement dated [DATE] indicated that she reflexively smacked Resident #1's shoulder and told him/her to stop hitting, slapping, scratching and spitting.

Based on observation, record review and staff interviews, the facility failed to follow the care plan regarding fall interventions for 2 of 13 (#2 and 13) applicable residents, out of total sample of 24 residents. 1. For Resident #13, the facility staff failed to ensure that the resident's alarm was consistently functioning and that the resident utilized proper footwear. Findings include: Resident #13 was admitted to the facility in 1/2015, with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 10/12/15, included the following interventions: - Fall assessment per facility protocol. - Assist of 2 for bed mobility, transfers, and toileting. - Alarms as ordered. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 4/19/16, indicated that the resident required extensive with ambulation and transfers and had no falls since the last assessment. Review of the Nurse's Note, dated 4/25/16, indicated that the resident was witnessed standing up from the wheelchair. The wheelchair leg rests were in front of the resident and he/she tripped over the leg rests, fell forward, hit his/her head, and sustained an abrasion. Review of the facility's internal investigation, dated 4/25/16, indicated that at 11:00 A.M. the resident stood up to go to the bathroom, his/her legs got caught between the wheelchair leg rests and the resident fell forward, hitting his/her head. The internal investigation further indicated that the resident's alarm was not functional and that 2 nurses had been notified at approximately 8:00 A.M., prior to the fall. The fall occurred at 11:00 A.M. and the resident's alarm did not sound, as care planned. There is no evidence that the nonfunctioning alarm had been addressed for 3 hours for a Resident at high risk of falls. Review of the quarterly MDS Assessment, dated 7/14/16, indicated that the resident's memory was impaired, required extensive with ambulation and transfers. Review of the Nurse's Note, dated 7/15/16, indicated that the resident fell to the floor. The Nurse's Note, further indicated that the resident was able to move all extremities and did not hit his/her head. Review of the facility's internal investigation, dated 7/15/16, indicated that at 3:15 P.M., a faint alarm sounded. The investigation indicated that the Certified Nurse Aide (CNA) observed the resident fall onto his/her hip. The internal investigation further indicated that the alarm was under the pillow and the CNA barely heard the alarm. The investigation indicated that the resident was able to move all extremities and did not appear to be in pain, there was no shortening of the leg or lower extremity [MEDICAL CONDITION] noted. The investigation did not state if any internal or external rotation of the hip was noted. The resident was then lifted back into bed using a mechanical lift. Review of the Nurse's Note, dated 7/16/16 at 6:30 A.M. indicated that at 1:40 P.M. during a transfer from the wheelchair to the bed, the resident complained of severe pain in the right hip, the hip was swollen and painful. Further review of the Nurse's Note indicated that at 3:20 P.M. the resident's hip was x-rayed and at 5:25 P.M. the facility received the results indicating an acute [MEDICAL CONDITION] hip. At 6:35 P.M. the resident was sent to the hospital. Review of the Annual MDS Assessment, dated 1/12/17, indicated that the resident's memory and cognitive status were impaired, was dependent for transfers, did not ambulate and had no falls since the last assessment. Review of the Nurse's Note, dated 1/14/17, indicated that the resident's alarm sounded and the resident was observed sitting on the carpet in front of his/her wheelchair. Review of the facility's internal investigation, dated 1/14/17, indicated the the fall occurred at 8:15 P.M. and the resident was last toileted at 4:30 P.M. The internal investigation further indicated that the had slippers on his/her feet. On 1/14/17, the falls care plan was updated to include the following intervention: - Shoes/sneakers on when out of bed. On 1/17/17, the falls care plan was updated to include the following intervention: - Sit to stand lift for transfers and assist of 2. Review of the Fall Risk Assessment, dated 1/19/17, indicated that the resident was at high risk for falls. Review of the Nurse's Note, dated 1/27/17, indicated that the resident was found on the floor and the alarm did not immediately sound. Review of the facility's internal investigation, dated 1/27/17 indicated indicated that the resident had slippers on his/her feet and not sneakers or shoes. On 1/27/17, the falls care plan was updated to include the following interventions: - 1/27/17 - Out of bed before breakfast, in bed before 8:00 P.M. if not agitated. - 1/27/17 - Bed in low position Review of the Nurse's Note, dated 2/4/17, indicated that the resident was found on the floor. The note further indicated that the resident reopened a laceration on his/her finger. Review of the facility's internal investigation, dated 2/4/17, indicated that the the resident's alarm was on however, did not sound. The surveyor observed Resident #13 on 2/16/17 at 9:53 A.M. Resident #13 was in the unit activity room seated at a table with 2 other residents, engaging in a table top activity. The resident's alarm was on his/her wheelchair. During an interview with Unit Manager (UM) #1 on 2/23/17 at 1:08 P.M., she said that the resident's alarms should be on and functioning, per the care plan. She further said that after 1/14/17, the resident should have worn shoes or sneakers when he/she were out of bed, as care planned. Please refer to F323. 2. For Resident #3, the facility failed to provide supervision and rest periods when fatigued to prevent falls per the plan of care. The resident had 6 falls between 8/2/16 and 2/13/17. One fall resulted in a laceration requiring 5 sutures, to the resident's eyebrow area, to close the wound and a second fall resulted in a laceration requiring 6 sutures, to the resident's forehead, to close the wound. Resident #3, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) Assessment of 5/19/16 indicated that the resident exhibited short and long term memory deficits, severely impaired decision making ability, inattention; highly impaired vision; required assistance with transfers and supervision while ambulating in the corridor and on the unit. The falls care plan of 6/2/16 indicated the following interventions: supervise with ambulation and transfers when fatigued, offer rest periods throughout the day and wanderguard on ankle. During an interview with Unit Manager (UM) #1 (on 2/16/17 at 3:10 P.M.), UM #1 said the resident usually gets out of bed on the 11:00 P.M. to 7:00 A.M. shift, ambulates up and down the hallways all day and when the resident is fatigued, she/he will exhibit facial grimacing which the staff need to monitor for. The ADL (Activities of Daily Living) care plan of 6/2/16 indicated the resident ambulates with distant supervision. Review of the Nurse's Note of 8/2/16 indicated the resident experienced an unwitnessed fall (3:15 P.M.), sustaining a laceration to the eyebrow area requiring 5 sutures to close the wound. Staff supervision while the resident was ambulating was not being provided, as planned. Per facility investigation, to prevent fall reoccurrence, the plan was to have no clutter or lifts in the unit hallway. Review of the quarterly MDS Assessment of 8/18/16 remained essentially unchanged. Review of the Nurse's Note of 8/19/16 indicated the resident experienced a fall (6:20 P.M.), with no injury. Per facility investigation, to prevent fall reoccurrence, the plan was to keep the resident out of the dayroom when not eating. Review of the falls care plan and ADL care plan of 9/1/16 remained essentially unchanged. Review of the Interdisciplinary Care Plan Meeting Notes of 9/1/16 indicated the resident ambulates ad lib in the hallway with distant supervision. Review of the Nurse's Note of 10/4/16 indicated the resident experienced a fall (5:30 P.M.), sustaining an abrasion on the left arm and knee. The investigation indicated that the resident's unsteady gait may have contributed to the fall. Per facility investigation, to prevent fall reoccurrence, the plan was: supervision, offer to sit in recliner, Neurology consult, lab work, orthostatic blood pressures and Physician review. Review of the Nurse's Note of 10/12/16 indicated the resident experienced an unwitnessed fall (5:30 P.M.), with no injury. During an interview with UM #1 (on 2/16/17 at 2:40 P.M.), she said that the fall was unwitnessed, therefore, the resident was not receiving supervision (as planned). The falls care plan was updated to include: resident to wear tight pants. Review of the quarterly MDS Assessment of 11/17/16 remained essentially unchanged. Review of the Nurse's Note of 11/23/16 indicated the resident experienced an unwitnessed fall (5:15 P.M.), sustaining a [MEDICAL CONDITION] requiring 6 staples to close the wound. Staff supervision while the resident was ambulating and wandered into another resident's room was not being provided, as planned. Per facility investigation, to prevent fall reoccurrence, the plan was to have no mats/objects on the unit floors. The falls care plan was updated to include: a yellow Velcro stop sign was placed at the room doorway where the resident had wandered into. Review of the 12/1/16 ADL care plan remained essentially unchanged. Review of the CNA (Certified Nursing Assistant) Care Card updated 12/29/16 (currently in effect per UM #1) indicated the resident required supervision/monitoring while ambulating and that the resident was known to wander. Review of the Licensed Nursing Summary's (of 8/30/16, 11/27/16, 12/28/17 and 1/31/17) with UM #1 (on 2/16/17 at 2:40 P.M.) indicated the resident required continual supervision/monitoring/verbal instruction while ambulating due to poor safety awareness. Further review with UM #1 of the (9/28/16 and 10/29/16) Nursing Summary's indicated the resident required assist of 1 to ambulate. Review of the Annual MDS Assessment of 2/9/17 remained essentially unchanged. Review of the Nurse's Note of 2/13/17 indicated the resident experienced an unwitnessed fall, with no injury. Staff supervision while the resident was ambulating was not being provided, as planned. Per facility investigation, to prevent fall reoccurrence, the plan was to trend bowel incontinence. Review of the ADL care plan of 2/13/17 indicated the resident continues to ambulate with distant supervision. On 2/14/17 at 3:50 P.M., the surveyor observed the resident ambulating up and down the hallway then wandered into another resident's room. Staff were not in the hallway nor in the other resident's room to provide the resident with the supervision, as planned. At 4:05 P.M., the surveyor observed the resident ambulating up and down the hallway and no staff were in the hallway to provide the supervision, as planned. On 2/15/17 at 7:50 A.M. and 4:25 P.M., the surveyor observed the resident ambulating up and down the hallway and no staff were in the hallway to provide the supervision, as planned. During an interview with CNA #1 on 2/16/17 at 10:55 A.M., she said the resident is constantly walking, (she/he) has no safety awareness and that the staff constantly need to keep an eye on (her/him) to supervise (her/him). During an interview with UM #1, (on 2/16/17 at 2:40 P.M.), UM #1 said the resident wanders aimlessly, has no safety awareness and that the resident needs to be monitored. At 3:10 P.M., the surveyor and UM #1 observed the resident ambulating in the hallway. UM #1 said the staff determine that the resident is fatigued when they can see facial grimacing. At the time of this observation, UM#1 said the resident did seem tired, due to the resident's facial grimacing observed, as she said the resident had been constantly ambulating the hallways since approximately 6:00 A.M. to 7:00 A.M. this morning. UM #1 said the resident's routine is to constantly ambulate the hallways from early morning till bedtime. A discussion was held with UM #1 regarding 5 of the 6 falls having occurred between 3:15 P.M. and 6:20 P.M.(3 of which occurred between 5:15 P.M. and 5:30 P.M.), when the resident may be tiring out after ambulating /wandering the hallways all day and needing the supervision, as planned. The facility failed to provide effective interventions and adequate supervision to prevent continued falls resulting in the resident sustaining lacerations on 2 separate occasions requiring sutures to close the resident's wounds.

Based on record review, observation, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 2 of 13 applicable residents (#3 and #13), out of a total sample of 24 residents. Findings include: 1. For Resident #3, the facility failed to provide adequate supervision and effective interventions to prevent falls. The resident had 6 falls between 8/2/16 and 2/13/17. One fall resulted in a laceration requiring 5 sutures, to the resident's eyebrow area, to close the wound and a second fall resulted in a laceration requiring 6 sutures, to the resident's forehead, to close the wound. Resident #3, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) Assessment of 5/19/16 indicated that the resident exhibited short and long term memory deficits, severely impaired decision making ability, inattention; highly impaired vision; required assistance with transfers and supervision while ambulating in the corridor and on the unit. The falls care plan of 6/2/16 indicated the following interventions: supervise with ambulation and transfers when fatigued, offer rest periods throughout the day and wanderguard on ankle. During an interview with Unit Manager (UM) #1 (on 2/16/17 at 3:10 P.M.), UM #1 said the resident usually gets out of bed on the 11:00 P.M. to 7:00 A.M. shift, ambulates up and down the hallways all day and when the resident is fatigued, she/he will exhibit facial grimacing which the staff need to monitor for. The ADL (Activities of Daily Living) care plan of 6/2/16 indicated the resident ambulates with distant supervision. Review of the Nurse's Note of 8/2/16 indicated the resident experienced an unwitnessed fall (3:15 P.M.), sustaining a laceration to the eyebrow area requiring 5 sutures to close the wound. Staff supervision while the resident was ambulating was not being provided. Per facility investigation, to prevent fall reoccurrence, the plan was to have no clutter or lifts in the unit hallway. Review of the quarterly MDS Assessment of 8/18/16 remained essentially unchanged. Review of the Nurse's Note of 8/19/16 indicated the resident experienced a fall (6:20 P.M.), with no injury. Per facility investigation, to prevent fall reoccurrence, the plan was to keep the resident out of the dayroom when not eating. Review of the falls care plan and ADL care plan of 9/1/16 remained essentially unchanged. Review of the Interdisciplinary Care Plan Meeting Notes of 9/1/16 indicated the resident ambulates ad lib in the hallway with distant supervision. Review of the Nurse's Note of 10/4/16 indicated the resident experienced a fall (5:30 P.M.), sustaining an abrasion on the left arm and knee. The investigation indicated that the resident's unsteady gait may have contributed to the fall. Per facility investigation, to prevent fall reoccurrence, the plan was: supervision, offer to sit in recliner, Neurology consult, lab work, orthostatic blood pressures and Physician review. Review of the Nurse's Note of 10/12/16 indicated the resident experienced an unwitnessed fall (5:30 P.M.), with no injury. During an interview with UM #1 (on 2/16/17 at 2:40 P.M.), she said that the fall was unwitnessed, therefore, the resident was not receiving supervision (as planned). The falls care plan was updated to include: resident to wear tight pants. Review of the quarterly MDS Assessment of 11/17/16 remained essentially unchanged. Review of the Nurse's Note of 11/23/16 indicated the resident experienced an unwitnessed fall (5:15 P.M.), sustaining forehead laceration requiring 6 staples to close the wound. Staff supervision while the resident was ambulating and wandered into another resident's room was not being provided, as planned. Per facility investigation, to prevent fall reoccurrence, the plan was to have no mats/objects on the unit floors. The falls care plan was updated to include: a yellow Velcro stop sign was placed at the room doorway where the resident had wandered into. Review of the 12/1/16 ADL care plan remained essentially unchanged. Review of the CNA (Certified Nursing Assistant) Care Card updated 12/29/16 (currently in effect per UM #1) indicated the resident required supervision/monitoring while ambulating and that the resident was known to wander. Review of the Licensed Nursing Summary's (of 8/30/16, 11/27/16, 12/28/17 and 1/31/17) with UM #1 (on 2/16/17 at 2:40 P.M.) indicated the resident required continual supervision/monitoring/verbal instruction while ambulating due to poor safety awareness. Further review with UM #1 of the (9/28/16 and 10/29/16) Nursing Summary's indicated the resident required assist of 1 to ambulate. Review of the Annual MDS Assessment of 2/9/17 remained essentially unchanged. Review of the Nurse's Note of 2/13/17 indicated the resident experienced an unwitnessed fall, with no injury. Staff supervision while the resident was ambulating was not being provided, as planned. Per facility investigation, to prevent fall reoccurrence, the plan was to trend bowel incontinence. Review of the ADL care plan of 2/13/17 indicated the resident continues to ambulate with distant supervision. On 2/14/17 at 3:50 P.M., the surveyor observed the resident ambulating up and down the hallway then wandered into another resident's room. Staff were not in the hallway nor in the other resident's room to provide the resident with the supervision. At 4:05 P.M., the surveyor observed the resident ambulating up and down the hallway and no staff were in the hallway to provide the supervision. On 2/15/17 at 7:50 A.M. and 4:25 P.M., the surveyor observed the resident ambulating up and down the hallway and no staff were in the hallway to provide the supervision. During an interview with CNA #1 on 2/16/17 at 10:55 A.M., she said the resident is constantly walking, (she/he) has no safety awareness and that the staff constantly need to keep an eye on (her/him) to supervise (her/him). During an interview with UM #1, (on 2/16/17 at 2:40 P.M.), UM #1 said the resident wanders aimlessly, has no safety awareness and that the resident needs to be monitored. At 3:10 P.M., the surveyor and UM #1 observed the resident ambulating in the hallway. UM #1 said the staff determine that the resident is fatigued when they can see facial grimacing. At the time of this observation, UM#1 said the resident did seem tired, due to the resident's facial grimacing observed, as she said the resident had been constantly ambulating the hallways since approximately 6:00 A.M. to 7:00 A.M. this morning. UM #1 said the resident's routine is to constantly ambulate the hallways from early morning till bedtime. A discussion was held with UM #1 regarding 5 of the 6 falls having occurred between 3:15 P.M. and 6:20 P.M.(3 of which occurred between 5:15 P.M. and 5:30 P.M.), when the resident may be tiring out after ambulating /wandering the hallways all day and needing the supervision. The facility failed to provide effective interventions and adequate supervision to prevent continued falls resulting in the resident sustaining lacerations on 2 separate occasions requiring sutures to close the resident's wounds. 2. For Resident #13, the facility staff failed to ensure that the resident's wheelchair leg rests were in the proper position, the resident's alarm was consistently functioning and the resident wore the proper footwear. Resident #13, was admitted to the facility in 1/2015, with a [DIAGNOSES REDACTED]. Review of the falls care plan, dated 10/12/15, included the following interventions: - Fall assessment per facility protocol. - Assist of 2 for bed mobility, transfers, and toileting. - Alarms as ordered. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 4/19/16, indicated that the resident required extensive with ambulation and transfers. Review of the Nurse's Note, dated 4/25/16, indicated that the resident was witnessed standing up from the wheelchair. The wheelchair leg rests were in front of the resident and he/she tripped over the leg rests, fell forward, hit his/her head, and sustained an abrasion. Review of the facility's internal investigation, dated 4/25/16, indicated that at 11:00 A.M. the resident stood up to go to the bathroom, his/her legs got caught between the wheelchair leg rests and the resident fell forward, hitting his/her head. The internal investigation further indicated that the resident's alarm was not functional and that 2 nurses were notified at approximately 8:00 A.M., however, this was not addressed prior to the fall at 11:00 A.M. The internal investigation further indicated that the staff were in-serviced on the use of wheelchair leg rests and toileting the resident, as needed. Review of the Fall Risk Assessment, dated 5/1/16, indicated that the resident was at a high risk for falls. Review of the quarterly MDS Assessment, dated 7/14/16, indicated that the resident's memory was impaired, required extensive with ambulation and transfers and had 1 fall with injury (except major) since the last assessment. Review of the Fall Risk Assessment, dated 7/15/16, indicated that the resident remained a high risk for falls. Review of the Nurse's Note, dated 7/15/16, indicated that the resident fell to the floor. Review of the facility's internal investigation, dated 7/15/16, indicated that at 3:15 P.M., a faint alarm sounded. The investigation indicated that the Certified Nurse Aide (CNA) observed the resident fall onto his/her hip. The internal investigation further indicated that the alarm was under the pillow and the CNA barely heard the alarm. The investigation indicated that the resident was able to move all extremities and did not appear to be in pain, there was no shortening of the leg or lower extremity edema noted. The investigation did not state if any internal or external rotation of the hip was noted. The resident was then lifted back into bed using a mechanical lift. Review of the 7/2016 Medication Flow Sheet, indicated that on 7/15/16 at 6:00 P.M. the resident received Tylenol for general pain/discomfort. Review of the Nurse's Note, dated 7/16/16 at 6:30 A.M. indicated that at 1:40 P.M. during a transfer from the wheelchair to the bed, the resident complained of severe pain in the right hip, the hip was swollen and painful. Further review of the Nurse's Note indicated that at 3:20 P.M. the resident's hip was x-rayed and at 5:25 P.M. the facility received the results indicating an acute fracture of the right hip. At 6:35 P.M. the resident was sent to the hospital. Review of the quarterly MDS Assessment, dated 10/13/16, indicated that the resident's memory and cognitive status were impaired, was dependent for transfers, did not ambulate and had no falls since the last assessment. Review of the Fall Risk assessment, dated 10/13/16, indicated that the resident remained a high risk for falls. Review of the Annual MDS Assessment, dated 1/12/17, indicated that the resident's memory and cognitive status were impaired, was dependent for transfers, did not ambulate and had no falls since the last assessment. Review of the Nurse's Note, dated 1/14/17, indicated that the resident's alarm sounded and the resident was observed sitting on the carpet in front of his/her wheelchair. Review of the facility's internal investigation, dated 1/14/17, indicated the the fall occurred at 8:15 P.M. and the resident was last toileted at 4:30 P.M. The internal investigation further indicated that the had slippers on his/her feet. On 1/14/17, the falls care plan was updated to include the following intervention: - Shoes/sneakers on when out of bed. Review of the Nurse's Note, dated 1/27/17, indicated that the resident was found on the floor and the alarm did not immediately sound, as care planned. Review of the facility's internal investigation, dated 1/27/17 indicated that the resident had slippers on his/her feet and not sneakers or shoes on, as care planned. On 1/27/17, the falls care plan was updated to include the following interventions: - 1/27/17 - Out of bed before breakfast, in bed before 8:00 P.M., if not agitated. - 1/27/17 - Bed in low position Review of the Fall Risk Assessment, dated 1/27/17, indicated that the resident remained a high risk for falls. Review of the Nurse's Note, dated 2/4/17, indicated that the resident was found on the floor. The note further indicated that the resident reopened a laceration on his/her finger. Review of the facility's internal investigation, dated 2/4/17, indicated that the the resident's alarm was on however, did not sound. The surveyor observed Resident #13 on 2/16/17 at 9:53 A.M. Resident #13 was in the unit activity room seated at a table with 2 other residents, engaging in a table top activity. The resident's alarm was on his/her wheelchair. During an interview with Unit Manager (UM) #1 on 2/23/17 at 1:08 P.M., she said that, regarding the fall of 4/25/16, the resident's leg rests should have been moved out of the way. She said that regarding the fall of 7/15/16, she could not recall if there was any internal or external rotation of the resident's hip. She also said that the resident's alarms should be on and functioning. She further said that after 1/14/17, the resident should have worn shoes or sneakers when out of bed.

Based on interviews and records reviewed, for 1 out of 3 sampled residents (Resident #1), the Facility failed to ensure the plan of care for assistance and use of a walker with ambulation was followed, when on 9/17/16 Resident #1 fell and fractured his/her nose. Findings include: Resident #1's [DIAGNOSES REDACTED]. A Fall Risk Evaluation dated 5/26/16 indicated Resident #1 had balance problems when standing and walking, had decreased muscular coordination, and required the use of a walker when ambulating. A Plan of Care dated 06/07/16 indicated Resident #1 required verbal cueing and use of an assistive device (a walker) with ambulation and transfers. A Nurse Progress Note dated 9/17/16, indicated Resident #1 sustained a fall while ambulating with 1 assist, landed face down on the floor, was bleeding from a laceration on his/her head and his/her nose, and was transferred to the emergency room for evaluation, and the Physician on call was later notified of the incident and transfer. Nurse #2 was interviewed at 12:42 P.M., on 10/18/16. Nurse #2 said she was at the Nurses' station, when she heard a loud noise, and looked up to see that Resident #1 had fallen, face down, onto the floor, and was bleeding from a laceration on his/her forehead. Nurse #2 said CNA #4 was standing next to Resident #1, and she did not see Resident #1's walker. CNA #4 was interviewed at 11:26 A.M., on 10/8/16. CNA #4 said that on 9/17/16, she had skimmed through the resident care card binder at the beginning of the 3:00 P.M., to 11:00 P.M., shift, and had received report from CNA #6. CNA #4 said she could not recall if CNA #6 had told her in report if Resident #1 needed a walker for ambulation, but she asked another CNA on the unit, whose name she could not recall, if Resident #1 required a walker for ambulation, and the other CNA said no. CNA #4 said she was walking alongside of Resident #1, without any physical support and without the use of a walker, past the Nurses's station, when Resident #1 fell forward, and landed face down on the floor. CNA #6 was interviewed at 10:11 A.M., on 10/25/16. CNA #6 said she had given report to CNA #4 at the start of the 3:00 P.M., to 11:00 P.M., shift on 9/17/16, and to the best of her recollection, she had reviewed Resident #1's ambulation status with CNA #4, which included use of a walker. A Hospital Emergency Medicine Note, dated 9/17/16, indicated Resident #1 presented with a nasal fracture sustained secondary to a fall while ambulating at the Facility without the use of a walker. On 10/18/16 at the time of this Complaint Investigation the Facility was found to be in past non-compliance, effective 9/21/16. A quality Assessment and Performance Improvement Plan dated 9/21/16 indicated an assignment sheet tool was developed to be used to familiarize agency staff to the care needs of the residents. An inservice education form, dated 9/21/16 indicated nursing staff were educated to fill out the agency assignment sheet tool at change of shift. Random audits were initiated and will be ongoing, to reinforce communication between Facility staff and agency staff.

Based on observation, record review, and staff interviews, the facility failed to follow the plan of care for 1 resident (#13) out of 24 residents, regarding fall interventions. Findings include: For Resident #13, the facility failed to follow the resident's plan of care relative to not leaving the resident unattended in the bathroom, resulting in one fall with a laceration and sutures, and one fall with a hematoma. Resident #13 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. The Resident had a previous medical history of [REDACTED].> (surgical removal of part of the bone from the skull to expose the brain) secondary to [DIAGNOSES REDACTED] ([DIAGNOSES REDACTED]). Review of the Nursing note of 5/10/15 indicated the resident had a fall at 9:15 P.M. when left alone and unattended in the bathroom. A care plan intervention was put into place not to leave the resident alone in the bathroom, and the family and the staff were educated. Review of an investigation completed on 11/22/15, indicated that a CNA brought the resident into the bathroom, and left the resident alone. At 12:10 P.M. the resident was found on the floor with a laceration requiring sutures above his/her top lip, despite the care plan not to leave the resident alone in the bathroom. Review of a Nursing note of 12/6/15 indicated that a CNA brought the resident into the bathroom to the toilet, then left the resident unattended in the bathroom and walked into the resident's bedroom, to get clothes for the resident. The plan of care was not followed as the resident was left alone in the bathroom. The resident sustained [REDACTED]. On 12/7/15 at 9:30 A.M., the resident was observed sitting in the bedroom in a wheelchair with the over the bed tray in front of him/her. The resident had a self release seat belt alarm on. During interview with the Director of Nursing on 12/8/15 at 10:15 A.M., regarding the falls of 11/22/15 and 12/6/15, she said that the Plan of Care was not followed. She also indicated that both CNAs have been educated regarding not to leave the resident alone in the bathroom. Please refer to F 323.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 15 applicable residents (#13) out of a total sample of 24 residents. The facility also failed to assure that the hot water in the facility was maintained at a safe temperature to avoid the risk of burns/accidents. Finding include: 1. For Resident #13, who had 13 falls between 5/10/15 and 12/6/15, the facility failed to provide an effective falls intervention program with effective interventions and adequate supervision to prevent falls. The facility also failed to follow the Resident's plan of care relative to not leaving the Resident unattended in the bathroom, resulting in one fall with a laceration and sutures, and one fall with a hematoma. Resident #13 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. The Resident had a previous medical history of [REDACTED].>(surgical removal of part of the bone from the skull to expose the brain) secondary to [DIAGNOSES REDACTED] ([DIAGNOSES REDACTED]). On 5/10/15 at 9:15 P.M., Resident #13 was found on the floor between the doorway of the bathroom and the Resident's room. A family member had left the Resident alone in the bathroom and asked the Resident to use the call light when done. No injuries were sustained from the fall. Staff and family education was provided not to leave Resident #13 alone in the bathroom. On 5/11/15 at 11:30 A.M., the Resident rolled out of the bed onto the floor. The Resident tried getting out of the bed without assistance, slid to the floor on his/her knees, and was found kneeling near the bed by the Occupational Therapist (OT). No injuries were sustained from the fall. A bed pad alarm and chair alarm were initiated. A Fall Risk Assessment was completed on Resident #13 on 5/11/15 which indicated the Resident scored 12. Total score of 10 or above represents a High Fall Risk. Review of an Admission Minimum Data Set (MDS) Assessment of 5/16/15 indicated that the Resident scored 12/15 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition, mood indicators of feeling down and depressed, poor appetite, was extensive assist for transfers, ambulation, dressing, and hygiene, was frequently incontinent of bowel and bladder, had 2 or more falls with no injury, utilized a walker for mobility, and received an antidepressant medication for 7 days during the past 7 days. The nursing note of 5/17/15 indicated Resident #13's pressure alarm sounded at 8:30 P.M The Resident was found on the floor on the right side of the bed. The Resident was confused with a pull-up around his/her ankles. The Resident was trying to put on a second brief, however the Resident was clean and dry. No apparent injury from the fall. The Resident's room was moved closer to the nursing station. Review of a Fall Risk Assessment completed after the fall on 5/17/15 indicated that Resident #13 scored 18. (6 points higher than the 5/11/15 Assessment). The Assessment indicated the Resident was having intermittent confusion and increased falls. Total score of 10 or above represents a High Fall Risk. The plan of care for Falls with a problem start date of 5/21/15, indicated that the Resident was at risk for falls due to weakness, impaired balance, mobility, cognition, and poor safety awareness. The goal indicated that the Resident would not sustain injury from falling daily times (x) 90 days. The interventions included: - Staff educated not to leave in bathroom alone. (5/10/15) - Room change closer to nursing station 4th floor. (5/18/15) - Encourage and assist resident to wear non-skid footwear when out of bed. (5/21/15) - Fall Assessment per facility protocol. (5/21/15) - Resident requires assist of 1 - 2 for bed mobility, transfers, toileting, and ambulation with use of walker. (5/21/15) - Pressure alarm to bed and chair, check for placement and function every shift. (5/11/15) - Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and as indicated. (5/21/15) Review of the Social Service Progress Notes indicated that Resident #13 was transferred from Unit 4 to Unit 1 on 6/23/15 for continued long term care. The Resident had four more falls. (6/29/15, 7/2/15, 7/14/15, and 7/25/15), with no apparent injury. Review of a Fall Risk Assessment completed on 8/11/15 indicated that the Resident scored 20. (2 points higher than the 5/17/15 Assessment). The Assessment indicated the Resident continued with intermittent confusion, and increased falls. Total score of 10 or above represents a High Fall Risk. Review of Quarterly MDS Assessment of 8/11/15 indicated that Resident #13 scored 13 of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact, had mood indicators of trouble sleeping, feeling tired, and restlessness, behaviors included wandering, and was now totally dependent for bathing. The Resident also utilized a wheelchair along with the walker, and had 2 or more falls with no injury. Review of a physician progress notes [REDACTED].#13 was unable to give his/her medical history secondary to Cognitive Impairment. Review of the nursing notes indicated that Resident #13 fell on [DATE] and 9/26/15 while attempting to transfer from the wheelchair. There were no apparent injuries from the falls. The cause of the falls on the 9/2/15 and 9/26/15 investigations were listed as non-compliance, (despite the Resident's intermittent confusion), poor safety awareness, and alteration in cognition. Following the fall of 9/26/15, a Velcro self-releasing seat belt was initiated. The nursing note and investigation of 10/16/15 indicated the Resident self- transferred from the wheelchair at 8:45 A.M., and fell . Resident #13 was found on the floor kneeling at the foot of the bed. The Resident was trying to get his/her cell phone from the table in the bedroom. The Resident was confused. The cell phone was on a lanyard around his/her neck at the time of the fall. No injuries were noted from the fall. Review of Quarterly MDS Assessment of 11/3/15 indicated that Resident #13 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact, had mood indicators of feeling down and depressed, feeling tired and restless, was occasionally incontinent of bowel, had a [DIAGNOSES REDACTED]. Review of the Licensed Nursing Summary's dated (7/26/15 - 11/23/15) indicated that the Resident was disoriented, unaware of personal care needs, had increased weakness and an unsteady gait. Review of a Fall Risk Assessment completed on 11/3/15 incorrectly indicated the Resident scored 20. The Assessment identified the Resident as having had 1 to 2 falls in the past 3 months; however, Resident #13 actually had 3 or more falls in the past 3 months, (9/2/15, 9/26/15, and 10/16/15). The Fall Risk Assessment score should have been 22. The assessment correctly indicated that the Resident was having intermittent confusion. This Fall Risk Assessment was 2 points higher than the 8/11/15 Assessment. Total score of 10 or above represents a High Fall Risk. Nursing note of 11/12/15 at 1:05 P.M., indicated Resident #13 turned off the alarm box in the wheelchair which was attached to the self-releasing seat belt alarm. The Resident self transferred and attempted to ambulate into the bathroom and fell to the floor. Resident #13 sustained no injury from the fall. The care plan was updated to move the alarm box under the wheelchair to a place the Resident could not reach it. On 11/22/15, an Agency Certified Nursing Assistant (CNA) brought Resident #13 into the bathroom, stepped outside of the bathroom, partially closed the door for privacy, despite the plan of care indicating not to leave the resident in the bathroom alone. At 12:10 P.M., the resident was found on the bathroom floor with no call light on. The resident tried to self-transfer from the toilet and fell to the floor sustaining a laceration above the upper lip. Following assessment and first aide by the nurse, the resident was sent to the hospital and returned to the facility at 8:30 P.M. with 3 sutures to a facial laceration above the resident's upper lip. A Computed Tomography (CT) Scan was also completed and negative for acute pathology. On 11/22/15 the Agency CNA was educated not to leave the resident unattended in the bathroom. Review of a Progress note completed by the Nurse Practitioner on 12/4/15 indicated that the resident was being followed by a Neurologist. The note indicated the Neurologist reviewed a previous Electroencephalogram (EEG) and Lumbar Puncture of (7/22/15), regarding the resident's Ataxia and Cognitive Dysfunction. The note indicated, that there were no benefits seen, suspecting secondary effects of whole brain radiation secondary to brain cancer. Review of a Nursing note of 12/6/15 indicated that the resident was found on the floor in the bathroom on his/her hands and knees. The resident stated that he/she was trying to fix his/her socks. The resident reported that he/she hit his/her head and upon assessment a bump was noted to the right forehead near the hairline. Neurological checks initiated. May apply ice pack. Review of the investigation indicated that a per-diem CNA brought the resident into the bathroom, sat the resident down on the toilet, then left the bathroom and walked into the resident's bedroom, to get clothes for the resident, and the CNA heard the resident fall to the bathroom floor from the toilet, despite the plan of care indicating not to leave resident in the bathroom alone. On 12/7/15 at 9:30 A.M., the surveyor observed the Resident sitting in the bedroom in a wheelchair with the over the bed tray in front of him/her. The Resident had a self-release seat belt alarm on. The surveyor said good morning to the Resident and the Resident did not respond. As the surveyor left the room a CNA who said she was familiar with the Resident indicated to the surveyor that the Resident was a high risk for falls. The surveyor asked if she could explain, and the CNA said the Resident was non-compliant, so the Resident has alarms at all times. The surveyor asked what alarms the resident utilized and the CNA indicated a self- release Velcro alarm and a bed alarm pad. During an interview with the Director of Nursing on 12/8/15 at 10:15 A.M., she said that the Agency CNA brought the Resident into the bathroom and left the Resident alone on the toilet, and left the bathroom because she did not know the Resident's plan of care, and Resident #13 fell . She indicated that the Agency CNA was educated after the fall. The Director of Nursing said that on 12/6/15 a Per-Diem CNA brought the Resident into the bathroom, and stepped out of the bathroom into the Resident #13's bedroom to get some clothes for the Resident and the Resident fell . The Director of Nurses said the Resident should not have been left alone in the bathroom and the CNA was educated. The surveyor observed the Resident on 12/8/15 at 11:35 A.M. lying in bed sleeping with the bed alarm on. During an interview on 12/8/15 with a Per-Diem CNA at 11:35 A.M., she said she had cared for the Resident before, and that Resident #13 was confused, wore a bracelet indicating Resident #13 was a high fall risk, and utilized a chair and bed alarm. 2. During the survey, it was observed that the hot water coming from the faucet in the staff rest room was extremely hot. The surveyor notified the Interim Administrator and the Maintenance Director and on 12/2/15 at 2:00 P.M., the surveyor, the Interim Administrator, and the Maintenance Director began taking numerous water temperatures throughout the survey. The hot water temperatures on the first day of the survey, 12/2/15, ranged from 102 degrees Fahrenheit to 131 degrees Fahrenheit. The temperatures out of range above 110 degrees Fahrenheit were on 3 of 4 Units in the facility, Unit 1, Unit 2, and Unit 3. On 12/2/15 at 2:00 P.M., during an Environmental Tour with the Administrator and the Maintenance Director, the hot water temperature in the bathroom sink of Room 64, on the Dementia Special Care Unit (DSCU) Unit 3, was recorded to be 120 degrees Fahrenheit. (Above the acceptable Federal Guideline of 110 degrees Fahrenheit). The water was hot to touch. In room 82 the hot water temperature in the bathroom was 111.2 degrees Fahrenheit. The surveyor, the Interim Administrator, and the Maintenance Director went to Unit 1 and entered Room 18. The hot water in the bathroom sink was 125.2 degrees Fahrenheit, and very hot to touch. The hot water was tested in room 14 which was 131 degrees Fahrenheit. The water was extremely hot to touch. Following the observation of the above temperatures, (120 degrees Fahrenheit in Room 64 on Unit 3), (125.2 degrees Fahrenheit in Room 18, and 131 degrees Fahrenheit in Room 14 on Unit 1), the surveyor indicated to the Interim Administrator that a plan had to be put into place immediately to assure the safety of the residents in the facility. The Interim Administrator indicated he would start working on a plan immediately, and the Maintenance Director said he would start trying to adjust the mixing valves. The surveyor asked the Maintenance Director if a record was kept of the testing of the facility's hot water temperatures. He indicated that he did check the temperatures, and he would bring the log to the surveyor for review. The surveyor made the Interim Administrator aware that the two residents who resided in Room 64 on Unit 3 were both independent with ambulation in the room, and there was concern for them going in the bathroom and using the sink. The surveyor interviewed Nurse #1 and CNA #1 at 2:25 P.M., on Unit 1, who both indicated that the resident who resided in Room 18, also used the sink in the bathroom independently. This information was passed onto the Interim Administrator before he left Unit 1. The surveyor also asked the Interim Administrator for the Policy on checking the Water Temperatures in the Facility. The Maintenance Director approached the surveyor at 3:00 P.M., and indicated the mixing valves had been adjusted, and the surveyor asked if water temperatures could be taken on Unit 4 and Unit 2. The Surveyor and the Maintenance Director approached Unit 4 and he indicated to the surveyor that this Unit had its own boiler room. A temperature was taken in the hall bathroom which was 102.5 degrees Fahrenheit. Another temperature was taken in Room 110 which was 102 degrees Fahrenheit. At 3:08 P.M., on Unit 2, the bathroom sink shared between rooms 31 and 33, had a water temperature of 122.3 degrees Fahrenheit, hot to touch. The Maintenance Director indicated that he would adjust the mixing valve. The surveyor asked the Maintenance Director for the logs to review the history of the facility's hot water temperatures for the second time, and he stated he would get the log for the surveyor. The surveyor approached the Interim Administrator and asked if it was possible to get the temperature log for review on 12/2/15 at 3:45 P.M., and he indicated he would check with the Maintenance Director. At 4:10 P.M., the surveyor still did not receive the logs, spoke again with the Interim Administrator, who indicated he would track down the log. Review of the facility policy (undated) regarding water temperatures indicated the following: To provide domestic hot water at the proper temperature to all resident rooms, shower rooms, laundry facilities and kitchens. PLAN: Periodically test delivered water temperatures in every room. Monitor all readings in the kitchen, shower rooms, laundry and boiler rooms daily. PROCEDURE: Inspect domestic hot water temperature in resident areas: - Hot water temperature is inspected by maintenance in two rooms on each floor twice a week for a total of eight rooms per week. Logs are kept in maintenance. - Resident rooms no higher than 110 degrees. - Shower rooms no higher than 110 degrees. The surveyor received the temperature logs from the Maintenance Director on 12/2/15 at 4:20 P.M. The last documented temperature in the log book was dated 10/15/15. The surveyor asked the Maintenance Director if that was the last time he checked the hot water temperatures. The Maintenance Director said that was the last October temperature he had checked, although he had some November temperatures written down on his desk calendar on his desk. The Maintenance Director then left the conference room and brought in a desk calendar and provided them to the surveyor. The surveyor reviewed the log and desk calendar from 8/2/15 through 11/28/15 and the temperatures were recorded as follows: 8/2/15 - 8/8/15 - Temperatures were within range. 8 rooms were checked according to the policy. 8/9/15 - 8/15/15 - Temperatures were within range. Only 7 rooms were checked despite the facility policy indicating to check 8 rooms per week. 8/16/15 - 8/22/15 - No recorded Temperatures. 8/23/15 - 8/29/15 - Temperatures within range. Only 7 rooms checked. 8/30/15 - 9/5/15 - Temperatures within range. Only 5 rooms checked. 9/6/15 - 9/12/15 - Temperatures within range. Only 4 rooms checked. 9/13/15 - 9/18/15 - Temperatures within range. Only 4 rooms checked. 9/20/15 - 9/26/15 - Temperatures within range. Only 7 rooms checked. 9/27/15 - 10/3/15 - Temperatures within range. Only 3 rooms checked. 10/4/15 - 10/10/15 - Temperatures within range. 9 rooms checked according to facility policy. 10/11/15 - 10/17/15 - Temperatures within range. Only 3 rooms checked. 10/18/15 - 10/24/15 - No recorded Temperatures. 10/25/15 - 10/31/15 - No recorded Temperatures. 11/1/15 - 11/7/15 - Temperatures within range. 13 rooms checked according to facility policy. 11/8/15 - 11/14/15 - Temperatures within range. Only 6 rooms checked. 11/15/15 - 11/21/15 - Temperatures within range. - Only 6 rooms checked. 11/22/15 - 11/28/15 - Temperatures within range - Only 3 rooms checked. On 12/2/15 at 4:30 P.M., the Interim Administrator approached the surveyor, discussed the written plan of which had been completed to address the elevated hot water temperatures by the Maintenance Director, and indicated the hot water temperature was slowly being raised again on Unit 3. The Interim Administrator assured the surveyor that audited temperatures were taken and they ranged between 89 degrees to 99 degrees Fahrenheit on Units 1, 2 and 3. The surveyor discussed the facility policy with the Interim Administrator and indicated that the policy was not being followed regarding the frequency of the temperatures being taken, and reviewed the facility log with him. The Interim Administrator said he was aware the facility policy has not been followed regarding the checking of the hot water temperatures. On 12/2/15, at 5:15 P.M., the surveyor and the Interim Administrator took a temperature of the hot water in room 64 on Unit 3. The temperature was 115.7 degrees Fahrenheit. The Administrator indicated he would address this immediately. The Interim Administrator's Plan of 12/2/15 for the Centers Evening Staff indicated to: Continue taking tap water temperatures throughout the night. Instructions were given to the evening staff to assist residents requiring hand washing if audited temperatures spiked above acceptable levels. If the temperature spikes continued, the evening and night supervisors were to call the Administrator immediately and contact a plumber and the Maintenance Director to address the issue. On 12/3/15 at 8:30 A.M. the Interim Administrator approached the surveyor and said that the temperatures were adjusted and no temperatures would be over 110 degrees. On 12/3/15 at 9:15 A.M., the surveyors went to Unit 3 and entered Room 64. The hot water in the bathroom sink was 118 degrees Fahrenheit. The surveyors then went to Unit 1 and entered Room 14 and the hot water in the bathroom sink was within range at 109 degrees Fahrenheit. On 12/3/15 at 10:00 A.M. the surveyor went to Unit 2, and the temperature of the hot water in the bathroom sink shared by rooms 31 and 33 was 118 degrees Fahrenheit. During interview with the Interim Administrator on 12/3/15 at 10:00 A.M., the surveyor discussed the above elevated temperatures, (Unit 3, Room 64, 118 degrees - Unit 2, Rooms 31 -33, 118 degrees). The surveyor also discussed the concern for the residents in the facility. The Interim Administrator said he understood the potential for harm with the elevated hot water temperatures and he had called a Plumber and the Regional Director of Property Management Corporation is here helping with the problem. At 11:00 A.M. the Interim Administrator and the Maintenance Director brought the surveyor the temperature monitoring sheet completed on the 3:00 P.M.-11:00 P.M. and the 11:00 P.M.-7:00 A.M. shift the following evening/morning. Review of the monitoring sheet indicated that the monitoring was not completed on Unit 2 according to the monitoring plan. The monitoring of the temperatures was only completed on Units 1 and 3. The plan also indicated to notify the Administrator for any spike in the hot water temperature. On Unit 1 the hot water temperature was 127.6 in Room 5 at 12:00 A.M., 123.2 in Room 15 at 2:00 A.M., 112.1 in Room 53 at 3:00 A.M., and 114.6 in Room 17 at 5:00 A.M On Unit 3, the hot water temperature was 114.9 in Room 70 at 11:00 P.M., 111.3 at 12:00 A.M., 114.7 in Room 67 at 1:00 A.M., 116.1 in Room 65 at 2:00 A.M., and 117 in Room 73 at 3:00 A.M The Administrator said he was never notified of any spikes in the hot water temperatures despite the plan he put into place for the evening staff on 12/2/15.

Based on record review, observation and staff interview, the facility failed to follow the Physician's Order/plan of care for 4 sampled residents (#11, #14, #16 and #21), out of a total sample of 24 residents. Findings included: 1. For Resident #11, the facility failed to follow the Physician's Orders/plan of care, as evidenced by not administering bowel medication, as ordered. Resident #11 was admitted to the facility in 1/11. Review of the Admission Physician's Orders dated 1/22/11 identified: - Milk of Magnesia (MOM) 30 cc (cubic centimeters) PRN (as needed) for constipation; - [MEDICATION NAME] Suppository (laxative) 10 mg (milligrams) PR (per rectum) PRN constipation, and - Fleets Enema PRN. The facility's bowel protocol, relative to the aforementioned Physician's Orders indicated: - 7:00 A.M. - 3:00 P.M. shift makes out list every day of residents who have not had a bowel movement (BM) in 3 days (9 shifts). - If no BM in three days, give MOM (Milk of Magnesia/a laxative) 30 cc. (cubic centimeters) on the 3:00 P.M. -11:00 P.M. shift; - If no BM after the MOM is given the 11:00 P.M. - 7:00 A.M. nurse administers a [MEDICATION NAME] Suppository (laxative medication), - If no BM after the suppository give a Fleet enema on the 7:00 A.M. - 3:00 P.M. shift. Review of the Medication Administration Records (MAR) from 1/23/11 - 2/2/11 revealed that no MOM, [MEDICATION NAME] ([MEDICATION NAME]) Suppository or Fleet Enemas were administered. The Annual MDS (Minimum Data Set) Assessment (dated 1/29/11), identified a "9" was coded for the bowel section, which indicated the resident did not have a bowel movement for 7 days. During an interview on 3/22/11 at 3:40 P.M., the Director of Nurses confirmed Resident #11 had not received the ordered bowel medications to prevent constipation, in accordance with the facility protocol. Please refer to F309. 2. For Resident #21, the facility failed to follow the resident's falls care plan relative to the following: assistance with transfers/ambulation was not provided, environment was not clutter free, alarmed seat belt was not being utilized, chair pad alarm was not on and the CNA (certified nursing assistant) did not place the resident's bed alarm on, as care planned. Resident #21 was admitted to the facility in 6/10. The plan of care for falls of 7/19/10 included the following interventions: ensure a clutter free environment, pressure pad alarm in bed, and assist of one to two staff members, as needed, for transfers and ambulation. Review of the 8/10 Physical Therapy note revealed the resident was utilizing a self-releasing alarming seat belt. Review of the 9/7/10 Nurse's Note revealed the resident experienced an unwitnessed fall (in bedroom), with no injuries. During an interview with UM #1 (3/28/11 at 2:20 P.M.), he/she acknowledged the following: a. the resident was not being assisted while transferring and ambulating, prior to the fall, as planned; b. the alarmed seat belt was hooked behind the resident and not on, as planned; c. the chair pad alarm was not on, as planned, and d. the environment was not clutter free, as planned. UM #1 stated the roommate's floor mat was on the floor and in the resident's pathway while the resident was ambulating, therefore, the floor mat contributed to the resident's fall. Review of the 10/22/10 Nurse's Note revealed the resident experienced an unwitnessed fall (in bedroom), with no injuries. During an interview with UM #1 (3/28/11 at 2:20 P.M.), he/she acknowledged the resident was not being assisted while transferring and ambulating, prior to the fall, as planned. The falls care plan was updated to include: attend to resident in a timely manner if resident verbalizes or shows signs of tiredness and readiness to go to bed. The falls care plan was rewritten on 1/5/11 to include the following interventions: pressure pad alarm in bed, alarming self releasing seat belt in wheelchair, ensure a clutter free environment and assist of one to two CNAs as needed for transfers and ambulation, floor mat and bed in lowest position. Review of the 3/20/10 Nurse's Note revealed the resident experienced an unwitnessed fall (in bedroom), sustaining a 3 to 4 centimeter (cm.) laceration on the forehead requiring 4-5 sutures, to close the wound, bilateral subarachnoid hemorrhage, extensive bruising on entire right arm with multiple bruises on the left arm. During an interview with UM #1 (3/28/11 at 2:20 P.M.), he/she acknowledged the resident's bed pad alarm did not activate, due to the assigned CNA had not placed/turned the resident's bed pad alarm on, when he/she assisted the resident to bed, as care planned. During an interview with UM #1 on 3/28/11 at 2:20 P.M., he/she acknowledged the resident's falls care plan was not being followed by the staff, as care planned. Please refer to F323, Example #1. 3. For Resident #14, the Facility failed to ensure that Diabetic foot care was provided, as ordered/care planned. Resident #14 was admitted to the facility in 2/11. The Resident's pertinent [DIAGNOSES REDACTED]. According to the clinical record, the Resident was identified as having Facility acquired pressure areas to both heels on 2/24/11. Review of the Treatment Record for 2/11, revealed an order for [REDACTED]. to 11:00 P.M. shift. Diabetic Foot care was not provided, as ordered/planned on 2/22, 2/23, 2/24 and 2/25/11. The surveyor observed Nurse #2 provide a treatment to the Resident's heels (on 3/23/11 at 11:16 A.M.). Both heels were observed to be scabbed and healing. Resident #14 told the surveyor that he/she had been very independent and self sufficient before falling and breaking a hip at home, and had been able to care for his/her own feet, but had to rely on facility staff to help him/her now. During discussion with UM (Unit Manager) #4 on 3/24/11 at 3:30 P.M., UM #4 confirmed that Diabetic Foot Care was not completed, as ordered/planned. 4. For Resident #16, the Facility failed to ensure that HS (hour of sleep) snacks were provided, as ordered/care planned. Resident #16 was admitted to the Facility in 1/08. The Resident's pertinent [DIAGNOSES REDACTED]. The Nutrition written plan of care (dated 11/09, and updated 3/11) identified the Resident's [DIAGNOSES REDACTED].M. and 7:00 P.M.. Review of the 12/10 through 3/11 Physician's Orders identified bedtime snack at 8:00 P.M.. Review of the MARs (Medication Administration Record) revealed that bedtime snacks were not provided for the entire month of 1/11 and for 3/1 through 3/27/11; and this was confirmed by UM #2 on 3/28/11 at 2:00 P.M.

Based on record review, observation, and acknowledged during staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 8 applicable residents (#21), out of a total sample of 24 residents. Findings included: For Resident #21, the facility failed to provide effective interventions and adequate supervision to prevent falls in order to provide an effective falls intervention program for the resident. The facility failed to follow the resident's falls care plan relative to the following: assistance with transfers/ ambulation was not provided, environment was not clutter free, alarmed seat belt was not being utilized, chair pad alarm was not on and the CNA (certified nursing assistant) did not place the resident's bed alarm on, as planned. Resident #21, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment of 7/5/10 identified the resident as exhibiting short and long-term memory deficits, moderately impaired decision-making ability and required extensive assistance during transfers and ambulation. The plan of care for falls (related to the resident's impaired mobility and cognition) of 7/19/10 included the following interventions: ensure a clutter free environment, pressure pad alarm in bed, utilize non-skid footwear and assist of one to two staff members, as needed, for transfers and ambulation. Review of the 8/12/10 Nurse's Note revealed that the resident experienced an unwitnessed fall (in bedroom), with no injuries. Review of the facility investigation revealed the facility identified the cause of the fall as the resident's health/mental status (defined as the resident's lack of safety awareness during an interview with Unit Manager- UM #1 on 3/29/11 at 10:15 A.M.). Review of the 8/15/10 Nurse's Note revealed the resident experienced a fall, with no injuries. Review of the facility investigation revealed the facility identified the cause of the fall as the resident's non-compliance. During an interview with UM #1 (3/29/11 at 10:15 A.M.), he/she acknowledged that due to the resident's dementia diagnosis, the resident was not capable of being compliant. During review of the alarm check sheets for 8/2010 (completed daily by the CNAs to ensure the resident's alarms were functioning at 7:00 A.M., 3:00 P.M. and 11:00 P.M.) with the Director of Nursing - DON- (3/28/11 at 2:40 P.M.), he/she acknowledged the alarm checks had not been completed, per facility policy, on August 3rd, 5th, 7th, 8th and 25th at 7:00 A.M., as care planned. Review of the 8/10 Physical Therapy note revealed the resident was a safety concern and was utilizing a self-releasing alarming seat belt. Review of the 9/7/10 Nurse's Note revealed the resident experienced an unwitnessed fall (in bedroom), with no injuries. The cause of the fall was again noted, on the facility investigation, as the resident's non-compliance. During an interview with UM #1 (3/28/11 at 2:20 P.M.), he/she acknowledged the following: a. the resident was not being assisted while transferring and ambulating, prior to the fall, as planned; b. the alarmed seat belt was hooked behind the resident and not on, as planned; c. the chair pad alarm was not on, as planned, and d. the environment was not clutter free, as planned. UM #1 stated the roommate's floor mat was on the floor and in the resident's pathway while the resident was ambulating, therefore, the floor mat contributed to the resident's fall. The falls care plan was updated to include: encourage resident to be out of the bedroom and in the common areas for better supervision and utilize a bed pad alarm. Review of the quarterly MDS assessment of 9/28/10 identified the resident as having fallen in the past 30 days and in the past 31 to 180 days. Review of the 10/22/10 Nurse's Note revealed the resident experienced an unwitnessed fall (in bedroom), with no injuries. The cause of the fall was again noted, on the facility investigation, as the resident's health/mental status and the resident's non-compliance. During an interview with UM #1 (3/28/11 at 2:20 P.M.), he/she acknowledged the resident was not being assisted while transferring and ambulating, prior to the fall, as planned. The falls care plan was updated to include: attend to resident in a timely manner if resident verbalizes or shows signs of tiredness and readiness to go to bed. During review of the alarm check sheets with the DON (3/28/11 at 2:40 P.M.), he/she acknowledged the alarm checks had not been completed, per facility policy, at 7:00 A.M. on October 26th, on November 9th and 23rd, on December 7th, 8th, 12th, 13th, 14th, 18th, 21st and 22nd, as planned. Review of the quarterly MDS assessment of 12/21/10 remained essentially unchanged. The falls care plan was rewritten on 1/5/11 to include the following interventions: assist resident to bed as soon as the resident verbalizes readiness, encourage resident out of room into common areas, pressure pad alarm in bed, alarming self releasing seat belt in wheelchair, ensure a clutter free environment, utilize non-skid footwear and assist of one to two CNAs as needed for transfers and ambulation, floor mat and bed in lowest position. During review of the alarm check sheets with the DON (3/28/11 at 2:40 P.M.), he/she acknowledged the alarm checks had not been completed, per facility policy, at 7:00 A.M. on January 18th, 19th, 25th, 26th and 27th and on February 26th , as planned. Review of the 3/20/11 Nurse's Note revealed the resident experienced an unwitnessed fall (in bedroom), sustaining a 3 to 4 centimeter (cm.) laceration on the forehead requiring 4-5 sutures, to close the wound, bilateral subarachnoid hemorrhage, extensive bruising on entire right arm with multiple bruises on the left arm. The cause of the fall was again noted, on the facility investigation, as the resident's health/mental status and the resident's non-compliance. During an interview with UM #1 (3/28/11 at 2:20 P.M.), he/she acknowledged the resident's bed pad alarm did not activate, due to the assigned CNA had not placed/turned the resident's bed pad alarm on, when he/she assisted the resident to bed, as planned. On 3/28/11 at 7:05 A.M., the surveyor observed the resident lying in bed, with the bed pad alarm in place. At 11:00 A.M., the resident was lying in bed, with the bed pad alarm in place, and the floor mat in place. During an interview with CNA #1 on 3/28/11 at 1:25 P.M., he/she stated the resident "...needs assist during transfers and when (the resident) is walking, (the resident) unbuckles the seat belt a lot and tries to get up alone...(the resident) is confused...(the resident) can be in the room alone...." During an interview with UM #1 on 3/28/11 at 2:20 P.M., he/she acknowledged that the facility failed to provide effective interventions and adequate supervision to prevent the falls. Please refer to F282, Example #2.