Every finding on record at Vantage at Westfield LLC

Based on interviews and records reviewed, the facility failed to ensure grievances and concerns reported during the Resident Council meetings in February and March 2026 were addressed timely and that a response/rationale by the facility was provided to the Council to address the concerns.Specifically, the facility failed to ensure that:-The facility provided a response to the concerns brought forth during Resident Council about timeliness of call bell response on the A-wing in February 2026.-The response by the facility relative to the repeated concerns about the timeliness of call bell response in March 2026 were relayed to the Resident Council. Findings include:Review of the facility policy titled Resident Council, created January 2017, indicated the Resident Council is mandated by law and is the recognized forum established for the residents to voice their ideas and/or concerns regarding their environment and care. This governing body works closely with the administration of the facility and other staffs to possible [sic] affect changes and resolve problems within the facility where they reside. The policy also included the following:-Concerns:Follow up on concerns.Demonstrate that all concerns addressed in resident council, either individually or from the group, are important.Address collective concerns using the Concern Form to inform the appropriate department of the concern in a timely manner.Communicate resolution of previous and current group concerns that are identified. On 4/10/26 at 10:30 A.M., a Resident Council Meeting was held with the survey team and 15 facility Residents who resided on both the A-wing and B-wing. The following concerns were discussed:-The facility staff do not always respond to the call bells timely.-When a resident turns on the call bell, staff will turn the call bell off and say they will return in five minutes, but they will not return to provide assistance until 30-45 minutes later. -Six out of the 15 residents present in the meeting said they have concerns about the facility staff's timeliness to respond to call bells and that the staff will turn the call bell off and not return until much later. -The residents said these concerns about the call bells have been brought up during previous resident council meetings (in February 2026 and March 2026), that there has been no resolution to these concerns and they were unaware of what the facility did to address these concerns. Review of the Resident Council Minutes from January 2026 through March 2026 included the following:-February 24, 2026:Old business: Resident on A-Wing continues to be concerned about waiting a long time for the call bell to be answered while he/she is in the bathroom.New business: Overall, all of the residents have two concerns about call bells. The call bells take a long time to be answered and the staff will come in and shut off the call bell and not return. -March 24, 2026:Old business: Residents overall on the A-Wing are concerned about the overall time for their call bells to be answered and state that they wait a long time. Not resolved.A-Wing residents overall continue to be concerned that staff come in and shut off their call bell and do not return. Not resolved. New Business: The concerns raised in the meeting for Nursing are in old business. Review of the Plan of Correction (Concern) Forms, provided by the Activity Director (AD), in response to the identified Resident Council concerns, included the following:-February 24, 2026:A notation to please return the Form to the AD by March 13, 2026.Resident on A-wing continues to be concerned that he/she waits a long time for the call bell to be answered while he/she is in the bathroom.Call Bells: The call bells take a long time to answer on both units, and staff come in and shut the bells off and do not come back. Further review of the Plan of Correction (Concern) Form indicated the responses to these concerns were blank. A handwritten notation on the Form indicated there was no response from nursing for the 3/24/26 meeting. -March 24, 2026:A notation to please return the form to the AD by April 10, 2026.Residents overall on A-wing are concerned about the overall time for their call bells to be answered and they state they wait a long time. A-wing residents overall continue to be concerned that staff come in and shut off their call bell and do not come back.Further review of the Plan of Correction (Concern) Form indicated the following response to the listed concerns: Staff educated. During an interview on 4/14/26 at 10:33 A.M., the AD said when concerns are discussed during the Resident Council meetings, she completes a Plan of Correction Form that identifies the concern and gives this Form to the department responsible to address the concern. The AD said the concerns from February 2026 and March 2026 about the call bell responses were brought to the Nursing department and given to the Director of Nurses (DON) and copies were also provided to the Administrator. The AD said the Department head would have two weeks to provide a response to the Resident Councils concerns and then this response/plan would be reviewed in the next scheduled Resident Council meeting. The AD said there was no response provided to the Resident Council's concerns in February 2026 and the concerns were still not resolved when it was discussed in March 2026. During an interview on 4/14/26 at 10:53 A.M., the DON said she was familiar with the process for addressing concerns brought forth after the Resident Council meetings. The DON said she was not sure what occurred when the concerns about the call bell response were brought forth by the AD after the February 2026 Resident Council meeting, but that staff education was provided after concerns were brought up again in the March 2026 Resident Council meeting. During an interview on 4/14/26 at 12:21 P.M., with the facility Administrator, the surveyor relayed the concerns about the facility's response to address the concerns brought forth by the Resident Council in February 2026, March 2026 and during the Resident Council meeting in April 2026 relative to the call bell response, and the Administrator said she understood the concerns.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1) who required a wheelchair accessible platform scale for weight monitoring, the Facility failed to maintain a safe, hazard free environment, when the dual ramp platform scale was obstructed on three of four sides, limiting staff access needed to safely assist the resident during weighing. On 12/31/25, Resident #1 began to fall from his/her wheelchair, and due to the obstructed access, Certified Nurse Aide #1 was unable to position herself to provide adequate physical assistance. As a result, Resident #1 fell to the floor and sustained a forehead laceration requiring five sutures.Findings include:Review of the Facility Policy titled Safety and Supervision of Residents, dated as revised in 2007, indicated the Facility strives to make the environment as free from accident hazards as possible. The Policy further indicated that resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident #1 was admitted to the Facility in June 2023, diagnoses included dementia with agitation and unspecified osteoarthritis. Resident #1's Quarterly Annual Minimum Data Set (MDS) Assessment, dated 11/06/25, indicated Resident #1 was severely cognitively impaired with a score of 3 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 also indicated Resident #1 required substantial assistance from staff members for transfers and activities of daily living. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/06/26, indicated that on 12/31/25 at 11:20 A.M., Resident #1 was weighed in his/her wheelchair by Certified Nurse Aide (CNA) #1. The Report indicated that when CNA #1 attempted to remove Resident #1 from the scale he/she abruptly lowered his/her feet and leaned forward. The Report further indicated that CNA #1 was unable to prevent Resident #1's momentum from propelling him/her forward out of the wheelchair, landing on the floor and striking his/her head. The Report indicated that Resident #1 was sent to the Emergency Department (ED) for evaluation and was noted to have a three (3) centimeter (cm) laceration which was closed with five sutures. Review of Resident #1's Emergency Department (ED) Discharge summary, dated [DATE], indicated he/she was diagnosed with an acute forehead laceration, due to a mechanical fall, that was closed with five sutures. During an environmental tour of the Unit B Shower Room, on 03/11/26 at 9:18 A.M., the surveyor observed the following:-A platform scale was positioned lengthwise against the left wall of the Shower Room, and a large full-length tub was on the opposite (right) wall of the room. -A very large shower bed was stored between the tub and the scale. -The platform scale had dual integrated ramps (left and right) and a platform that allowed a resident to remain seated in a wheelchair while being weighed. -Both ramps, and the scale platform were covered with a non-skid surface (much like sandpaper). -The ramp on the right side of the platform was obstructed by the back wall of the Shower Room, prohibiting anyone from entering and/or exiting the scale from the right side. -The back side of the platform was positioned against the left wall of the Shower Room. -The front side of the platform scale, where staff might stand to assist a resident, without interfering with the weighing mechanism, was obstructed by a very large shower bed. -The ramp on the left side of the platform was the only side of the scale that was accessible to residents and staff. During an interview on 03/11/26 at 11:45 A.M., Certified Nurse Aide (CNA) #1 said that she had worked regularly at the Facility through a staffing agency for around one year at the time of the incident and was familiar with the scale, periodically weighing residents as needed. During the interview, CNA #1 (while in the Unit B Shower Room accompanied by the surveyor) demonstrated how on 12/31/25, she assisted Resident #1 on and off the platform scale in the wheelchair. CNA #1 said she stood behind the wheelchair, used the handgrips to pull and back up Resident #1 on the small ramp on the left side of the scale, in his/her wheelchair. CNA #1 said that once the wheelchair was positioned on the platform, she was confined up against the wall (behind Resident #1) on the right side of the scale, and that a shower bed obstructed the long edge of the scale, limiting her ability to maneuver. CNA #1 said that after she obtained Resident #1's weight, she pushed him/her in the wheelchair from behind to exit the left side of the platform when Resident #1 unexpectedly put his/her foot down causing him/her to tip forward. CNA #1 said she could not get around in front of the wheelchair quickly to assist Resident #1, due to the obstacles and limited space around the scale. CNA #1 said that Resident #1 fell forward out of the wheelchair and hit his/her head on the floor. During an interview on 03/11/26 at 1:54 P.M., Nurse #1 said that while working the day shift on 12/31/25 at around 11:20 A.M., a CNA notified her of a resident fall in the shower room. Nurse #1 said she responded immediately and observed Resident #1 on the floor in front of the wheelchair near the left side of the scale. Nurse #1 further said that CNA #1 reported Resident #1 unexpectedly placed his/her foot down and fell forward out of the wheelchair while being assisted off the scale. Nurse #1 said that Resident #1 had a laceration on his/her forehead and that orders were obtained to send Resident #1 to the ED for further evaluation. Nurse #1 and CNA #1 reviewed the surveyor's photos of the Unit B Shower Room and said the pictures accurately represented how the scale and the shower bed were positioned on 12/31/25, at the time of the fall. CNA #1 said she was not aware of any residents that required the use of the shower bed. CNA #1 further said that the shower bed was stored in the Unit B shower room, alongside the platform scale, for as long as she had worked at the Facility (approximately one year). During an interview on 03/11/26 at 2:45 P.M., Unit Manager #1 said that she was working on 12/31/25 and responded to the fall. Unit Manager #1 said that upon entering the Unit B Shower Room, she observed Resident #1 lying on his/her right side on the floor while Nurse #1 applied pressure to a forehead laceration to control bleeding. Unit Manager #1 said that CNA #1 told her that Resident #1 placed his/her foot down unexpectedly while being wheeled off the scale platform, causing him/her to be propelled forward out of the wheelchair. Unit Manager #1 said that CNA #1 reported that she was positioned behind Resident #1's wheelchair, pushing it down the ramp on the left side of the scale at the time of the fall. Unit Manager #1 further said that no residents currently required the use of the shower bed and that it had previously been stored in the basement. Review of Resident #1's Skin Assessment, dated 01/01/26 indicated the following from a witnessed fall on 12/31/25: forehead laceration and bruising on the forehead, under both eyes, and left hand. Review of Resident #1's Nurses Note, dated 01/09/26, indicated that he/she had five sutures removed from his/her forehead. During an interview on 03/11/26 at 2:31 P.M., the Director of Nurses (DON) said that she was unaware the shower bed was stored in the Unit B Storage Room, or that it limited staff's ability to navigate around the scale.

Based on records reviewed and interviews for four of four sampled residents (Resident #1, Resident #2, Resident #3, and Resident #4), who all had a diagnosis of Diabetes (a condition when a hormone called insulin does not work properly or there is not enough of it which causes the level of glucose (sugar) in the blood to become too high), the facility failed to ensure they maintained a complete and accurate medical record when Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets related to meal intake were not consistently completed and often left blank.Findings include:Review of the Facility Policy titled, Charting and Documentation, dated as last revised July 2017, included but was not limited to: -All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Review of the Facility Policy titled, Nursing Care of the Resident with Diabetes Mellitus, dated as last revised in 2015, included but was not limited to: -Documentation - percentage of meals consumed. 1) Resident #1 was admitted to the facility in June 2025, diagnoses included Type 2 Diabetes Mellitus, osteomyelitis (a bone infection) to his/her left ankle and foot, and a diabetic foot wound to his/her left heel.Review of Resident #1's Documentation Survey Report (ADL Flow Sheets) for 06/09/25 through 06/16/25 indicated for the following meals, documentation on the flow sheet was incomplete:- Breakfast Meal - 4 days (out of 6) were left blank.- Lunch Meal - 4 days (out of 6) were left blank.- Dinner Meal - 2 days (out of 7) were left blank. 2) Resident #2 was admitted to the facility in July 2025, diagnoses included Type 2 Diabetes and Diabetic Retinopathy (an eye disease caused by Diabetes that damages blood vessels in the tissue in the back of the eye).Review of Resident #2's ADL Flow Sheets for 06/01/25 through 06/30/25 indicated for the following meals, documentation on the flow sheet was incomplete:- Breakfast Meal - 7 days (out of 30) were left blank.- Lunch Meal - 10 days (out of 30) were left blank.- Dinner Meal - 1 day (out of 30) was left blank.Review of Resident #2's ADL Flow Sheets for 07/01/25 through 07/28/25 indicated for the following meals, documentation on the flow sheet was incomplete:- Breakfast Meal - 8 days (out of 28) were left blank.- Lunch Meal - 8 days (out of 28) were left blank.- Dinner Meal - 9 days (out of 28) were left blank. 3) Resident #3 was admitted to the facility in October 2020 with a diagnosis of Type 2 Diabetes.Review of Resident #3's ADL Flow Sheets for 07/01/25 through 07/28/25 indicated for the following meals, documentation on the flow sheet was incomplete:- Breakfast Meal - 8 days (out of 28) were left blank.- Lunch Meal - 8 days (out of 28) were left blank.- Dinner Meal - 7 days (out of 28) were left blank.4) Resident #4 was admitted to the facility in January 2022 with a diagnosis of Type 2 Diabetes.Review of Resident #4' s ADL Flow Sheets for 07/01/25 through 07/28/25 indicated for the following meals, documentation on the flow sheet was incomplete:- Breakfast Meal - 3 days (out of 28 days) were left blank.- Lunch Meal - 3 days (out of 28 days) were left blank.- Dinner Meal - 8 days (out of 28 days) were left blank.During an interview on 07/29/25 at 10:35 A.M., Certified Nurse Aide (CNA) #1 said that all CNA documentation is to be completed in the computer by the end of their shift. CNA #1 said if there are blank spaces on the CNA Flow Sheet, that means the documentation was not completed.During an interview on 07/29/25 at 4:25 P.M., CNA #2 said all CNA documentation should be entered in the computer by the end of their shift. CNA #2 said there should be no blank spaces on the CNA Flowsheet and if there were any, that meant the CNA did not document what they did.During an interview on 07/29/25 at 4:36 P.M., CNA #3 said it was important to document residents' meal intake on the CNA Flowsheet. CNA #3 said if a resident refused a meal, the CNA should document the refusal with a code RR (resident refused) so there should not be any blank spaces on the CNA Flowsheet and said if there were blank spaces that meant the CNA did not complete their documentation.During an interview on 07/29/25 at 4:45 P.M., CNA #4 said all meals and other ADL assistance CNAs provide for the residents, are supposed to be entered in the computer by the end of their shift and if there is no information on the CNA Flow Sheet, that meant the CNA did not input their documentation.During an interview on 07/29/25 at 10:45 A.M., Nurse #1 said CNAs will often write residents' meal intake on a sheet of paper which is kept on a clipboard at the nursing station and that documentation should also be entered into the computer for each resident by the end of the shift. Nurse #1 said that there should not be blank spaces on the CNA Flow Sheets and said if there were blank spaces, that meant the CNA did not document on those days or shifts.During an interview on 07/29/25 at 11:16 A.M., Unit Manager #1 said all CNAs should be documenting all ADL care they provide, including meal percentages in the computer. Unit Manager #1 said if the CNA Flow Sheet has blank spaces, that meant the documentation was not completed, as required.During an interview on 07/29/25 at 1:00 P.M., the Director of Nursing (DON) said that CNAs were required to complete their ADL documentation (including meal percentages) in the computer by the end of their shift and said if there were blank spaces on the ADL Flow Sheets, the CNAs did not document as required.

Based on records reviewed and interviews for one of four sampled residents (Resident #1), who had a change in condition requiring a transfer to the Hospital Emergency Department (ED), the facility failed to ensure they communicated pertinent clinical information to the ED when there was no clinical, medical, or contact information sent with the resident or communicated to the ED at the time of transfer. Findings include: Resident #1 was admitted to the facility in June 2025, diagnoses included Type 2 Diabetes Mellitus, osteomyelitis (a bone infection) to his/her left ankle and foot, as well as a diabetic ulcer on his/her left heel. During a telephone interview on 07/25/25 at 1:15 P.M., the Emergency Department (ED) Nurse said on the morning of 06/16/25, Resident #1 was transported to the ED via Ambulance from the Facility. The ED Nurse said when Resident #1 arrived, she received verbal and written report of his/her condition from the paramedics, however the only documentation she received from the Facility was a Face Sheet (which includes demographic information such as the Resident's name, date of birth , home address, admission date to the Facility, payor source, care providers, emergency contact information and a diagnosis list) and a medication list.The ED Nurse said the facility did not send a copy of Resident #1's Health Care Proxy Form or a copy of his/her Massachusetts Medical Orders for Life Sustaining Treatment (MOLST, a medical order form that relays instructions between health professionals about life-saving care), or a Nursing Home to Hospital Transfer Form.The ED Nurse further said the Facility nurse never called the ED to provide a nurse-to-nurse report on what had transpired prior to Resident #1 being sent to the ED and said that once she got Resident #1 situated, that almost two hours later after not hearing from the facility, that she had to call there to elicit additional pertinent medical information about him/her and his/her care needs.During an interview on 07/29/25 at 10:45 A.M., Nurse #1 said she was the nurse who sent Resident #1 to the ED on the morning of 06/16/25 and she said she provided clinical information verbally to the Emergency Medical Service (EMS). Nurse #1 said she thought she sent a copy of Resident #1's Face Sheet and Physician's Orders with the paramedics but was not certain. Nurse #1 said she did not send copies of Resident #1's MOLST, Health Care Proxy Form, and she said she did not complete the Hospital Transfer Form to send with EMS. Nurse #1 also said that she does not normally call the ED to provide nurse-to-nurse report.During an interview on 07/29/25 at 2:54 P.M., Nurse #3 said she was working the morning of 06/16/25 when Resident #1 was transferred to the ED but did not take part in his/her transfer. Nurse #3 said later in the morning she received a call from the ED Nurse who was looking for information about Resident #1's clinical status prior to his/her transfer.Nurse #3 said when a resident is transferred to the ED, it was the expectation that they would be sent with copies of their Face Sheet, MOLST, the Health Care Proxy Form, Physician's Orders and a completed Hospital Transfer Form. Nurse #3 said it is best practice to call the receiving hospital to provide nurse-to-nurse report, and she said if the Hospital Transfer Form cannot be completed prior to the resident's transfer, the expectation was to fax the form to the ED as soon as possible.During an interview on 07/29/25 at 11:16 A.M., Unit Manager #1 said she assisted Nurse #1 in transferring Resident #1 to the ED on 06/16/25, however she said she did not complete any of the transfer paperwork herself. Unit Manager #1 said when a resident is transferred to the hospital, it is the expectation that they are sent with copies of their Face Sheet, Health Care Proxy Form, MOLST, Physician's orders, and a Hospital Transfer Form.Unit Manager #1 said occasionally during emergency transfers, the nurse is unable to complete the Hospital Transfer Form, but the expectation is that the transferring nurse completes the form as soon as possible and fax the form to the receiving provider.Unit Manager #1 said if Nurse #1 completed a Hospital Transfer Form for Resident #1's hospital transfer on 06/16/25, it would be found under the Assessment tab in the Electronic Health Record (EHR). After reviewing Resident #1's EHR, Unit Manager #1 said there was no documentation in Resident #1's EHR to support that Nurse #1 completed the Hospital Transfer Form, as required.

Based on record review, and interview, the facility failed to complete a performance review at least once every 12 months for five Certified Nurses Aides ([CNA's] #1, #2, #3, #4 and #5) out of five employee records reviewed. Specifically, the facility failed to complete annual performance evaluations for CNA's #1, #2, #3, #4 and #5 as required, to address areas of weakness identified in the evaluation and the special needs of the facility residents. Findings include: Review of the facility employee records indicated that: -CNA #1 was hired on 1/21/22 -CNA #2 was hired on 5/15/18 -CNA #3 was hired on 10/16/23 -CNA #4 was hired on 12/19/17 -CNA #5 was hired on 11/27/18 Further review of the employee records did not indicate that performance evaluations had been completed for the employees for the past 12 months. During an interview on 1/7/25 at 11:22 A.M., CNA #1 said that she had worked at the facility for over a year and had never received an employee performance evaluation since being employed at the facility. During an interview on 1/7/25 at 2:28 P.M., the Director of Nursing (DON) said that she was responsible to complete performance reviews for all CNA staff. The DON said that CNA's #1, #2, #3, #4 and #5 had not been given a performance review in the past 12 months but should have. The DON further said employee performance reviews should be done every year on the employees' anniversary date of hire to evaluate the CNA performance and opportunities for improvement if needed.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#45) out of a total sample of 19 residents were free from significant medication errors. Specifically, the facility failed to ensure the proper administration of Isorbide Mononitrate ER (an extended release [ER] medication used to prevent chest pain) and Metoprolol Succinate ER (an extended-release medication used to treat chest pain and high blood pressure) when the manufacturer's specifications regarding the preparation and administration of both medications were not followed, putting the resident at risk for worsening cardiac symptoms. Findings include: Review of the facility policy titled Medication Administration-General Guidelines, dated 1/1/21, indicated: -Tablet Crushing/Capsule Opening: Crushing tablets may require a Physician's order, per facility policy. -Long acting or enteric coated dosage forms should not be crushed, an alternative should be sought. -Consult with the Pharmacist for an alternative medication. -The Pharmacist should be contacted to review all medications being considered for crushing, whether a Physician's order is present or not. The Pharmacist can assist in finding appropriate alternatives to medications that should not be crushed. When identified, the Prescriber shall be contacted for an order change. -Instructions for crushing medications should be included on the resident's orders and the medication administration record (MAR) so that all personnel administering medications are aware of this need. -Please consult with product literature or Do Not Crush lists which the facility may have or with the Pharmacist if there is a question about medications to be crushed when crushing multiple medications for the same resident. Review of the facility policy titled Crushing Medications, dated April 2018, indicated: -The nursing staff and/or Consultant Pharmacist shall notify any attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or enteric coated medications). a. The attending Physician or Consultant Pharmacist must identify an alternative medication and/or dosage form; or b. The attending Physician must document (or provide the Nurses with a clinically pertinent reason to document) why crushing the medication will not adversely affect the resident; or c. The facility or Practitioner must provide literature from the manufacturer or peer-reviewed journal to justify why modification of the dosage form will not compromise resident care . Review of Davis's Drug Guide for Nurses, 19th edition, Copyright 2025, Vallerand, A. H. and Sanoski, C.A. indicated the following: -Isosorbide Mononitrate - Swallow extended-release tablets whole; do not break, crush, or chew. -Metoprolol - **Do not crush** High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. Extended-release tablets may be broken in half; do not crush or chew. Resident #45 was admitted to the facility December 2024 with diagnoses including Hypertensive Heart Disease with Heart Failure and Atherosclerotic Heart Disease of Native Coronary Artery. Review of Resident #45's Physician's orders, dated January 2025, indicated: -Isorbide Mononitrate ER Oral Tablet Extended Release, give 30 mg by mouth one time a day for Heart Failure, initiated 12/10/24. -Metoprolol Succinate ER Oral Tablet Extended Release give 25 mg by mouth one time a day for HTN (hypertension), initiated 12/10/24. Further review of Resident #45's Physician's orders did not indicate to crush the Isorbide Mononitrate ER and/or Metoprolol Succinate ER medications. Review of Resident #45's clinical record showed no documented evidence that the Pharmacy had been consulted relative to the crushing of the extended-release medications. On 1/3/25 at 8:15 A.M., during a medication pass observation on the B wing unit, the surveyor observed Nurse #1 crush, mix in applesauce, and administer the following medications to Resident #45: -Isorbide Mononitrate ER Oral Tablet 30 mg, one tablet, given by mouth. -Metoprolol Succinate ER Oral Tablet 25 mg, one tablet, given by mouth. During an interview on 1/3/25 at 8:50 A.M., Nurse #1 said that she had crushed the ER medications because the Resident had difficulty swallowing the medications. The surveyor and Nurse #1 reviewed the individual medication cards for Isorbide Mononitrate ER 30 mg and Metoprolol Succinate ER 25 mg. Nurse #1 said she should not have crushed the extended-release medications and she would notify the Physician that she had crushed and administered the medications. During an interview on 1/3/25 at 10:31 A.M, Nurse #2 said that there should be a list of medications that cannot be crushed, but she was not sure where the list was and that she would check with the Unit Manager (UM). During an interview on 1/3/25 at 10:49 A.M., Nurse #3 said that she is not sure if there was a list of do not crush medications, but if a medication cannot be crushed, it would be indicated on the medication card. During an interview on 1/3/25 at 10:53 A.M., UM #1 said that extended-release, delayed release and enteric coated medication should not be crushed. UM #1 said that the facility used to have a list of medications that cannot be crushed located on each medication cart, but she was unable to locate any of these lists. The surveyor and UM #1 reviewed Resident #45's medication cards for Isorbide Mononitrate ER and Metoprolol Succinate ER and found no instructions relative to crushing the medications was indicated on the medication card. During an interview on 1/3/25 at 11:49 A.M., the Director of Nursing (DON) said Resident #45's Isorbide Mononitrate ER and Metoprolol Succinate ER medications should not have been crushed by Nurse #1. During an interview on 1/3/25 at 1:34 P.M, the Consultant Pharmacist said Isorbide Mononitrate ER and Metoprolol Succinate ER should not have been crushed. The Consultant Pharmacist said the pharmacy had no evidence of a facility notification that Resident #45 needed his/her medications crushed. The Consultant Pharmacist further said it is the responsibility of the facility to follow the instructions for medication administration and that the pharmacy does not print administration instructions on the label unless it is part of the Physician's order. The Consultant Pharmacist said that nursing staff could call the pharmacy 24 hours a day for instructions if there were any questions regarding the crushing of medications.

Based on observation, record review, and interview, the facility failed to ensure that it was free of a medication error rate of five percent (5%), or greater when one Nurse (#1) out of three Nurses observed during the medication pass procedure, made two errors in 27 total opportunities, for a medication error rate of 7.41%, impacting one Resident (#45) out of five residents observed, out of a total sample of 19 residents. Specifically, for Resident #45, the facility failed to ensure that: -Nurse #1 did not crush medications that were not ordered to be crushed. -Nurse #1 properly administered two Extended Release (ER) medications. Findings include: Review of the facility policy titled Medication Administration-General Guidelines, dated 1/1/21, indicated: -Tablet Crushing/Capsule Opening: Crushing tablets may require a Physician's order, per facility policy. -Long acting or enteric coated dosage forms should not be crushed, an alternative should be sought. -Consult with the Pharmacist for an alternative medication. -The Pharmacist should be contacted to review all medications being considered for crushing, whether a Physician's order is present or not. The Pharmacist can assist in finding appropriate alternatives to medications that should not be crushed. When identified, the Prescriber shall be contacted for an order change. -Instructions for crushing medications should be included on the resident's orders and the medication administration record (MAR) so that all personnel administering medications are aware of this need. -Please consult with product literature or Do Not Crush lists which the facility may have or with the Pharmacist if there is a question about medications to be crushed when crushing multiple medications for the same resident. Review of the facility policy titled Crushing Medications, dated April 2018, indicated: -The nursing staff and/or Consultant Pharmacist shall notify any attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or enteric coated medications). a. The attending Physician or Consultant Pharmacist must identify an alternative medication and/or dosage form; or b. The attending Physician must document (or provide the nurses with a clinically pertinent reason to document) why crushing the medication will not adversely affect the resident; or c. The facility or Practitioner must provide literature from the manufacturer or peer-reviewed journal to justify why modification of the dosage form will not compromise resident care . Resident #45 was admitted to the facility December 2024 with diagnoses including Hypertensive Heart Disease with Heart Failure and Atherosclerotic Heart Disease of Native Coronary Artery. Review of the Physician's orders, dated January 2025, indicated the following: -Isorbide Mononitrate ER (medication used to prevent chest pain) Oral Tablet Extended Release, give 30 mg by mouth one time a day for Heart Failure, initiated 12/10/24. -Metoprolol Succinate ER (medication used to treat chest pain and high blood pressure) Oral Tablet Extended Release, give 25 mg by mouth one time a day for HTN (hypertension), date initiated 12/10/24. Further review of the Physician's orders did not indicate the Isorbide Mononitrate ER 30 mg and/or Metoprolol Succinate ER 25 mg medications should be crushed. Review of Resident #45's clinical record showed no documented evidence that the Pharmacy had been consulted relative to the crushing of the two extended-release medications. On 1/3/25 at 8:15 A.M., during a medication pass observation on the B wing unit, the surveyor observed Nurse #1 crush, mix in applesauce, and administer the following medications to Resident #45: -Isorbide Mononitrate ER Oral Tablet 30 mg, one tablet, crushed, mixed with applesauce and given by mouth. -Metoprolol Succinate ER Oral Tablet 25 mg, one tablet, crushed, mixed with applesauce and given by mouth. During an interview on 1/3/25 at 8:50 A.M., Nurse #1 said that she had crushed the medications very fine because the Resident had difficulty swallowing them. The surveyor and Nurse #1 reviewed Resident #45's individual medication cards for Isorbide Mononitrate ER 30 mg and Metoprolol Succinate ER 25 mg and Nurse #1 said she should not have crushed the extended-release medications. Nurse #1 said that she would notify the Physician that she had crushed and administered the medications. During an interview on 1/3/25 at 11:49 A.M., the Director of Nursing (DON) said Isorbide Mononitrate ER and Metoprolol Succinate ER should not have been crushed. The DON further said Nurse #1 had been instructed to complete a Medication Error Report. During an interview on 1/3/25 at 1:34 P.M, the Consultant Pharmacist said Isorbide Mononitrate ER and Metoprolol Succinate ER should not be crushed. The Consultant Pharmacist said the pharmacy would have no way to know that a Resident needed crushed medications unless the pharmacy had been notified by the facility, and he had no evidence of this notification for Resident #45. The Consultant Pharmacist said it is the responsibility of the facility to follow the instructions for medication administration. The Consultant Pharmacist further said that nursing staff could call the pharmacy 24 hours a day for instructions if there were any questions regarding the crushing of medications.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#25) out of a total sample of 18 residents, increasing the risk of contamination and the spread of infections to the Resident and other residents within the facility. Specifically, for Resident #25, the facility staff failed to appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing: -high contact care to the Resident when performing ADLs (Activities of Daily Living such as bathing, dressing, grooming, personal hygiene). -administration of an Intravenous (IV- method of delivering medication through the vein) medication to the Resident. Finding include: Review of the facility policy titled Enhanced Barrier Precautions, revised March 2024, indicated: -Enhanced barrier precautions (EBPs)are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistance organisms (MDROs) to residents. -EBPs employ targeted gown and glove use in addition to standard precautions during high contact care activities. -Examples of high contact care activities requiring the use of gown and gloves for EBPs include: >dressing >bathing/showering >transferring >changing linens >changing briefs or assisting with toileting >device care or use (central line, urinary catheter, feeding tube (a flexible tube that provides nutrition and hydration when a person is unable to eat or drink safely by mouth), tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe) /ventilator (a mechanical device that helps people breathe by moving air in and out of their lungs), etc) >wound care (any skin opening require a dressing). -EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. >Wounds generally include chronic wounds (i.e pressure ulcers, diabetic foot ulcers .) >Indwelling medication devices include central lines, urinary catheters, feeding tubes and tracheostomies. Resident #25 was admitted to the facility in November 2024 with diagnoses including Acute Osteomyelitis and Pressure Ulcers to the left and right heels. Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out a total possible score of 15. Review of Resident #25's Physician's orders for January 2025 indicated: -PICC (Peripherally Inserted Central Catheter) NonValved: BRAND Bard Power PICC Provena Gauge 4 FR total Length 37 cm (centimeters). Double lumen-use purple lumen for med administration, active 11/29/24 -Normal Saline Flush, use 10 milliliters (ml) intravenously two times a day for SASH/SAS (Saline, Antibiotic, Saline and Heparin/ Saline, Antibiotic, Saline - procedure based on device type) technique prior to med administration, initiated 11/29/24 -Vancomycin HCL Intravenous Solution Reconstituted 1 GM, use 1 gram intravenously two times a day for bilateral Calcaneus Osteomyelitis, to administer via: (Device type) [sic] Single lumen to be used Diluent/volume per manufactures recommendation utilize SASH/SAS technique, initiated 11/29/24 -Normal Saline Flush, use 10 ml intravenously two times a day for SASH/SAS technique after med administration, initiated 11/29/24 -Heparin Lock Flush solution 10 Unit/ML, use 5 ml intravenously two times a day for SASH technique after administration of Saline, initiated 11/29/24. Review of Resident #25's Plan of Care, initiated 11/29/24 and revised 12/5/24, indicated: -Resident #25 needed assistance with his/her ADLs (activities of daily living, includes bathing, dressing, hygiene, personal care) due to decreased strength and endurance, bilateral heel ulcers with osteomyelitis, pain, non-weight bearing, weakness. -Intervention for Enhanced Barrier Precautions, initiated 12/3/24 During an observation on 1/2/25 at 10:02 A.M., Resident #25 was observed lying in bed next to the window with the head of the bed elevated. Resident #25 was observed to have left and right heels wrapped in gauze and elevated off the bed. The surveyor observed an Intravenous (IV) machine pump running and attached to his/her left arm via a PICC IV line. The Resident said that he/she was receiving the IV antibiotic to treat Osteomyelitis in his/her heals. Resident #25 further said that he/she received wound treatments to both his/her heels and to another area on his/her buttock (sacrum). On 1/2/25 from 10:02 A.M. to 10:33 A.M., the surveyor observed the following: -Signage outside of Resident #25's room, below the room name plate, indicating Enhanced Barrier Precautions (EBP). The EBP sign indicated: >Perform hand hygiene before and after patient contact, contact with environment, and after removal of PPE (Personal Protective Equipment). >Wear gown and gloves prior to these activities: *During High Contact Care Activities: *Dressing *Bathing/Showering *Transferring *Providing hygiene *Changing linens *Changing briefs or assisting with toileting *Device Care or use of a device (i.e central lines, urinary catheters, feeding tubes, tracheostomies, ventilators). -Clear storage bin with PPE including gloves and clean reuseable yellow gowns outside of the room. -Black Bin labeled for dirty reuseable gowns. -10:05 A.M.- CNA #6 donned gloves, did not don a gown, entered Resident #25's room and closed the door for privacy. -10:09 A.M.- Nurse #4 did not don gloves or gown, entered Resident #25's room with medications in a cup to be dispensed, and closed the door. -10:11 A.M.- Nurse #4 exited the room, and CNA #6 remained in the room. -10:33 A.M.- CNA #6 exited the room holding a clear bag of dirty linens, was not wearing a gown or gloves, and walked down the hall to the dispose of the bag of dirty linens. CNA #6 was not observed disposing of any used PPE in the bin outside the room upon exiting the room. During an interview on 1/2/25 at 10:11 A.M., Nurse #4 said that the EBP sign outside of Resident #25's room indicated that staff should wear gloves and gowns when providing direct care for Resident #25. Nurse #4 said EBP is needed when Residents have wounds, catheters, or other open areas which are a risk for infection. Nurse #4 said that Resident #25 had the EBP in place because of his/her wounds and IV line. Nurse #4 said that the facility has an Infection Preventionist (IP) who monitors and oversees any infection control needs. Nurse #4 said the facility was well stocked with PPE. Nurse #4 further said that when removing PPE, there are plastic bags available inside the Resident rooms so that staff can remove the gowns, place dirty gowns in the bag, and place bags in the bin outside of the room labeled for soiled gowns. During an interview on 1/2/25 at 10:36 A.M, the surveyor and CNA #6 reviewed the EBP signage outside of Resident #25's room. The CNA said when the sign is hung above or below the room number, it indicates which bed in the room. CNA #6 said that the sign hanging under the room number would indicate Resident #25's bed. CNA #6 said that the sign indicated staff should wear a gown and gloves when giving direct care to the Resident. CNA #6 said when she leaves the room and removes PPE, she would remove the gown, place the dirty gown in the bag, remove her gloves, do hand hygiene, and then place the dirty bagged gown into the bin outside of the room. CNA #6 said that she should have been wearing a gown when providing direct care to Resident #25 and had not been. On 1/3/25 at 8:34 A.M., the surveyor observed the following: -Nurse #4 performed hand hygiene, donned gloves, and prepared the infusion IV machine to administer Vancomycin medication to Resident #25 at 100 ml/hr. -Nurse #4 doffed gloves, performed hand hygiene, and donned new gloves. Nurse #4 was not observed to don a gown. -Nurse #4 cleansed the central line lumens (access device attached to the IV line) of Resident #25's PICC line with alcohol wipes, opened the sealed syringe package, prepared 10 ml saline solution in a syringe, administered saline via the purple IV lumen, checked blood return, and demonstrated the IV line was patent (open and unobstructed). -Nurse #4 connected Vancomycin to the infusion pump, and demonstrated that the IV was running as ordered. During an interview at the time, Nurse #4 said that the medication would run about 90 minutes total and after the infusion was finished, she would administer the second doses of saline and then Heparin as ordered per the SASH technique. During an interview on 1/3/25 at 1:25 P.M., the Unit Manager (UM) said that EBP is to prevent infections and that residents with catheters, wounds, or those on IV medications have EBP in place. The UM said that staff are expected to wear a gown and gloves when providing direct care to a resident with EBP precautions. The UM said that CNA #6 and Nurse #4 should have been wearing gowns when providing care for Resident #25. During an interview on 1/3/25 at 1:40 P.M., the Infection Preventionist (IP) said that CNA #6 should have been wearing a gown during direct care. The IP further said that Nurse #4 should have been wearing a gown when administering IV medications. During a follow-up interview on 1/3/25 at 2:12 P.M., Nurse #4 said that she should have been wearing a gown when she administered the IV medication earlier, and had not been.

Based on interview and record review, the facility failed to ensure that one Resident (#366) out of a total sample of 17 residents, was free from unnecessary medication administration. Specifically, for Resident #366, the facility failed to ensure that the Resident had adequate indication for the use of an antibiotic medication (Clarithromycin - used to treat chest and skin infections) that was ordered by the Physician to be administered for twenty-nine days. Findings include: Review of the facility policy titled Medication Monitoring and Management, dated 1/1/21, indicated: >When a resident receives a new medication, the medication order is evaluated for the following: -The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. -A written diagnosis, an indication, and/or documented objective findings support each medication. -The prescriber documents the clinical rationale in the resident's active record for using a medication outside these stated guidelines. Resident #366 was admitted to the facility in December 2024 with diagnoses of Crohn's Disease, Muscle Weakness and Wedge Compression Fractures of the Vertebra. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #366 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. During an interview on 1/3/25 at 9:42 A.M., Resident #366 said he/she was taking Clarithromycin medication for a bacterial infection called Mycobacterium Chelonae (severe skin infection that causes prolonged skin lesions that is resistant to standard antibiotic therapy) to the skin. Review of Resident #366's January 2025 Physician's orders indicated: -Clarithromycin Oral Tablet 500 milligram (mg), give one table by mouth every 12 hours for infection for 29 days, start date of 12/22/24. During an interview on 1/3/24 at 1:48 P.M., Nurse #4 said Resident #366 was taking the Clarithromycin medication for an infection but was unsure what type of infection. The surveyor and Nurse #4 reviewed the Resident's clinical records and Nurse #4 said there was no documented diagnoses for the use of the Clarithromycin medication. During an interview on 1/3/25 at 1:56 P.M., the Director of Nursing (DON) said she thought the Resident was being treated for a Urinary Tract Infection (UTI - infection in the bladder) but would review the Resident's clinical record and update the surveyor. During an interview on 1/3/25 at 2:09 P.M., the Infection Preventionist (IP) said she knew Resident #366 was receiving the Clarithromycin medication but was unsure why the Resident was taking the Clarithromycin medication. During a follow-up interview on 1/3/25 at 2:45 P.M., the DON said all medications administered should have an indication for use. The DON said Resident #366 had no documented indication for the use of the prescribed Clarithromycin medication.

Based on observation, interview, and record review, the facility failed to ensure that staff competencies were assessed for three employees (Certified Nurses Aides [CNAs #7 and #8], and Activities Assistant [AA #1]) out of three employees reviewed and relative to meal monitoring and documentation for one Resident (#14). Specifically, the facility failed to: -Assess competency for Activities Assistant (AA) #1 relative to accurately monitoring meal percentage intakes when AA #1 was tasked with monitoring and recording resident meal percentage intakes in the facility's main dining room and AA #1 monitored and recorded an inaccurate meal intake for Resident #14. -Assess nursing assistant competencies, identified by the facility for assessment, for CNAs #7 and #8 upon hire, and since working at the facility, when CNAs #7 and #8 were working in the facility and providing direct care to residents. Findings include: Review of the Facility Assessment Work Document, dated 8/5/24, indicated the following: -The facility provided care for residents with cognitive impairments. -The facility provided care for residents requiring assistance with activities of daily living (ADLs). -The facility provided care relative to nutrition for residents. -Staff training/education programs were conducted to provide the level and types of support and care needed for the resident population. -Training programs applied to all facility staff to include direct care staff, managers, supervisors, contracted staff, and volunteers, as appropriate. -Training programs, as appropriate were provided as part of the facility's orientation process for new and newly assigned staff, annually, and/or as needed. -Training programs contain learning objectives, performance standards, and evaluation criteria. Review of the facility policy titled Staffing, Sufficient and Competent Nursing, dated 2001, indicated but was not limited to the following: -The facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. - . the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment. -Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles . -Staff must demonstrate the skills and techniques necessary to care for resident needs . -Competency requirements . for nursing staff are established and monitored by nursing leadership . to ensure that gaps in education are identified and addressed . Review of the facility's document titled Facility Orientation Competency: Nursing Assistant, undated, indicated the following: -The evaluator will place their initials in the appropriate column on the line that corresponds to the skill after competency in the area is achieved by employee. -All evaluators are to sign the bottom of this form identifying their signature, title, initials, and date. -Checklist must be complete and handed in prior to coming off orientation. -Topics requiring competency assessment included meal percentage monitoring. Review of the Dietary Intake Guide, undated, provided by the facility indicated but was not limited to the following: -The Dietary Intake Guide was a resource to help measure meals, liquids, . consumed. -Record amount of the total meal . consumed using the following guidelines: >Refused - 0% (refused meal completely or consumed only one or two bites of each item). >Poor - 25% (approximately 25% of entree or 50% of one item consumed). >Fair - 50% (approximately half of food is consumed, [e.g., 50% of entree, 25% of vegetable and soup left]. If total entree is consumed but no other food is touched, record as Poor/25%, not Fair/50%). >Good - 75% (majority of meal is consumed but a significant amount of one or more items is left [e.g., 25% of entree or 75% of vegetable left]). >All - 100% (entire meal is consumed except for a minimal amount of food [e.g., less than 25% of vegetable left]). Resident #14 was admitted to the facility in August 2024 with a diagnoses of Dementia and Dysphagia. Review of Resident #14's Minimum Data Set (MDS) Assessment, dated 10/31/24, indicated the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) of nine out of 15 total possible points. Review of Resident #14's Nutrition Care Plan, revised 11/5/24, indicated: -Diet as ordered (monitor and record). On 1/3/25 between 12:05 P.M. and 12:45 P.M., the surveyor observed the following in the facility's main dining room: -Resident #14 was seated in a wheelchair at a table with one other resident. -Resident #14 was served a meal which included chicken breast, cooked carrots, rice, one dinner roll, and one bowl of pineapple wedges. -The Resident fed him/herself during the meal. -At the end of mealtime, Resident #14 had consumed most of the chicken breast (leaving a few small pieces on the plate) and most of the cooked carrots (leaving a few carrots on the plate). The Resident did not eat any of the rice and dinner roll, or any of the pineapple wedges. During an interview on 1/3/25 at 12:30 P.M., Resident #14 said that he/she liked the food and that he/she just did not have a big appetite. At the same time, the surveyor observed AA #1 approach Resident #14's table, ask the Resident if he/she was done eating, and removed the Resident's meal plate. Review of the facility's Lunch Meal Intake Sheet, dated 1/3/25 and completed by AA #1, indicated Resident #14 consumed 80% of his/her lunch meal that same day. During an interview on 1/3/25 at 1:45 P.M., AA #1 said she recorded meal percentage intakes for residents who ate lunch in the facility's main dining room that same day and that she recorded Resident #14's lunch meal intake percentage. AA #1 said that when she records resident meal intakes, she looks at the residents' plates and estimates how much of the total meal the resident consumed. AA #1 said she recorded Resident #14's lunch meal intake as 80% consumed. AA #1 said that after she completes the Meal Intake Sheet, she leaves the sheet at the nurses station and the meal percentages documented on the sheet are then entered into the residents meal records on the computer by the CNAs. At the time, the surveyor and AA #1 reviewed the Lunch Meal Intake Sheet and discussed the lunch meal observation for Resident #14. AA #1 said that the meal percentage she recorded on the Meal Intake Sheet may have been inaccurate. During an interview on 1/3/25 at 1:54 P.M., with CNA #7 and CNA #8, CNA #8 said that all resident meal intake percentages are entered into the computer. CNA #7 said that when meal percentages are recorded from staff in the main dining room, the staff bring the completed meal percentage sheet to the nurses station and a CNA enters the meal percentages recorded into the resident meal records on the computer. Review of Resident #14's electronic meal intake record for 1/3/25 indicated Resident #14 consumed 51% -75% of his/her lunch time meal on 1/3/25. During an interview on 1/7/25 at 10:20 A.M., the Registered Dietician (RD) said it was important to have accurate information relative to meal percentage intakes to ensure residents consume percentages of food that matches their estimated dietary needs. The RD said that she was not sure how staff had been trained to monitor and record meal percentages, and offered that the surveyor should ask the Staff Development Coordinator (SDC). During a follow-up interview on 1/7/25 at 11:08 A.M., the RD said the standard for measuring meal intake percentage relative to the items Resident #14 consumed at lunch time on 1/3/25 should have been recorded as 25%-50%. The RD then provided the surveyor with the Dietary Intake Guide used to measure meals consumed. During an interview on 1/7/25 at 11:58 A.M., the SDC said nursing staff competencies were completed during orientation, when staff were newly hired, and annually. The SDC said that competency assessments were recorded on the competency checklists and maintained in the employee education files. The SDC said that meal percentage monitoring was included in topics requiring competency assessment for CNAs and that there was no competency assessment checklist for activities staff. The SDC said that AA #1 does record meal percentages for residents who eat in the main dining room and that AA #1 would have needed to be trained to ensure she was recording meal percentages accurately. The SDC said that she would provide the survey team with evidence that the required competencies had been completed. During a follow-up interview on 1/7/25 at 4:22 P.M., the SDC said CNA #7 began working at the facility on 11/1/23, CNA #8 began working at the facility on 4/29/24, and AA #1 began working at the facility on 7/31/24. The SDC said there was no evidence that any competency assessments had been completed for CNA #7 and CNA #8. The SDC also said there was no evidence competency had been assessed for AA #1 relative to monitoring and recording resident meal percentages.

Based on observation, interview, and record review, the facility failed to provide care according to professional standards of practice for one Resident (#14) out of a total sample of 17 Residents, relative to nutrition interventions and weight monitoring when the Resident was identified as being at nutritional risk and had severe weight loss. Specifically, for Resident #14, the facility failed to: -Implement Provider recommendations in a timely manner for a nutrition consult. -Implement weekly weight monitoring, as recommended by the Physician Assistant (PA) when the Resident was identified with greater than 20 pounds weight loss over a period of two weeks. -Accurately monitor and record the Resident's meal intake percentage. -Accurately assess the Resident for weight loss when the Resident had a severe weight loss of greater than 10% in less than six months. Findings Include: Review of the facility's Policy titled, Weight Assessment and Intervention, dated 2001 and last reviewed March 2022, indicated: -Residents are weighed upon admission and at intervals established by the interdisciplinary team. -Weights are recorded in each unit's weight record chart and in the individual's medical record. -Any weight change of 5% (percentage) or more since the last weight assessment is retaken the next day for confirmation. >If the weight is verified, nursing will immediately notify the dietician in writing. -The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual)/ (usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe c. 6 months - 10% weight loss is significant; greater than 10% is severe Review of the Dietary Intake Guide, undated, provided by the facility indicated: -The Dietary Intake Guide was a resource to help measure meals, liquids, . consumed. -Record amount of the total meal . consumed using the following guidelines: -Refused - 0% (refused meal completely or consumed only one or two bites of each item). -Poor - 25% (approximately 25% of entree or 50% of one item consumed). -Fair - 50% (approximately half of food is consumed, [e.g., 50% of entree, 25% of vegetable and soup left]. If total entree is consumed but no other food is touched, record as Poor/25%, not Fair/50%). -Good - 75% (majority of meal is consumed but a significant amount of one or more items is left [e.g., 25% of entree or 75% of vegetable left]). -All - 100% (entire meal is consumed except for a minimal amount of food [e.g., less than 25% of vegetable left]). Resident #14 was admitted to the facility in August 2024, with diagnoses including Dementia, Type 2 Diabetes Mellitus, Pure hypercholesterolemia, and Dysphagia. Review of Resident #14's Minimum Data Set (MDS) Assessment, dated 10/31/24, indicated that the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of 15. Review of Resident #14's Weights and Vitals Summary Report indicated the Resident weighed 195.3 pounds (lbs) on 8/1/24. Further review of Resident #14's Weights and Vitals Summary indicated: -8/8/24: weight of 192.4 lbs -8/15/24: weight of 172.3 lbs -8/15/24: a re-weigh of 170.8 lbs -9/5/24: weight of 171.4 lbs -10/4/24: weight of 165.6 lbs -11/4/24: weight of 168.2 lbs -12/3/24: weight of 166.2 lbs -1/1/25: weight of 165.4 lbs Review of Resident #14's Physician order, dated 8/1/24, indicated: -Monthly weight. Review of Resident #14's Speech Therapy Evaluation, dated 8/2/24, indicated: -The Resident had dysphagia. -Treatment plan included interventions for swallowing dysfunction and/or oral function for feeding. -The Resident required a dysphagia advanced (food that is soft, moist, and easy mashed with a fork) diet texture. Review of Resident #14's Nutritional Care Plan, initiated 8/6/24, indicated: -The Resident had a nutritional problem/potential nutritional problem. -Registered Dietician (RD) to evaluate and make diet change recommendations PRN (as needed) -Provide, serve diet as ordered. -Monitor intake and record every meal. -Weigh as ordered, at same time of day and record. Review of Resident #14's Nursing Progress Note, dated 8/2/24, indicated: -Currently receiving dysphagia diet and in [sic] working with SLP (Speech Language Pathologist). Review of Resident #14's Nutrition Assessment, dated 8/6/24, indicated: -The Resident's usual body weight was not known. -The Resident weighed 195.3 lbs. (weight documented on 8/1/24) -The Resident's body mass index (BMI: numerical value that indicates weight status and estimates body fat) was 31.8. -The Resident was considered as obese, and obesity was not a concern due to advanced age and diagnoses. -The Resident had not experienced significant/severe weight loss or gain. -The Resident was eating well, per documentation. -The nutrition plan included routine surveillance of weight per facility protocol and physician orders, ., offer snacks between meals . -The Registered Dietician (RD) was available as needed. Review of Resident #14's Change in Condition (CIC) Note, dated 8/13/24, indicated the following: -Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts). -Functional decline (worsening function and/or mobility). -Other change in condition with recommendations for speech screen. Review of Resident #14's Nursing Progress Note, dated 8/14/24, indicated the following: -The Resident ate less than 25% of two meals. -Staff reported increased coughing during meals. -Speech evaluation requested. Review of the Resident's clinical record indicated the Resident was actively receiving therapy for Speech and Language services on 8/14/24. Review of Resident #14's Weights and Vitals Summary indicated the Resident weighed 172.3 lbs on 8/15/24 (weight loss of 20.1 lbs. from the 8/8/24 weight). Further review of the Resident's Weights and Vitals Summary indicated a re-weigh was obtained on 8/15/24 and the Resident's weight was 170.8 lbs. Review of Resident #14's CIC Form, dated 8/16/24, indicated: -Significant weight loss of approximately 20 lbs. was noted. -Facility staff notified the Physician Assistant (PA) of the weight loss. -The PA recommended: >Supplement drinks three times daily. >Dietician consult. >Weekly weight monitoring. Review of Resident #14's Nursing Alert Progress Note, dated 8/16/24, indicated: -Dietician notified via email. States she (Dietician) will assess Resident. Review of Resident #14's Physician Assistant (PA) Encounter Note, dated 8/27/24, indicated: -Weight loss. -RN (Registered Nurse) reports 20 lbs weight loss over 2 weeks. -Will order health shakes. -Dietary evaluation. -House Supplement three times daily. Review of Resident #14's Weights and Vitals Summary indicated the Resident weighed 171.4 lbs on 9/5/24. Review of Resident #14's Physician Encounter Note, dated 9/17/24, indicated: -Continue health shakes. -Dietician to follow. Review of Resident #14's Speech Therapy Discharge Summary, dated 9/27/24, indicated: -The Resident had met his/her goal for swallowing. -The Resident's diet had been upgraded to regular texture with thin liquids. Review of Resident #14's Physician order, dated 9/27/24, indicated: -CCHO (Consistent Carbohydrate Diet) diet, Regular Texture, Thin Liquids consistency. Review of Resident #14's Weights and Vitals Summary indicated the Resident weighed 165.6 lbs on 10/4/24. Review of Resident #14's Minimum Data Set (MDS) Assessment, dated 10/31/24, indicated: -The Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. -The Resident weighed 166 lbs. -Weight loss of 5% or more in last month or 10% or more in last six months was marked as: -No or unknown. Review of Resident #14's clinical record did not indicate that weekly weights as ordered on 8/1/24, were implemented and were being done consistently for Resident #14. Further review of the Resident's clinical record indicated a nutrition assessment recommended by the PA on 8/16/24, was not completed until 11/1/24 (approximately 2.5 months after the PA recommendation). Review of the Nutrition Assessment, dated 11/1/24, indicated: -The Resident's usual body weight was not known. -The Resident was at potential nutritional risk due to advanced age, varied intake, and triggered for significant weight loss trends. -The Resident's current weight loss was -13.9% over three months (severe). -The Resident weighed 165.6 lbs. -The Resident's BMI was 27. -The Resident started on dietary supplement shakes in August 2024 which may have slowed the Resident's weight loss trend. -No new recommendations were made. Review of Resident #14's Weights and Vitals Summary indicated the Resident weighed 165.4 lbs on 1/1/25. On 1/3/25 between 12:05 P.M. and 12:45 P.M., the surveyor observed the following in the facility's main dining room: -Resident #14 was seated in a wheelchair at a table with one other resident. -Resident #14 was served a meal which included chicken breast, cooked carrots, rice, one dinner roll, and one bowl of pineapple wedges. -The Resident fed him/herself during the meal. -At the end of mealtime, Resident #14 had consumed most of the chicken breast (leaving a few small pieces on the plate) and most of the cooked carrots (leaving a few carrots on the plate). -The Resident did not eat any of the rice and dinner roll and left both food items on the plate. -The Resident did not eat any of the pineapple wedges. During an interview on 1/3/25 at 12:30 P.M., the Resident said that he/she did not have a big appetite, and did not eat much. During an interview on 1/3/25 at 1:45 P.M., Activity Assistant (AA) #1 said that she picked up Resident #14's lunch meal tray on 1/3/25 and that the Resident ate 80% of the meal. Review of the CNA (Certified Nursing Assistant) tasks sheet, dated 1/3/25, indicated meal percentage documented as follows: -51-75% of lunch meal consumed. On 1/7/25 at 8:41 A.M., the surveyor observed Resident #14 eating breakfast. The Resident's meal included one biscuit with jelly, scrambled eggs, cream of wheat, one glass of orange juice, one glass of milk, and one cup of coffee. The surveyor observed that the Resident ate all of the biscuit and jelly, drank all of the orange juice and coffee and ate a few bites of the scrambled eggs. At the end of the meal, the Resident left the rest of the scrambled eggs uneaten, ate no cream of wheat, and drank none of the milk. The surveyor further observed the Resident request that staff remove his/her breakfast meal. During an interview on 1/7/25 at 9:47 A.M., the Unit Manager (UM) said residents at the facility were weighed monthly and some residents required daily and weekly weights. The UM said CNAs weighed residents according to the required frequency determined by the Physician and that after the CNAs obtained resident weights, the weights were to be reviewed by the Nurse. The UM said if there was a change in weight of three to five pounds, a re-weight would be required, and if the weight change was validated, the Nurse would be required to complete a Change in Condition (CIC) form. The UM said that the Nurse would also be responsible to notify the Physician of the weight change. The UM said that she was responsible to notify the Registered Dietician (RD) of the weight change. The UM also said that recommendations made by the Physician when notified of a change in weight would be implemented by the Nurse who obtained the recommendations. The surveyor and the UM reviewed Resident #14's clinical record, and the UM said that facility staff identified Resident #14 as having had a significant change in weight between 8/1/24 and 8/15/24. The UM said that based on the CIC form completed on 8/16/24, facility staff had notified the Physician Assistant (PA) of the weight change, and that the PA recommended implementing dietary supplements, weekly weights, and a consult by the RD. The UM said that she would have to look into whether the weekly weights had been implemented and whether a consult with the RD had occurred. During a follow-up interview on 1/7/25 at 11:52 A.M., the UM said that she was unable to locate any evidence of follow-up with the Physician regarding Resident #14's weight changes and was unable to locate any weekly weight assessments in the Resident's clinical records. The UM further said that there should have been follow-up with the RD to ensure the dietary evaluation was completed and whether any new interventions were recommended. The UM also said that weekly weights should have been implemented for Resident #14 on 8/16/24, but the weekly weights had not been implemented. During an interview on 1/7/25 at 10:20 A.M., the RD said that she recently started working at the facility and that she had recently identified Resident #14 as having had severe weight loss. The RD said that Resident #14 had been identified as having had a greater than 10 percent weight loss over the previous five months. The RD said that she had also identified other residents with significant weight changes and was in the process of evaluating them. The RD said that she had not yet evaluated Resident #14. The RD said that accuracy for monitoring meal percentages was important because meal intake percentages need to be compared with the estimated needs for each resident's nutrition. The surveyor and the RD reviewed Resident #14's clinical record and the RD said that no dietary consult had been provided for Resident #14 when the severe weight change was identified, and the dietary consult was ordered by the PA. The RD further said that the dietary consult was not completed until 11/1/24, and was not completed relative to weight loss, but for a routine quarterly assessment. The RD also said that a dietary consult should have been completed within a week of the 8/16/24 PA request for a consult. During a follow-up interview on 1/7/25 at 11:08 A.M., the RD said the standard for measuring meal intake percentage relative to the items Resident #14 consumed at lunch time on 1/3/25 should have been recorded as 25%-50%. The RD then provided the surveyor with the Dietary Intake Guide used to measure the amounts of meals consumed. During a telephone interview on 1/7/25 at 11:37 A.M., the PA said that she did not work in the facility from July 2024 to November 2024, and that when she returned, she evaluated Resident #14 on 11/13/24. The PA said that a covering PA worked in the facility at that time (July 2024 to November 2024), and Resident #14 would have been assessed in August 2024 by the covering PA. The PA further said that the recommendations ordered by the covering PA for weekly weights and a dietary consult on 8/16/24, should have been implemented for Resident #14 at that same time. During an interview on 1/7/25 at 11:52 A.M., the UM said that weekly weights had not been implemented as ordered by the PA on 8/16/24. The UM also said no dietary consult had been completed until 11/1/24 after being ordered by the PA on 8/16/24. The UM said that facility staff should have followed-up with the RD relative to the ordered dietary consult and any recommended interventions. During an interview on 1/7/25 at 1:31 P.M., the RD said that a higher body mass index (BMI) was considered protective for the nursing facility population and that she would not want to see Resident #14 with a lower BMI than what it was currently (27). During an interview on 1/7/25 at 1:42 P.M., the Physician said that she attended QAPI meetings monthly at the facility and that resident weight variances were discussed at the QAPI meetings. The Physician said that she did not recall the facility discussing weight loss concerns for Resident #14. The Physician said that she was not sure that the facility's initial weight of 195.3 lbs for Resident #14 was accurate, but that there was no information available to indicate that the weight was inaccurate. Please refer to F726.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice relative to the use of compression stockings for one Resident (#51) out of a total sample of 17 residents. Specifically, the facility failed to: -Assess Resident #51 for the proper use of compression stockings for the Resident's lower extremities when the Resident had lower extremity swelling and staff applied improperly fitted compression stockings, which increased the Resident's risk for impaired skin integrity and blood circulation. Findings include: Review of the Cardinal Health document titled T.E.D. (thrombo-embolic-deterrent: type of hosiery used to prevent blood clots) Anti-Embolism (obstruction of an artery, typically by a clot of blood or an air bubble) Stockings, dated 2020 and located at https://www.cardinalhealth.com/content/dam/corp/web/documents/brochure/cardinal-health-ted-anti-embolism-stockings-for-acute-care-brochure.pdf indicated: -T.E.D. Anti-Embolism Stockings have been clinically proven to reduce the risk of developing deep vein thrombosis (DVT: blood clot that forms in a vein) in physician reviewed, published studies on hospitalized patients and to promote increased blood flow velocity in the legs. -For knee length stockings, measure in standing position if possible. -Measure calf circumference at greatest portion to determine size. -Measure the distance from bend of knee to bottom of heel to determine length. -T.E.D. stocking precautions: Proper sizing and application must be assured for optimal benefit of stockings. -It is important to measure the patient's leg size to assure that the appropriate pressure pattern is applied. Resident #51 was admitted to the facility in December 2024 with diagnoses including Fracture of Neck of Left Femur (thigh bone) and Personal History of Pulmonary Embolism. Review of Resident #51's Minimum Data Set Assessment, dated 12/19/24, indicated the Resident: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) of 15 out of 15 total possible points. -had a hip fracture. -demonstrated no rejection of care. -required substantial/maximal assistance to transition from sitting to standing. -required the use of a wheelchair. -required substantial/maximal assistance for lower body dressing. Review of Resident #51's Provider Encounter Note, dated 12/19/24, indicated the Resident had non-pitting (not impacted by pressure) edema (accumulation of excess fluid in soft tissues, causing swelling) to his/her left lower extremity. Review of Resident #51's Provider Encounter Note, dated 12/23/24, indicated the Resident had trace (small amount) edema in his/her right and left lower extremities. Review of Resident #51's Nursing Progress Note, dated 12/24/24, indicated the Resident had 1+ (one plus: 2 millimeter indent with rapid return to normal) pitting (when an external force causes an indentation) edema in his/her lower extremities. Review of Resident #51's Provider Encounter Note, dated 12/27/24, indicated the Resident had trace edema in his/her right and left lower extremities. Review of Resident #51's Activities of Daily Living (ADL) Care Plan, revised 12/30/24, indicated: -The Resident required assistance with ADLs due to decreased strength and endurance, recent left femur fracture, weakness, and pain. -The Resident required substantial/maximal assistance for lower body dressing. -The Resident required substantial/maximal assistance for putting on/taking off footwear. On 1/2/25 at 9:52 A.M., the surveyor observed the following: -Resident #51 was sitting in a wheelchair beside his/her bed. -The Resident's feet were positioned off the floor and resting on the wheelchair foot rests. -The Resident wore full length pants and slipper socks. -The surveyor observed that the Resident's pants were tight around his/her lower legs, below the knees bilaterally and the slipper socks were tight over the Resident's feet and creased over the tops of the Resident's ankles. During an interview at the time, Resident #51 said that he/she had been experiencing swelling in his/her bilateral lower legs and that the swelling had been present prior to being admitted to the facility. The Resident then pulled his/her pant legs up to knee level bilaterally and the surveyor observed T.E.D. stockings on both of the Resident's lower legs. The surveyor further observed both stockings were rolled down under the Resident's knees, forming an indentation directly below both knees, around the full circumference of each of the Resident's lower legs. Resident #51 said that the stockings felt tight right below his/her knees and that he/she did not know why, but the stockings always rolled down. On 1/2/25 at 4:50 P.M., the surveyor observed the following: -Resident #51 was sitting in a wheelchair beside his/her bed. -The Resident's feet were positioned on the wheelchair footrests and the Resident wore the same full length pants observed earlier in the day and slipper socks. -The surveyor observed that the Resident's pants remained tight around his/her lower legs, below the knees bilaterally and the slipper socks were tight over the Resident's feet and creased over the tops of the Resident's ankles. During an interview at the time, Resident #51 said that he/she required assistance from staff for lower body dressing and that due to his/her hip fracture, he/she was unable to put on his/her own pants and socks. Resident #51 said that staff who assisted him/her to get dressed in the morning applied the T.E.D. stockings to help with his/her swelling and that he/she had been wearing the stockings daily for a couple of weeks. At this time, Resident #51 pulled his/her pant legs up to knee level and the surveyor observed the T.E.D. stockings on the Resident's lower legs. The surveyor observed the tops of the stockings were rolled down directly under the Resident's knees, and formed an indentation directly below both knees and around the full circumference of each of the Resident's lower legs. Review of Resident #51's Lower Body Dressing Flow Sheet indicated: -The Resident required substantial/maximal assistance for lower body dressing on 1/2/25. -The Resident required dependence on staff for lower body dressing on 1/3/25. Review of Resident #51's Kardex Report indicated the following for dressing as of 1/3/25: -Substantial/maximal assistance for clothing management. -May need dependent assist if fatigued. During an interview on 1/3/25 at 7:50 A.M., Certified Nurses Aide (CNA) #2 said Resident #51 wore T.E.D stockings every day. During an interview on 1/3/25 at 9:06 A.M., Nurse #3 said she overheard the surveyor speaking with CNA #2 earlier that morning regarding Resident #51 and the use of compression stockings, so she reviewed the Resident's Physician orders and Treatment Administration Records (TARs) to identify whether the Resident had a treatment order for the use of compression stockings. Nurse #3 said that all residents requiring the use of compression stockings needed to have a Physician's order for the stockings. Nurse #3 also said that when compression stockings were ordered by the Physician, the Nurse was required to measure the resident's legs to ensure the proper size stocking was used. Nurse #3 said that when she reviewed Resident #51's Physician's orders and TARs, there was no order for compression stockings. Nurse #3 further said that the compression stockings would only be applied if ordered by the Physician. Nurse #3 said that the facility did not use T.E.D. stockings for any residents and that the facility only used MediGrip Support and Compression Stockings, unless a different stocking was ordered by the Physician. During a follow-up interview on 1/3/25 at 9:22 A.M., Nurse #3 said Resident #51 did have T.E.D. stockings, so the stockings must have come with the Resident when he/she was admitted from the hospital. Nurse #3 said that the Resident needed to be assessed for the use of the compression stockings to ensure the stockings were appropriate for the Resident's condition and an order would need to be obtained. Nurse #3 also said residents need to be measured for the proper size compression stockings to ensure proper fit and that compression stockings should never be rolled down below the knees. Nurse #3 further said that Resident #51 was not able to put on his/her own socks and depended on staff to complete his/her lower body dressing. During an interview on 1/3/25 at 9:51 A.M., the Unit Manager (UM) said that a Physician's order was required for implementing the use of compression stockings for a resident and that the Nurse was required to measure the resident's legs to ensure the proper size stockings were used. The UM said that compression stockings should not be rolled down under a resident's knees and that the top of the stockings should be flat around the circumference of the lower legs. The UM said that Resident #51's compression socks rolling down under his/her knees and causing indentation in the tissue increased the Resident's risk for alteration in skin integrity and impaired circulation due to prolonged pressure.

Based on record review and interview the facility failed to maintain complete medical records for one Resident (#57) out of a total sample of 15 residents. Specifically, for Resident #57, who was being monitored for weight loss, the Certified Nurses Aides (CNAs) failed to consistently monitor and document meal intake percentages as required, per the Resident's Nutritional Risk care plan. Findings include: Resident #57 was admitted to the facility in August 2023 with a diagnoses including left tibia (bone in the leg) fracture, left fibular (bone in the leg) fracture, and Dementia with behavioral disturbance (a condition that impairs memory and is accompanied by behavioral or psychological disturbances such as agitation, depression, and psychosis). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a 5% or more weight loss in the last month and was not on a Physician prescribed weight loss regimen. Review of the Dietitian's Nutritional assessment dated [DATE], indicated the following interventions: -Monitor PO (per os-by mouth) intake. Review of the Nutritional Risk care plan, initiated 8/17/23, indicated an intervention to monitor intake at all meals. During an interview on 11/28/23 at 3:06 P.M., CNA #2 said the procedure for monitoring meal intakes was after each meal the CNAs took note of what percentage the Resident ate of his/her meal. She said that the percentage was supposed to be documented in the Resident's medical record each shift as part of the CNA shift documentation. CNA #2 further said if the Resident refused his/her meal, that information would also be documented in the medical record. During an interview on 11/29/23 at 1:05 P.M., the Director of Nurses (DON) said the CNAs collect meal trays after each meal and they should document the percentage of meal the residents had eaten during their shifts. She further said all residents should have documentation for each meal showing the percentage that the resident ate or if the resident refused the meal. The surveyor and the DON reviewed the CNA Amount Eaten documentation for November 2023 (11/1/23 through 11/28/23) and noted multiple dates that contained no documentation of what percentage the Resident had eaten during that meal.15 out of 84 meals on the CNA Amount Eaten documentation were left blank (had no meal percentages) during the look back period. During an interview on 11/29/23 at 1:13 P.M., the facility Dietitian said the CNAs should be tracking meal percentages for each meal as she utilizes this information to complete her assessments on the Resident's nutritional status. The Dietitian further said the meal percentage documentation allows her to get a clear picture on how the Resident is doing with his/her meal intake.

Based on interview, policy and record review, the facility failed to ensure that routine dental services were provided for one Resident (#38), out of a total sample of 15 residents. Specifically, the facility staff failed to ensure that an annual dental exam and prophylactic (preventative) cleaning every six months were completed as recommended. Findings include: Review of the facility policy titled Dental Services, revised 9/1/22, indicated the following: -Centers will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient. -Routine dental services means an annual inspection of the oral cavity for signs of disease .dental cleaning . Resident #38 was admitted to the facility in December 2021. Review of the most recent Minimum Data Set (MDS) Assessment, dated 9/12/23, indicated the Resident scored a 9 out of 15 in the Brief Interview of Mental Status (BIMS) indicating the Resident was moderately cognitively impaired and was usually able to make him/herself understood. During an interview on 11/28/23 at 8:46 A.M., Resident #38 said he/she had not seen the Dentist in some time and that he/she was in need of a dental cleaning. Review of the dental provider progress note dated 6/8/22, indicated the following recommendations: -Next annual exam 6/8/23 -Recommend prophylactic (preventative) cleaning every six months Further review of the Resident's medical record indicated no documentation that he/she had been seen every six months for a prophylactic cleaning. The medical record also indicated no documentation that an annual dental examination had been completed for the Resident. During an interview on 11/28/23 at 4:01 P.M., the surveyor and Nurse #2 reviewed the Resident's medical record, and Nurse #2 said she was unable to find any additional documentation that the Resident had been seen for a prophylactic cleaning or annual dental examination since his/her last annual dental examination on 6/8/22. During an interview on 11/29/23 at 12:09 P.M., Unit Manager (UM) #1 said the Resident should have been seen for a dental cleaning since his/her last dental examination and should have also been seen for an annual examination and this had not been done. UM #1 said she could find no documentation as to why the Resident had not been seen. She further said the Dentist had been in the facility to provide dental services since Resident #38's last dental examination and the Resident was not seen, as required.

Based on observations, interviews, record and policy review, the facility failed to provide Activities of Daily Living (ADLs - tasks such as bathing, grooming, maintaining dental hygiene, nail and hair care) assistance for one Resident (#12) out of a total sample of 15 residents. Specifically, the facility failed to ensure that the Resident's nails were trimmed, when the Resident was dependent for care. Findings include: Resident #12 was admitted to the facility in February 2013 with diagnoses including hemiplegia (one-sided muscle paralysis) and hemiparesis (partial weakness or the inability to move on one side of the body) following cerebral vascular disease affecting right dominant side (paralyzed on his/her right side due to a stroke). Review of the facility policy titled, Activities of Daily Living (ADLs), revised 5/1/23 indicated the following: -Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's ADL abilities are maintained or improved and do not diminish unless circumstances of the patient's clinical condition demonstrate a change was unavoidable -Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident: -had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15 -was usually understood and could understand others -had impairment on one side (both upper and lower extremeties) -required substantial/maximal assistance with personal hygiene. Review of the Resident's ADL Care Plan, initiated 12/4/17, and revised 6/15/18, indicated the Resident had decreased ability to perform ADLs related to having suffered a stroke with the following interventions: -Provide Resident with limited to extensive assistance of one person for personal hygiene (grooming), due to limited range of motion, initiated 12/21/17 and revised on 11/2/23. Review of the Nursing Unit Shower Schedule, updated 8/16/23, indicated the following: -Fingernails are to be trimmed on shower days. -The Resident's shower day is every Friday during the 11:00 P.M. - 7:00 A.M. shift (shower is done in the morning before the night shift ends). Review of the Resident's medical record indicated no evidence that the Resident refused ADL care. During an observation and interview on 11/28/23 at 9:25 A.M., the surveyor observed the Resident seated in his/her wheelchair, noting that the Resident's right hand was in the closed position. The surveyor asked the Resident if he/she could open his/her hand. The Resident took his/her left hand and demonstrated he/she was able to open his/her right hand, but his/her right hand would not remain open without assistance. The surveyor observed the Resident's fingernails on both hands had grown past his/her fingertips, when the Resident opened his/her right hand. The surveyor also noted the right hand fingernails to be longer with jagged edges, and the jagged edges to be in contact with the Resident's right palm at all times when his/her hand was closed. When the surveyor asked the Resident if he/she required assistance with trimming his/her nails, the Resident said yes and that he/she would like the nails to be trimmed. During an observation and interview on 11/29/23 at 12:58 P.M., the surveyor observed the Resident seated in his/her wheelchair. The Resident indicated to the surveyor that his/her nails remained untrimmed by holding out his/her left hand followed by opening up his/her right hand with his/her left hand. The surveyor asked the Resident if he/she still wished to have staff assist him/her in trimming his/her nails and he/she nodded his/her head and said yes. During an interview on 11/29/23 at 1:03 P.M., the Rehabilitation Director said the Resident required assistance of one person for ADL care and cannot cut his/her own nails. During an observation and interview on 11/29/23 at 1:37 P.M., Certified Nurses Aide (CNA) #3 said the Resident required substantial assistance with ADL care and the overnight shift was responsible for washing him/her up and getting him/her dressed in the morning. CNA #3 further said the Resident should receive a shower weekly which included tasks such as shaving and nail care. The surveyor and CNA #3 observed the Resident's fingernails together and CNA #3 said his/her fingernails were clean, but they were long and jagged and needed to be trimmed. During an interview on 11/29/23 at 1:50 P.M., Nurse #3 said if the Resident refused care, the CNA was supposed to report the refusal to the Nurse and the Nurse should document the refusal in a progress note in the medical record. Nurse #3 further said that CNAs had their own area in the electronic medical record (EMR) where ADL care and refusals should be documented.

Based on observations, interviews, record and policy reviews, the facility failed to ensure that its staff implemented an infection prevention and control program in order to prevent the transmission of communicable diseases. Specifically, the facility failed to ensure its staff: A) adhered to the Centers of Disease Control & Prevention (CDC) and Massachusetts Department of Public Health (MA DPH) guidance in order to minimize the risk of transmission of infections by implementing the required Personal Protective Equipment (PPE) practices on two out of two units observed, and B) disinfected multiple use equipment to prevent the potential spread of infection. Findings include: Review of the MA DPH Memorandum titled Comprehensive PPE Guidance, dated 4/12/22, included the following: -Facilities should eliminate the practice of reuse of N95 respirators. N95 respirators should always be discarded after doffing (removing), such as when leaving a patient room, during a break or when eating or drinking . -Disposable eye protection should be removed and discarded when it is removed for any reason; it should not be reused . -Reusable eye protection should be cleaned and disinfected when visibly soiled and after removal/doffing of eye protection -Eye protection may be used for multiple patient care encounters under the following conditions: >Eye protection should be removed and reprocessed if it becomes visibly soiled or difficult to see through. > Eye protection should be discarded if it becomes damaged (e.g., face shield can no longer fasten securely to the provider, if visibility is obscured and reprocessing does not restore visibility). > If reusable goggles or face shields are used each facility must ensure appropriate cleaning and disinfection between uses according to manufacturer's instructions. > After cleaning and disinfection, reusable eye protection should be stored in a designated location. Review of the MA DPH Memorandum titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 10/13/22, included the following: -Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with residents and in alignment with DPH and CDC guidance. -Full PPE, including N95 respirator or alternative, eye protection, gloves, and gown, should be worn per DPH and CDC guidelines for the care of any resident with known or suspected COVID-19. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 27, 2022, included the following: -Health Care Personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2(COVID-19) 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). -Dedicated medical equipment should be used when caring for a patient with suspected or confirmed COVID-19 infection. -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. Review of the CDC instructions, undated, titled How to Safely Remove PPE, included the following relative to eye protection: - Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. - the Outside of goggles or face shield are contaminated! - If your hands get contaminated during goggle or face shield removal, immediately wash your hands or use an alcohol-based hand sanitizer - Remove goggles or face shield from the back by lifting head band or ear pieces - If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container Review of the facility policy titled Infection Control Polices and Procedures: COVID-19, revised 2/14/23, indicated the following: -in addition to Standard Precautions, Special Droplet and Contact Precautions will be implemented for patients/residents suspected or confirmed to have COVID-19 based on the CDC guidance -Special Droplet and Contact Precautions requires wearing an N95 respirator upon entry into the patient's room, in addition to the recommended PPE, and keeping the door to the patient's room closed, when safe to do so -the facility follows the CDC published guidance related to the use of facemasks, respirators, gowns, gloves and eye protection -Clean and disinfect patient care items using appropriate Environmental Protection Agency (EPA) approved, hospital grade disinfectant and following the manufacturer's instructions. During the entrance conference on 3/1/23 at 9:00 A.M., the Director of Nurses (DON) said the following: -Both Units A and B had residents that were positive for COVID-19 infections, some residents who were recovered and some residents who were negative (have not tested positive for COVID-19 within the last 30 days) -the facility staff were expected to wear full PPE (gown, gloves, N95 mask and eye protection) with all resident care regardless of COVID-19 status -there were no shortage of PPE supplies 1. Review of the resident COVID-19 status list, updated 3/1/23, indicated the facility had the following on Unit B: -9 COVID-19 positive residents, -6 recovered residents, and -11 negative residents Resident #1, who resided on Unit B, was admitted to the facility in February 2023, and tested positive for COVID-19 infection on 2/27/23. Resident #2, who resided on Unit B, was admitted to the facility in January 2023, and was negative for COVID-19 infection. During an observation on 3/1/23 at 10:40 A.M., the surveyor observed that two Precaution Signs were posted outside of Resident #1 and Resident #2's rooms which indicated the following: -Special Contact and Droplet Precautions -Enhanced Barrier Precautions. A PPE bin containing N95 masks, gloves, gowns and disinfectant wipes and a black covered bin were observed between these two room which were adjacent to each other. During an observation on 3/1/23 at 10:42 A.M., the surveyor observed Activity Staff #1 exit Resident #1's (COVID-19 positive) room with a clear bag containing a gown, which she placed in the black covered bin outside of the room. Activity Staff #1 did not doff her N95 mask nor disinfect her face shield which remained in place after exiting the room. During an interview after the observation, Activity Staff #1 said that prior to entering Resident #1's room, she would don (put on) a gown and gloves, and that she would already have her N95 mask and face shield in place. She said that prior to exiting Resident #1's room, she would remove her gloves and gown place them in a clear bag and discard the bag into the black bin outside of the room. She further said that she was told that she did not have to remove her N95 mask or face shield upon exiting the resident rooms. Activity Staff #1 said that she would do this process for all residents because they were all on Droplet Precautions, and that she did not have to change her N95 mask or face shield because she was not providing direct resident care. During an observation on 3/1/23 at 10:47 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 enter Resident #1's room (COVID-19 positive), with an N95 mask, face shield, gown and gloves in place to answer a call light. Shortly after entering the room, CNA #1 exited the room with a clear bag containing a gown which she placed in the black bin, conducted hand hygiene but did not remove her N95 mask or eye protection. During an interview after exiting the room, CNA #1 said that gown, gloves, an N95 mask and eye protection were required prior to entering resident rooms. She said that prior to assisting Resident #1 with care, she needed to ask therapy a question so she had to go into Resident #2's room (COVID-19 negative) where therapy was located. CNA #1 was observed to put on a new gown, gloves and enter Resident #2's room and close the door. She did not remove her N95 mask or remove/disinfect her eye protection prior to entering Resident #2's room. At 10:53 A.M., CNA #1 exited Resident #2's room with a clear bag containing the gown, disposed the bag in the black bin outside of the room, conducted hand hygiene, donned a gown and gloves and re-entered Resident #1's room and closed the room door. During an observation on 3/1/23 at 11:00 A.M., Nurse #2 was observed to place a Contact Precautions Plus Airborne Precaution sign outside of Resident #1's room (which already contained signage indicating Enhanced Barrier Precautions and Special Contact and Droplet Precautions in place). During an interview at this time, Nurse #2 said that Resident #1's roommate just tested positive for COVID-19 infection about 10 minutes prior. She said that an N95 mask, gown, gloves and eye protection were required to be put on prior to entering the resident rooms, and if the resident was COVID-19 positive. She further said that prior to exiting the room, the staff would need to remove the gown, gloves, dispose in the black bin and then remove the N95 mask and disinfect the eye protection. Nurse #2 said that if the resident was not COVID-19 positive, only the gown and gloves would need to be removed. When the surveyor asked how facility staff were aware of which residents were COVID-19 positive since all had either Droplet or Airborne Precaution signage in place, Nurse #2 said that a verbal report was given to staff prior to the shift and that prior to entering resident rooms, the staff should be checking in with the Nurse. Nurse #2 further said that disinfectant wipes were located in the PPE bins and in the nursing medication carts for staff to utilize. During an observation on 3/1/23 at 11:02 A.M., the surveyor observed CNA #1 exit Resident #1's room with a clear bag containing the gown which was placed in the black bin. During an interview at this time, the surveyor asked what should occur when exiting Resident #1's room. CNA #1 said that upon exiting Resident #1's room, she should change her N95 mask and clean (disinfect) her face shield. CNA #1 said that she did not change her N95 mask or disinfect her eye protection after exiting Resident #1 (COVID-19 positive)'s room previously and should have prior to entering Resident #2 (COVID-19 negative)'s room. 2. Review of the resident COVID-19 status list, updated 3/1/23, indicated the facility had the following on Unit A: -18 COVID-19 positive residents, -9 recovered residents, and -3 negative residents Resident #4, who resided on Unit A, was admitted to the facility in January 2020, and tested positive for COVID-19 infection on 2/25/23. Resident #5, who resided on Unit A, was admitted to the facility in March 2022, and tested positive for COVID-19 infection on 2/21/23. Resident #6, who resided on Unit A, was admitted to the facility in March 2022, and tested positive for COVID-19 infection on 2/23/23. During an observation on 3/1/23 at 11:33 A.M., the surveyor observed Airborne Precaution signage was posted outside of Resident #4's room. Nurse #1 was observed to have a face shield, N95 mask, gown and gloves in place prior to entering Resident #4's room. Shortly after, Nurse #1 exited Resident #4's room with the removed gown in a clear bag which was placed in a bin outside of the room. Nurse #1 conducted hand hygiene but did not remove her N95 mask nor remove or disinfect her face shield after exiting the room. During an observation on 3/1/23 at 11:36 A.M., the surveyor observed Nurse #1 enter Resident #5 and Resident #6's room with an N95 mask, face shield, gown and gloves in place. The surveyor observed Special Contact and Droplet Precaution signage posted outside of Resident's #5 and #6's room. At 11:57 A.M., Nurse #1 exited Resident #5 and #6's room with the removed gown in a clear bag which was placed in a bin outside of the room. She conducted hand hygiene but did not remove her N95 mask or eye protection and returned to the medication cart. At 11:59 A.M., the surveyor observed Nurse #1 remove her face shield, place it on top of the medication cart and clean the inside and outside of the face shield with blue top container labeled PDI Sani-hands (hand cleansing wipes). During an interview, Nurse #1 said that an N95 mask, gown, gloves and eye protection are required prior to entering resident rooms. She said upon leaving the room, gloves and gown are removed, discarded in a clear bag and placed in designated bin and hand hygiene is conducted. Nurse #1 said that she would clean the face shield with PDI Sani-hands, but that her N95 mask did not need to be changed between residents and that it was to be kept on at all times. Nurse #1 said that Unit A had a mixture of COVID-19 positive, recovered and negative residents and that she monitored the COVID-19 positive residents first relative to temperature, heart rate, respirations with the vitals machine and then would monitor the negative residents after. She further said that vitals machine would be wiped down with the PDI Sani-hands which was located in a basket on the machine. During an interview on 3/1/23 at 11:41 A.M., CNA #3 said that upon exiting a resident room, the gown and gloves would be removed, hand hygiene conducted and then her N95 mask would need to be removed. and replaced. CNA #3 said that the face shield would need to be cleaned with the blue top PDI Sani-hands prior to entering another resident room. On 3/1/23 at 11:54 A.M., the surveyor observed CNA #2 exit a resident room. CNA #2 was observed to remove her eye protection and utilize the PDI Sani-hands which was located on the PPE bin outside of the room she exited. During an interview, CNA #2 said that eye protection should be cleaned with PDI Sani-hands or Cavi-Wipes upon exiting the resident rooms. When the surveyor asked if she was aware of which resident rooms were COVID-19 positive on the unit, CNA #2 said she did not know. During an interview on 12:32 P.M., the DON said that upon exiting a COVID-19 positive resident room, all PPE should be removed and hand hygiene conducted. A new N95 mask should be donned and the face shield should be disinfected with Cavi-wipes or bleach wipes. She said that PDI Sani-hand wipes should not be used to disinfect eye protection. She further said that regardless of whether the signage on the resident rooms indicated Contact Plus Airborne Precautions or Contact and Droplet Precautions, facility staff would follow the same instruction to don N95 mask, eye protection, gown and gloves prior to room entry and doff gloves, gown and N95 mask upon room exit, conduct hand hygiene, donn a new N95 mask and disinfect the eye protection with the appropriate disinfectant wipes. During an interview on 3/1/23 at 3:44 P.M., the Infection Preventionist (IP) said that the facility was following MA DPH guidance on PPE requirements. She said that the guidance was confusing because it indicated that N95 masks needed to be removed after exiting a COVID-19 positive resident room, but did not indicate that eye protection needed to be removed or disinfected. She further said that once the resident COVID-19 positive cases increased in the facility, all residents, regardless of COVID-19 status, were placed on Contact and Droplet Precautions so an N95 mask, gown, gloves and eye protection were to be worn with all resident interactions.

Based on observation, record review, and interview, the facility failed to ensure COVID-19 testing for staff was done in in a timely manner, to prevent the spread of infection, during a COVID-19 outbreak at the facility. Specifically, the facility staff failed to conduct outbreak testing every 48 hours for one staff member (Laundry Personnel #1), out of three sampled staff members. Findings include: Review of the Massachusetts Department of Public Health Memorandum, dated October 13, 2022, Appendix B indicated the following: -If the facility identifies one new resident or staff case then the facility should take the following steps to mitigate any further transmission. -Testing exposed staff and residents on the affected units must take place as soon as possible. -If the long-term care facility identifies that the resident or staff member's first exposure occurred less than 24 hours ago then they should wait to test until, but not earlier than, 24 hours after any exposure, if known. Review of the facility policy for Infection Control Policies and Procedures, last reviewed 12/7/22, indicated that health care personnel will be tested according to CMS (Centers for Medicare and Medicaid Services) state department of public health requirements and guidance. During an interview on 3/1/23 at 10:47 A.M., the Infection Preventionist (IP) said that the facility is conducting testing every other day and that the staff must test on the day that they return to work if they have been off or on vacation. She said that the facility had been in outbreak testing since 2/17/23. Review of the COVID-19 staff testing logs and schedules for 2/12/23 to 2/25/23 indicated that Laundry Personnel #1 had returned to work after being off for two days and worked on 2/20/23, 2/21/23 and 2/22/23. He/she had not been tested for COVID-19 until 2/22/23, three days after he/she should have initially been tested . During an interview on 3/1/23 at 3:15 P.M., the IP said that the staff member should have been tested when he/she returned to work and should have been tested every other day, which he/she was not.

Based on interview, record review, and policy review, the facility and its staff failed to ensure a Notice of Transfer and Discharge, including the reasons for transfer/discharge to the hospital, was provided in writing to the Resident and/or the Resident's Representative for three Residents (#69, #36 and #59), out of a total of 18 sampled residents. Specifically, the facility did not provide a Notice of Transfer and Discharge for residents on a medical leave of absence. Findings Include: Review of the facility policy titled Discharge and Transfer, revised 2/1/19, indicated the following: For patients transferred to a hospital: -For unplanned, acute transfers where it is planned for the patient to return to the Center, the patient and/or resident representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or state specific transfer form. 1. Resident #69 was admitted to the facility in May 2022. Review of the Skilled Nursing Facility/Nursing Facility to Hospital Transfer Form dated 7/21/22 indicated Resident #69 was transferred to the hospital on 7/21/22. Further review of the Resident's medical record indicated no documentation that a written Notice of Transfer and Discharge had been provided to the Resident and/or Resident's Representative at the time of discharge. During an interview on 9/12/22 at 11:09 A.M., the Social Worker said she did not provide a written Notice of Transfer and Discharge to Resident #69 and/or the Resident's Representative when the Resident was transferred to the hospital as required. 2. Resident #36 was admitted to the facility in April 2022. Review of the Resident's clinical record included a progress note that indicated the Resident was transferred to the hospital on 6/1/22 for a medical leave of absence. During an interview on 9/13/22 at 9:05 A.M., the Unit Manager (UM) said transfer/discharge notifications are not completed when a resident goes out on a medical leave of absence, only when they are discharged from the facility. She further said Resident #36 and/or his/her Representative did not receive a notice of transfer or discharge as required. 3. Resident #59 was admitted to the facility in July 2022. Review of the Resident's clinical record included a progress note that indicated the Resident was transferred to the hospital on 9/3/22 for a medical leave of absence. During an interview on 9/13/22 at 2:25 P.M., The Unit Manager said neither the Resident and/or his/her Representative received a notice of transfer or discharge as required.

Based on observations, interviews and record review, the facility staff failed to ensure that its staff provided respiratory care and services consistent with professional standards for four Residents (#36, #45, #60 and #69) out of a total of 18 sampled residents. Specifically, a) Failing to store and maintain respiratory equipment in a manner to prevent contamination and airway infection for (Residents #36, #45 and #60), and b) Failing to ensure a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. Resident #36 was admitted to the facility in April 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of the Resident's room on 9/8/22 at 8:25 A.M., the surveyor observed an oxygen concentrator (a device that takes in air and filters it into purified oxygen) running at 2.5 liters per minute (LPM) with the nasal cannula (a lightweight tube used to deliver supplemental oxygen in which one end splits into two prongs to be inserted into one's nostrils and one end which connects to the oxygen concentrator) tubing resting, unbagged, on top of the oxygen concentrator. During an observation on 9/9/22 at 1:28 P.M., the surveyor observed a wheelchair in the Resident's room with a portable oxygen concentrator hanging off of the wheelchair handle and an unbagged nasal cannula draped over the wheelchair back. During an interview on 9/09/22 at 1:46 P.M., the Unit Manager (UM) said all oxygen tubing should be contained in a bag when not in use. 2. Resident #45 was admitted to the facility in October 2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the September 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Clean external filter on oxygen concentrator every 7 days and as needed, initiated 2/1/22 During an observation and interview on 9/08/22 at 8:33 A.M., the surveyor observed the Resident wearing a nasal cannula connected to an oxygen concentrator running at 2.5 LPM. The Resident said he/she wears Oxygen all the time. The surveyor observed the concentrator to be covered in white particles, the area beneath the humidifier bottle (attaches to an oxygen concentrator to moisten the inhaled Oxygen) and the filter on the back of the concentrator to be completely dust laden. There was an additional nasal cannula draped over back of the Resident's wheelchair with the connecting tube resting against the wheel. During observations on 9/9/22 at 7:21 A.M. and 1:30 P.M., the surveyor observed the Resident in his/her recliner chair utilizing Oxygen being delivered at 2.5 LPM via a nasal cannula attached to an oxygen concentrator. The surveyor observed the concentrator and filter remained dirty and dust laden. During an interview on 9/9/22 at 1:45 P.M., the UM said that staff should have been cleaning the concentrator and filter weekly, however this Resident's concentrator and filter did not appear to be cleaned as required. During an observation and interview on 9/09/22 at 2:06 P.M., the surveyor observed Nurse #6 replacing the Resident's oxygen concentrator. Nurse #6 said it did not appear that the concentrator and filter were cleaned weekly. During an interview on 9/9/22 at 2:44 P.M., upon viewing the surveyor photos of Resident #45's oxygen concentrator, the Corporate Nurse said staff should have been more diligent with cleaning the Resident's oxygen concentrator and filter. 3. Resident #60 was admitted to the facility in January 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the following dates and times the surveyor observed the following: Resident utilizing Oxygen being delivered via a nasal cannula with the oxygen concentrator set at 2 LPM, no associated signage indicating Oxygen was in use outside the Resident's room, and a nebulizer machine (a device used to administer inhaled medication) with the associated tubing and face mask resting face down on his/her nightstand both unbagged and undated. 9/8/22 at 10:53 A.M. 9/9/22 at 7:25 A.M. 9/9/22 at 10:26 A.M. 9/9/22 at 1:35 P.M. During an interview on 9/09/22 at 1:45 P.M., the UM said that the Resident's nebulizer tubing and mask should have been both dated and stored in a bag while not in use and there should have been signage outside the Resident's door indicating Oxygen was in use. 4. For Resident #69, facility staff failed to ensure there were physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #69 was admitted to the facility May 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, created on 5/13/22, titled At Risk for Respiratory Complications Related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Encourage the Resident to keep O2 at 2 LPM .created on 5/24/22 -O2 as ordered via nasal cannula (NC) created on 5/13/22 Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident utilized Oxygen within the last 14 days. During an interview on 9/8/22 at 11:04 A.M., the Surveyor observed the Resident holding oxygen tubing in his/her hand. The Resident said he/she only wore the Oxygen at night and had been using it since his/her admission to the facility. During an interview on 9/12/22 at 8:53 A.M., Nurse #1 said Resident #69 had been utilizing Oxygen since his/her admission to the facility. She further said residents who utilize Oxygen should have orders in their charts for oxygen concentrator filter cleaning and tubing changes weekly. On 9/13/22 at 7:12 A.M., the Surveyor observed Resident #69 in bed sleeping, she had Oxygen on via NC and it was set at 2 LPM. Review of the September 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Clean external filter on oxygen concentrator every night shift every Sunday with a start date of 9/6/22 -Oxygen (O2) at 2 LPM via NC at bedtime (HS) for shortness of breath .with a start date of 9/6/22 Further review of the Resident's medical record indicated no orders prior to the 9/6/22 orders listed above for the care and services of Oxygen. During an interview on 9/12/22 at 12:06 P.M., the Respiratory Therapist said any resident who has Oxygen should have Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/12/22 at 12:10 P.M., the Infection Preventionist said Resident #69 did not have orders for care and services of his/her Oxygen in place prior to 9/6/22 as required.

Based on interview and record review, the facility and its staff failed to monitor for behaviors and side effects on [CONDITION(S)] medications (medications that affect mental processes and behavior) for three Residents (#50, #121 and #17), out of a total of 18 sampled residents. Findings include: Review of the facility policy titled Psychotherapeutic Medication Use, revised 11/28/17 indicated that center staff will monitor the behavior of a patient on psychotherapeutic medication using a behavioral monitoring form per nursing policy. 1. Resident #50 was admitted to the facility in July 2022 with diagnoses including Depression and Anxiety. Review of the nursing care plan dated 7/22/22 indicated the Resident was at risk for complications related to the use of [CONDITION(S)] drugs and that a behavior monitoring flow sheet should be completed, the Resident should be monitored for changes in mental status and for side effects and the Physician should be consulted as needed. Review of the September 2022 Physician's Orders indicated the following: [MEDICATION(S)] (a medication used to treat anxiety) for anxiety, initiated 8/24/22. [MEDICATION(S)] (a medication used to treat depression) for depression, initiated 7/22/22. Is Resident behavior free? If behavior present, document behavior, interventions and outcomes in nurses notes every shift, initiated 9/11/22 Is Resident free from side effects of psychotherapeutic medications? If no, document side effects in progress notes every shift, initiated 9/11/22 Review of the July, August, and September 2022 Medication Administration Records (MAR) indicated Resident #50 had received [MEDICATION(S)] daily, as ordered, since admission, and that the Resident had received [MEDICATION(S)] as ordered from 8/24/22 through present. Review of the medical record indicated no documented evidence that the Resident had been monitored for behaviors or side effects of the [CONDITION(S)] medications until the monitoring orders were initiated during the survey. During an interview on 9/12/22 at 4:38 P.M., the Unit Manager reviewed Resident #50's EMR and said residents on [CONDITION(S)] medications should be monitored every shift for behaviors and side effects and Resident #50 was not monitored as required. 2. Resident #121 was admitted to the facility in September 2022 with the following diagnoses: Depression and [CONDITION(S)] (difficulty sleeping). Review of the September 2022 Physician's Orders indicated the following: [MEDICATION(S)] (a medication used to treat depression, anxiety, and sleep disorders), initiated 9/2/22 [MEDICATION(S)] ([MEDICATION(S)]: a medication used to treat depression and panic disorders), initiated 9/3/22 [MEDICATION(S)] (a medication to treat depression), initiated 9/2/22 [MEDICATION(S)] (a medication to treat anxiety), initiated 9/2/22 Behavior monitoring every shift ordered, initiated 9/11/22 Psychotherapeutic medication side effects monitoring every shift, ordered 9/11/22 Review of the nursing care plan initiated 9/2/22 indicated the Resident was at risk for or was experiencing adjustment issues related depression and his/her mood state and behavior should be evaluated. Review of the September 2022 MAR indicated: -Resident #121 received [MEDICATION(S)] on 11 of 11 opportunities. -[MEDICATION(S)] on 9 of 11 opportunities. -[MEDICATION(S)] on 4 of 4 opportunities, and as needed. -[MEDICATION(S)] on four occasions. -[MEDICATION(S)] as needed, once. The September MAR also indicated that the Resident was not monitored for behaviors and side effects until 9/11/22 when the order was entered during the survey. During an interview on 9/13/22 at 2:26 P.M., UM #1 said that Resident #121 was on [CONDITION(S)] medications and should have been monitored for behaviors and side effects. She further said the care plan and monitoring for behaviors and side effects for the use of psychotropics should have been initiated upon Resident #121's admission, and that was not completed as required. 3. For Resident #17 the facility and its staff failed to monitor the use of [MEDICATION(S)] (an antipsychotic medication) for potential adverse consequences. Resident #17 was admitted to the facility in December 2021 with a diagnosis of Dementia with Behavioral Disturbance. Review of the September 2022 Physician's Orders indicated the following order: -[MEDICATION(S)] Tablet 25 milligrams (mg) give one tablet by mouth two times a day .with a start date of 3/8/22 -Is resident free from side effects of psychotherapeutic medications? (If no, document side effects) every shift with a start date of 9/10/22 Review of the September 2022 Medication Administration Record (MAR) indicated Resident #17 received [MEDICATION(S)] as ordered from 9/1/22 through 9/9/22. Further review of the MAR indicated no documentation that prior to 9/10/22 the Resident was being monitored for potential adverse consequences from his/her [MEDICATION(S)] use. During an interview on 9/12/22 at 12:12 P.M., the Infection Preventionist said there should have been an order in place when the Resident started taking [MEDICATION(S)] to monitor for adverse side effects and there was no documentation prior to 9/10/22 to indicate the Resident was being monitored for adverse side effects, as required.

Based on record review, observations and staff interviews, the facility failed to follow the resident's plan of care relative to fall interventions and utilizing arm/leg protectors, for 3 residents (#1, #6 and #14), out of a total of 15 sampled residents. Findings include: 1. For Resident #14, the facility failed to follow the resident's falls plan of care relative to: eyeglasses were not being utilized, environment was not clutter free, walker was not within reach/being utilized, alarms did not activate and Orthostatic Blood Pressures (BP's) were not taken, as planned. Resident #14 was admitted to the facility in 1/2015. Review of the falls care plan of 1/12/15 indicated the following interventions: eyeglasses within reach/encourage use, verbal cues for safety when needed and remind resident to use call light when attempting to ambulate or transfer. Review of the 1/26/15 Progress Note indicated the resident experienced an unwitnessed fall. Action taken after the fall included: non-skid footwear, uncluttered environment, chair alarm and bed alarm. Review of the 2/15/15 Progress Note indicated the resident experienced an unwitnessed fall, sustaining skin tears to the right forearm measuring 7.9 cm. (centimeters) by 3 cm., right upper back measuring 10 cm. by 1 cm., right inner wrist measuring 3.2 cm. by 0.9 cm. and an abrasion on the upper left back area and the lower right back area. During an interview with the Assistant Director of Nursing (ADON) (on 9/2/15 at 3:40 P.M.), she said that the resident did not have her/his eyeglasses on and the environment was not clutter free, as planned. Review of the 3/1/15 Progress Note indicated the resident experienced a fall, sustaining a chin laceration (requiring steri-strips) and a tooth fracture. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident did not have her/his eyeglasses on, as planned. Review of the 3/2/15 Progress Note indicated the resident experienced an unwitnessed fall, sustaining a laceration to the middle of the head, requiring 4 staples to close the wound. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident did not have her/his eyeglasses on, the chair alarm did not activate, the environment was not clutter free (tripped on sheet) and the resident's walker was not being utilized, as planned. The falls care plan was updated to include an environmental review. Review of the 3/14/15 Progress Note indicated the resident experienced a fall, sustaining a laceration to the temporal area, requiring 4 staples to close the wound. The resident also sustained a right elbow skin tear measuring 1.5 cm. and an abrasion to the right outer knee. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident did not have her/his eyeglasses on, as planned. Review of the 3/17/15 Progress Note indicated the resident experienced an unwitnessed fall, sustaining a fractured wrist, a laceration above the eye (steri-strips applied) and a laceration to the thumb. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the chair alarm did not activate, as planned. Corrective action noted on the investigation included: Orthostatic BP's every shift, for 3 days. Review of the Orthostatic BP's planned for every shift, for 3 days, after the 3/17/15 fall, indicated the following: On 3/17/15 and 3/18/15 - BP was not taken on the 3:00 P.M. to 11:00 P.M. shifts, On 3/19/15 - BP was not taken on the 7:00 A.M. to 3:00 P.M. shift and on the 3:00 P.M. to 11:00 P.M. shift, and On 3/20/15 - BP was not taken on the 11:00 P.M. to 7:00 A.M. shift and on the 7:00 A.M. to 3:00 P.M. shift, as planned. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident experienced an unwitnessed fall on 6/26/15, sustaining a laceration requiring 4 staples to the scalp and 26 staples to her/his right knee to close the wounds (measuring 6.5 inches). The ADON said the resident's alarm did not activate, (disarmed by resident), as planned, and that her/his eye glasses were not on at the time of the fall, as planned. The falls care plan was updated to include: wall sensor alarm, wireless alarm system and assist resident getting in and out of bed. Review of the 8/1/15 Progress Note indicated the resident experienced an unwitnessed fall, re-opening the knee laceration (sustained on 6/26/15 which required 26 staples) and required additional steri-strips. During an interview with the ADON on 9/2/15 at 3:40 P.M., she said the resident did not have her/his eye glasses on, at the time of the fall, as planned. During an interview with the ADON on 9/2/15 at 3:40 P.M., it was discussed that the facility failed to follow the resident's plan of care relative to falls interventions to ensure the resident's safety. Please refer to F323, Example #1. 2. For Resident #6, the facility failed to ensure the written plan of care/physician's orders [REDACTED]. Resident #6 was admitted to the Facility in 4/2015 after sustaining a fall with a fractured wrist at home. The residents pertinent [DIAGNOSES REDACTED]. Review of the 4/17/15 (to current date 9/3/15) physician's orders [REDACTED].#6 to wear non-skid footwear for safety. The initial Minimum Data Set (MDS) assessment, dated 4/23/15, indicated that the resident had severe cognitive impairment (indicated by a Brief Interview for Mental Status score of 7 out of 15); received extensive assist from staff for bed mobility, transfers, did not ambulate, had balance problems, falls with an injury (fracture), and received antianxiety and antidepressant medications. Review of the 4/2015 (and revised on 8/24/15) at risk for falls care plan indicated the following interventions: - Assess restlessness, has RLS. If staff notes legs are moving in bed, alert the nurse for further care needs and reposition as needed for safety (created 7/19/15). - Family to provide comfort light (initiated 8/2/15) - Non-skid socks when out of bed (initiated 8/24/15. However, the physician's orders [REDACTED]. - Motion alarm on when in bed. According to the clinical record and risk management reports, Resident #6 had been found on the floor in his/her bedroom [ROOM NUMBER]/25/15, 5/5/15, 5/13/15, 5/25/15, 7/7/15, 7/17/15, 7/18/15, 7/23/15 and 8/2/15. Through family involvement/input, the facility determined that Resident #6 places self on the floor and according to the Resident's Health Care Proxy (HCP), the resident has done this for [AGE] years. Review of the care plan for at risk behaviors and a safety hazard to self and others evidenced by sleeping on the floor (created 5/26/15) indicated a low bed with mats on the floor would be implemented and to make resident comfortable on the floor with pillow and blanket, recheck resident later and offer return to bed. Review of a nursing progress note and risk management report indicated the resident had an unwitnessed fall, and was found behind the door in the resident's room on 8/24/15. The report indicated that Resident #6 was self-ambulating, and had not been wearing non-skid footwear at the time of the fall, when out of bed, and in accordance with the physician's orders [REDACTED]. On 8/31/15 at 9:45 A.M., the surveyor observed Resident #6 sitting on the edge of his/her bed. The resident was wearing white, cotton socks, and was not wearing non-skid footwear, as ordered/planned. On 8/31/15 at 11:15 A.M., the surveyor observed Resident #6 lying across the bed sideways. The resident's knees were flexed, and his/her feet were bare. The resident was wearing long, red with white printed cotton pants. The legs to the pants were gathered under the heels of the resident's bare feet. The room was dark and the lights were off. The Resident was not wearing non-skid footwear, and there was no comfort light observed in or around the resident's room, as planned. On 8/31/15 from 1:15 P.M. - 1:30 P.M., the surveyor observed Resident #6 lying in a low bed sideways, with knees flexed and bare feet flat on a fall mat. The resident was not wearing non-skid footwear, as planned. The motion sensor was sounding. Nursing and Rehabilitation staff walked by the room, and no one entered to check on the resident or silence the motion alarm. The room was dark, there were no lights on or a comfort light provided, as planned. On 8/31/15 from 3:20 P.M. - 3:30 P.M., the surveyor observed Resident #6 lying in a low bed, with his/her head toward bottom of the bed. The resident's feet and legs were bare as he/she extended both legs up and out in front, then raised them up, one at a time, into the air toward the ceiling. The resident was not wearing non-skid socks, as ordered. Staff walked past the resident's room, and past the surveyor who had been observing Resident #6. No staff were observed entering the resident's room to check on the resident who was observed lying in an unsafe position, therefore, Nurses were not alerted to reposition the resident or check on care needs, as planned when restless. The room was dark, there was no comfort light on, as planned. On 9/1/15 at 4:00 P.M., the surveyor observed the resident in bed. The resident was crooked in bed, and his/her head was towards the foot of the bed. The resident's legs and feet were bare, as the resident flexed and stretched legs in front, then one at a time lifted each leg up periodically. The resident was talking to him/herself. The resident crossed then uncrossed his/her legs, and was restless. The resident was not wearing non-skid footwear, as ordered. The room was darkened, and there was no comfort light on, as planned. On 9/2/15 at 8:00 A.M., the surveyor observed Resident #6 sitting on the edge of the bed with bare feet. The resident kicked out his/her legs intermittently. Then placed them flat on the floor mat. The room was dark. The resident was not wearing non-skid footwear, as ordered. There was no comfort light on, as planned. Certified Nursing Assistant (CNA) #1 was walking out of the adjacent room, and walked past Resident #6's room. During interview on 9/2/15 at 8:05 A.M., CNA #1 said that she was assigned to Resident #6 today. CNA #1 said that the resident required extensive assist for bathing and dressing, and now required increased assistance for transfers and ambulation related to a gout flare-up. CNA #1 said that Resident #6 has behaviors, such as, standing on the side of the bed to urinate on the floor, even though the resident is asked to wait for assistance, and that the resident will sit him/herself on the floor, as the cold floor provides relief from pain and restless legs. During interview on 9/3/15 at 10:30 A.M., the Director of Nursing (DON) said that the plan of care had not been followed consistently for the resident to wear non-skid footwear, and for staff to alert nursing when the resident is restless to reposition, and assess for care needs (such as pain management etc.). The DON said that the comfort light was a night light the resident used at home. The DON said that she will follow-up with the resident's family to ensure it is brought in, as planned. 3. For Resident #1, the facility failed to ensure the resident wore protective covering/sleeves on both arms and legs. Resident #1 was admitted to the facility in 12/2014. The resident's [DIAGNOSES REDACTED]. Review of a nursing progress note, dated 12/27/14, indicated the resident sustained [REDACTED]. Review of a nursing progress note, dated 1/18/15 indicated the resident had bruising and pain to the top of the left foot, and an x-ray was obtained with negative findings. Review of a nursing progress note, dated 2/1/15, indicated the resident was found to have a bruise on the right shin and had complained of pain when the bruise was touched. Review of the 5/14/15 nursing progress note indicated that the resident was found to have a skin tear on the left lower leg. Review of the 5/24/15 nursing progress note indicated that the Resident was found with bruises on the left arm. Review of a risk management report indicated that the resident is resistant and pulls away when being toileting, transferring and ambulating, and that staff should re-approach when resistant to care and provide two assist for transfers. Review of a 7/11/15 nursing progress note indicated that the resident was found to have a bruise measuring 5.8 centimeters (cm) x 4 cm on the lower shin, and a bruise on the forearm, measuring 15 cm x 7 cm. Review of the risk management report indicated that the resident is restless, attempts to move w/c within his/her location, but unable to safely navigate around obstacles, other residents or furniture, skin is very fragile and is at risk for injury, therefore protective garment/sleeves would be provided for both legs and arms. Review of the 7/12/15 physician's orders [REDACTED]. On 8/31/15 at 12:00 P.M., the surveyor observed Resident #1 sitting in the Main Dining Room with a visitor. The resident was not wearing protective sleeves on bare arms or bare legs, as planned. On 8/31/15 at 2:20 P.M., the surveyor observed Resident #1 sitting in the Unit's Dining Room, leaning to the right, while attempting to apply a slipper that had fallen off the right foot. The resident's was not wearing Derma-savers to the arms or legs, as planned. Review of the 8/2015 Treatment Administration Record (TAR) indicated that Nursing initialed Derma-Savers had been applied on the 7:00 A.M. to 3:00 P.M. shift on 8/31/15, although the surveyor observed that they were not on, as planned. On 9/1/15 at 7:15 A.M., and at 10:15 A.M., the surveyor observed Resident #1 in the the surveyor observed the Resident in the unit's Dining Room. The resident was not wearing Derma-savers on his/her bare arms or bare legs to protect the resident from injury (bruises, skin tears), as planned. During interview on 9/1/15 at 10:20 A.M., CNA #4 said that the Derma-savers were not available, so they were not applied when she got the resident up and dressed at 7:00 A.M. During interview on 9/3/15 at 11:30 A.M., the Director of Nursing said that Resident #1 should always have Derma-savers on, as planned to protect the resident from injury, such as bruises and skin tears.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 2 of 8 applicable residents (#3 and #14), in a total sample of 15 residents. Findings include: 1. For Resident #14, the facility failed to provide adequate supervision and effective interventions to prevent 8 falls (6 of 8 falls were unwitnessed), sustaining multiple injuries (fractured wrist and lacerations requiring staples to close the wounds). Resident #14, with [DIAGNOSES REDACTED]. Review of the falls care plan of 1/12/15 indicated the following interventions: eye glasses within reach/encourage use, medication evaluation as needed, verbal cues for safety when needed, call light within reach, remind resident to use call light when attempting to ambulate or transfer and place personal items within reach when in bed. Review of the Admission Minimum Data Set (MDS) assessment of 1/14/15 identified the resident as exhibiting cognitive impairment; exhibiting verbal behavioral symptoms toward others; utilizing eye glasses; requiring assistance during transfers, being unsteady when moving from a seated to a standing position, when walking and during surface to surface transfers (between bed and chair or wheelchair). Review of the 1/26/15 Progress Note indicated the resident experienced an unwitnessed fall, sustaining an elbow abrasion. Further review indicated action taken after the fall included: non-skid footwear, uncluttered environment, chair alarm and bed alarm (in place). Review of the 2/15/15 Progress Note indicated the resident experienced an unwitnessed fall, sustaining skin tears to the right forearm measuring 7.9 cm. (centimeters) by 3 cm., right upper back measuring 10 cm. by 1 cm., right inner wrist measuring 3.2 cm. by 0.9 cm. and an abrasion on the upper left back area and lower right back area. During an interview with the Assistant Director of Nursing (ADON) (on 9/2/15 at 3:40 P.M.), she said that the resident did not have her/his eyeglasses on, as planned, and the environment was not clutter free, as planned. Corrective action noted on the investigation included: staff to assist resident in daily cleaning of bedside area and cue the resident regarding safety. The falls care plan was updated to include: Orthostatic Blood Pressure (BP) review with Physician, medication review and Physical Therapy (PT) screen. Review of the 3/1/15 Progress Note indicated the resident experienced a fall, sustaining a chin laceration (requiring steri-strips) and a tooth fracture. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident did not have her/his eyeglasses on, as planned. She further said that although the resident was ambulating with staff, a gait belt was not in use, at the time of the fall, (despite the resident's gait being unsteady). Corrective action noted on the investigation included: family notified regarding clothing needs (tripped on pant leg when resident fell ), Orthostatic BP review and review with Physician. Review of the 3/2/15 Progress Note indicated the resident experienced an unwitnessed fall, sustaining a laceration to the middle of the head, requiring 4 staples to close the wound. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident did not have her/his eyeglasses on, the chair alarm did not activate, the environment was not clutter free (tripped on sheet) and the resident's walker was not being utilized, as planned. She further said the resident had a history of [REDACTED]. Corrective action noted on the investigation included: Psychiatric (Psych.) consult and therapy screen. The falls care plan was updated to include: environmental review and neuro (neurological) checks. Review of the 3/14/15 Progress Note indicated the resident experienced a fall, sustaining a laceration to the temporal area, requiring 4 staples to close the wound. The resident also sustained a right elbow skin tear measuring 1.5 cm. and an abrasion to the right outer knee. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident did not have her/his eyeglasses on, as planned. The ADON further said the resident was anxious and agitated, prior to the fall, and had been unable to focus on more than what she/he was fixated on. Corrective action noted on the investigation included: meeting with the Physician/Nurse Practitioner (NP), lab work ordered and set up appointment with Neurologist. The falls care plan was updated to include: neuro checks and supervision/redirection while ambulating in the hall. Review of the 3/17/15 Progress Note indicated the resident experienced an unwitnessed fall, sustaining a fractured wrist, a laceration above the eye (steri-strips applied) and a laceration to the thumb. During an interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident was confused at the time of the fall, increasingly anxious and that the chair alarm did not activate, as planned. Corrective action noted on the investigation included: lab work pending, medication review, dietary review and Orthostatic BP's every shift, for 3 days. The falls care plan was updated to include: attempt to refocus resident past obsession in order to maintain safety and Psych. consult (behavior review). Review of the Orthostatic BP's planned for every shift, for 3 days, after the 3/17/15 fall, indicated the following: On 3/17/15 and 3/18/15 - BP was not taken on the 3:00 P.M. to 11:00 P.M. shifts, On 3/19/15 - BP was not taken on the 7:00 A.M. to 3:00 P.M. shift and on the 3:00 P.M. to 11:00 P.M. shift and On 3/20/15 - BP was not taken on the 11:00 P.M. to 7:00 A.M. shift and on the 7:00 A.M. to 3:00 P.M. shift, as planned. Review of the 3/20/15 Progress Note indicated the resident was admitted to the hospital secondary to abnormal labs and abnormal EKG (electrocardiogram). Review of the Change in Status MDS assessment of 4/10/15 remained essentially unchanged except to identify that the resident no longer exhibited cognitive impairment; exhibited inattention/ disorganized thinking and required assistance during ambulation. Review of the Care Area Assessment (CAA) of 4/21/15 indicated the resident continued to be at risk for falling secondary to impaired cognition/communication, impaired strength, impaired gait, impaired coordination, daily use of psychotropic medications and impaired functional mobility. Review of the 6/26/15 Progress Note indicated the resident had a new onset/change in skin integrity as evidenced by a skin tear on the right knee. The note further indicated the resident was transferred to the Emergency Department. During interview with the ADON (on 9/2/15 at 3:40 P.M.), she said the resident experienced an unwitnessed fall on 6/26/15, sustaining a laceration requiring 4 staples to the scalp and 26 staples to her/his right knee to close the wounds (measuring 6.5 inches). She further said the clinical record was incomplete and did not indicate the resident's fall. The ADON said the resident's alarm did not activate as planned (disarmed by resident) and that her/his eye glasses were not on, at the time of the fall, as planned. She said the resident was confused and was not able to focus. Corrective action noted on the investigation included: maintenance to review plumbing, consistent staff and Psych. consult. The falls care plan was updated to include: wall sensor alarm, wireless alarm system and assist resident getting in and out of bed. Review of the quarterly MDS assessment of 7/8/15 remained essentially unchanged from the previous assessment. Review of the 8/1/15 Progress Note indicated the resident experienced an unwitnessed fall, re-opening the knee laceration (sustained on 6/26/15 which required 26 staples) and required additional steri-strips. During an interview with the ADON on 9/2/15 at 3:40 P.M., she said the resident did not have her/his eye glasses on, at the time of the fall, as planned, and the resident continued to exhibit poor safety awareness. The falls care plan was updated to include: cue/assist resident with toileting. During further interview with the ADON on 9/2/15 at 3:40 P.M., she said the facility was aware that the resident exhibited severe OCD with increased behaviors, was very impulsive and had a history of [REDACTED]. She further said the resident should have been receiving increased supervision in order to prevent continued falls. During an interview with the Director of Nursing (DON) on 9/3/15 at 9:40 A.M., a discussion was held that despite the facility implementing interventions, securing Psych. consults for therapy/medication recommendations and several Physician/Nurse Practitioner visits, the resident continued to fall sustaining injury. It was further discussed that the facility failed to provide adequate supervision to prevent falls for this resident and effective interventions. The resident experienced 8 falls, requiring 38 staples, in total, to close her/his wounds, along with sustaining a fracture. 2. For Resident #3, the Facility failed to ensure adequate supervision and effective interventions to prevent accidents/falls (3 falls on 4/26/15 and 1 fall on 8/30/15) with no injury. Resident #3 was admitted to the facility in 4/2015. The resident's [DIAGNOSES REDACTED]. Review of the 4/23/15 Initial MDS assessment indicated that Resident #3 had cognitive and memory impairments; had wandering behaviors; required extensive assist with transfers and ambulation; was not steady transitioning from one surface to another or turning around and was only able to stabilize with staff assistance, utilized a walker and wheelchair (w/c); was occasionally incontinent of bladder, had falls prior to being admitted to the facility, and received antianxiety medications. Review of the 4/2015 risk for falls care plan indicated the following interventions: - assist with activities of daily living (ADLs); keep the call light in reach, and utilize a bed/chair alarms. Review of the 4/26/15 change in condition progress note indicated that at 10:30 A.M., Resident #3 was found on the floor next to the w/c in the Foyer/Lobby. The tabs alarm was sounding. The resident was sitting on the floor between the w/c and a straight back chair. Review of the circumstances surrounding the 4/26/15 fall indicated the fall was unwitnessed, staff were alerted by an alarm sounding, but by the time they reached Resident #3, the fall had already occurred. The immediate intervention was to bring the resident back to his/her unit for closer supervision. There were no staff interviews or statements obtained related to this fall. Review of a 4/26/15 change in condition progress note indicated at 12:10 P.M., Resident #3 fell while sitting in the unit's dining room, and the fall was unwitnessed. Review of the circumstances surrounding the 4/26/15 fall at 12:10 P.M. indicated the resident had increased confusion as the day progressed; the resident had been sitting in the dining room, the alarm sounded, but by the time staff responded, the resident was already on the floor, lying on the left side with legs underneath the table. The immediate intervention was to place a reverse wedge cushion on the w/c underneath the resident, and apply a pad alarm. Review of an interview statement, dated 4/26/15, indicated staff heard an alarm, and found the resident on the floor in the Activity Room. According to the staff interview statement, staff were passing trays at the time of the resident's fall. Review of another change in condition progress note, dated 4/26/15, indicated that Resident #3 fell at 8:55 P.M., and the fall was unwitnessed (3 falls in one day, whereby, adequate supervision had not been provided again). Review of the circumstances surrounding the 3rd unwitnessed fall on 4/26/15 indicated the resident had been placed in w/c near the Nursing Desk. The alarm sounded, but by the time staff responded to the alarm, Resident #3 was already on the floor, lying on his/her back. The fall report indicated that close supervision should have been in place, prior to the fall; the fall was unwitnessed; resident had poor safety awareness; was restless; had an infection, was incontinent of loose stool, stood up and fell . There were no staff interview/statements related to this fall. Review of the 7/21/15 Quarterly MDS assessment indicated that the resident had impaired short and long term memory, moderately impaired cognitive abilities, had wandering behaviors 4-6 days, was sometimes understood and sometimes could understand, was depressed, received extensive assist for bed mobility, transfers, ambulation, and had impaired balance problems transitioning from one surface to another or turning, and was only able to stabilize with staff assistance; had pain and received pain medication, had no falls since the last assessment (last assessment was a medicare MDS); received antipsychotic, antianxiety, antidepressant medications in the last 7 days. Review of a change in condition progress note, dated 8/30/15, indicated Resident #3 had a fall. Review of the circumstances surrounding the 8/30/15 fall indicated at 6:00 P.M., the alarm sounded, but by the time staff responded to the alarm, the resident was on the floor. The fall report indicated the resident was in the Activity Room, was attempting to transfer from the w/c into a stationary chair, alone, without assistance, and fell . The fall was unwitnessed. The resident was identified as being restless, with poor safety awareness, was confused and was wandering. Review of a staff's interview statement, dated 8/30/15, indicated this staff member was walking by the dining room after dinner, and found the resident on the floor. On 8/31/15 at 8:00 A.M., the surveyor observed Resident #3 sitting in a w/c in the unit's dining/activity room. Resident #3 had an alarm device on the back handle of the w/c. Staff walked past the dining room area, getting other residents ready for breakfast. There was no direct or distant supervision in the dining room area. On 9/1/15 at 8:15 A.M., the surveyor observed Resident #3 self propelling in the w/c around the unit's dining/activity room. There were no staff members present in the dining room, as breakfast trays were being passed. During interview on 9/3/15 at 10:30 A.M., the Director of Nursing (DON) said that alarms were utilized to alert staff the resident was attempting to get up/move. The DON said that adequate supervision and effective interventions were not provided to prevent 4 of the 4 falls, 3 on 4/26/15 or the last fall on 8/30/15.

Based on record review, interview, and observation, for one of three sampled residents (Resident #1), the Facility failed to ensure the mechanical lift sling was correctly attached when on 12/7/13, Certified Nurse Aide (CNA) #1 and CNA #2 transferred Resident #1 in the mechanical lift, he/she fell out of the sling and sustained a fracture of the left tibia and fibula. The Findings include: Resident #1 was admitted to the Facility in November, 2008 with [DIAGNOSES REDACTED]. The Nursing Assessment, dated 11/14/13, indicated Resident #1 was at risk for falling and used a mechanical lift for transferring. The assessment indicated Resident #1 did not ambulate and exhibited contractures of the shoulders. The assessment indicated Resident #1 had poor balance. The quarterly Minimum Data Set (MDS) assessment, dated 11/22/13, indicated Resident #1 was dependent on staff for assistance with transferring. The MDS indicated Resident #1 was severely cognitively impaired. The Activities of Daily Living (ADL) Care Plan, dated 12/3/13, indicated Resident #1 required the assistance of two persons for transfers via a mechanical lift. The Fall Risk Care Plan, dated 12/3/13, indicated Resident #1 was transferred using a mechanical lift, with a split pad ( two separate pieces of material, straps, to go between a resident's legs), and the assistance of two persons. The Change in Condition Note, dated 12/7/13, indicated Nurse #1 was called into Resident #1's room and found Resident #1 lying on the floor, on his/her back, next to the the bed. The note indicated that CNA #1 and CNA #2 said Resident #1 fell from the mechanical lift during a transfer. The physician progress notes [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 on 1/8/14 at 11:00 A.M. CNA #1 said she went to Resident #1's room with CNA #2 in order to transfer Resident #1 to a shower chair. She said they used a mechanical lift sling that was in Resident #1's room and said the sling had plastic clips which were used to hook it to the lift. She said she and CNA #1 placed Resident #1 on the sling and hooked the sling to the lift with the leg straps on the outside of Resident #1's legs. She said she thought that would be alright, but now knew that the straps should have been between resident #1's legs. She said she did not know why they did it the way they did. CNA #1 said she was controlling the lift and CNA #2 was guiding Resident #1 into the shower chair. She said when CNA #2 pushed the handle down to position the sling Resident #1 slipped through the opening in the sling and fell to the floor. CNA #2 was not available for interview. A written statement by CNA #2, dated 12/8/13, indicated that Resident #1 fell from the mechanical lift during a transfer from the bed to a shower chair. The statement indicated the straps of the mechanical lift pad were not under or between Resident #1's legs. The statement indicated CNA #2 questioned CNA #1 on the procedure and CNA #1 told her that it was okay. The Surveyor interviewed the Director of Nurses (DON) on 1/14/14 at 11:00 A.M. The DON said that CNA #2 asked CNA #1 if the straps should go under and between Resident #1's legs and CNA #1 told her they could do it the way they were doing it (with the straps on the outside of Resident #1's legs).The DON said CNA #1 told her that she had a lapse of judgement and CNA #2 told her that she should have stopped CNA #1. She said both CNAs were aware of the correct procedure. During a demonstration of the incident by CNA #1, she said that the sling present at the time of the demonstration was the same type of sling used during the incident. CNA #1 demonstrated that the sling straps were placed on the outside of Resident #1's legs. The Marissa Lift manual indicated that the leg straps are to be placed between a residents legs prior to being attached to the lift. On the day of survey, 1/8/14, at 9:15 A.M. and 10:25 A.M., the Surveyor observed two teams of two CNAs transfer two separate residents on different units with the mechanical lift. The Surveyor noted that the proper procedure was followed and staff was able to verbalize the procedure. The Risk Management report (Incident Report), dated 1/2/14, indicated that on 12/7/13, Resident #1 fell from the mechanical lift due to improper procedure used by staff transferring him/her.

2. For Resident #11, the Facility failed to follow the care plan and/or Physician's orders for functional bed and chair pad alarms, close supervision and assistance for transfers, ambulation and toilet needs, scheduled supervision during wandering, shift changes, and at hallway/restorative dining locations, and for wheelchair anti-tippers and Lap Tray application to prevent 12 falls with injury. Resident #11 was admitted to the facility in 2/11. [DIAGNOSES REDACTED]. . Nurse's Notes of 3/2/11 at 10:30 A.M., 3/4/11 (evening shift), and 4/3/11 at 7:10 P.M. indicated the resident "needed close supervision for safety, and needs reminder to use RW" (Rolling Walker.) Nursing Notes of 4/7/11 on the "7-3 shift" revealed the "pt. (patient) fell in Dining Room." No apparent injury until 4/8/11 at 7:00 A.M. when the resident complained of shoulder pain. There was no evidence of close staff supervision. when the resident was in the dining room. The care plan was updated to now provide: -Bed and chair alarms for safety, -and Ambulate with rolling walker, gait belt and stand by assist. Nursing Notes, Change of Condition Documentation, and Investigation of 5/4/11 at 5:00 P.M. indicated the resident's alarm was sounding, and staff found the resident on the floor, lying on back with feet facing the bedside chair. The resident complained of hip pain and had a small left wrist bruise (dime-size). The care plan was updated to include supervising the resident in restorative dining area from 3:00 P.M. to bedtime. Nursing Notes of 5/18/11 at 2:30 P.M. indicated the resident was ambulating in the bedroom without the walker, became weak, and was lowered to the floor by a CNA (Certified Nursing Assistant). No injury was noted. The resident was referred to Rehabilitation. The care plan was updated to include: -toilet patient every 2-3 hours on each shift to reduce impulsivity related to toileting needs. Nursing Notes, Change of Condition Documentation, and Investigation of 5/23/11 at 2:00 P.M. indicated the resident was ambulating in the hallway with distant supervision (rather than with "close" supervision, or a gait belt and stand-by assist, as care planned). The resident changed direction, but did not change the walker position, and fell . The resident hit his/her upper back and head on the hallway wall. Physical Therapy Notes of 5/26/11 indicated the resident required increased caregiver "dependency/supervision." Nursing Notes, Change of Condition Documentation, and Investigation of 6/19/11 at 11:35 A.M. indicated the resident was alone, quickly stood up from chair in restorative dining area, set off alarm, took a step forward and tripped on the chair, falling face forward. The resident hit his head on the floor, sustaining 2 lacerations (one to the mid-forehead that was irregular, 1 inch wide and 0.1 cm. (centimeter) deep, and one to the upper right eyebrow area that was 1/2 inch wide and 0.1 cm. deep). Steri-strips were applied to the lacerations. There was no evidence the resident was kept in close supervision or provided assist when the resident self-transferred, as planned. The care plan was updated to: -Keep in view of staff-encourage resident to sit in hallway to supervise, -and Anti-tippers on wheelchair to decrease falls. Nursing Notes of 7/15/11 at 2:45 P.M. (near shift change) indicated the resident had an unwitnessed fall in the dining room when the resident got up out of the wheelchair and fell . Staff noted the "chair alarm on later," (delayed in sounding.) There was no evidence of "close" supervision of the resident, nor was the resident placed in the hallway to be supervise, as planned. Nursing Notes, Change of Condition Documentation, and Investigation of 8/2/11 at 9:05 P.M. indicated staff were called to the resident's room and found the resident sitting on buttocks on side of bed with back leaning up against bed. The fall was unwitnessed (no supervision prior to bedtime) and the bed alarm was removed as it was non-functional. No injury was noted. The resident was not wearing any footwear (non-skid socks) There was no evidence the resident had been toileted every 2-3 hours to reduce impulsivity, as planned. Nursing Notes, Change of Condition Documentation, and Investigation of 8/3/11 at 8:30 A.M., like that of 8/2/11's fall, indicated staff found the resident on the floor, incontinent and crawling to the bathroom. The bed alarm did not sound, and the resident had no footwear on. No injury was noted, and the Multidisciplinary Screening Notes of 8/3/11 now recommended toileting the resident every 2 hours. The care plan was updated to include: -an Alarmed seat belt.(self-releasing). Nursing Notes indicated on 8/5/11 an alarmed seat belt was placed in use on the resident's wheelchair daily. Change of Condition Documentation and Investigation of 8/9/11 at 2:30 P.M. indicated the resident was in a wheelchair in the hallway at the Nurse's Station, attempted to get up and slid under the self-releasing seat belt onto the floor. No injury was noted. The alarm did not sound. There was no evidence that the resident had been toileted, was continent or incontinent at the time of the fall, or was receiving close supervision at this time, near the shift change. Nursing Notes, Change of Condition Documentation, and Investigation of 8/17/11 at 9:15 A.M. indicated the resident was in a wheelchair in the hallway at the Nurse's Station, attempted to get up and fell on to buttocks on the floor. Like the 8/9/11 fall, staff were present but not close enough to the resident to intervene. It was recommended that the resident be toileted after meals, ambulated every 2 hours while awake, use items in the busy box to provide an activity for the resident, and keep the resident in a supervised area. Nursing Notes and Investigation of 8/19/11 at 7:20 A.M. indicated that the resident had an unwitnessed fall from the wheelchair at the Nursing Station. No injury was noted, the resident was incontinent, and the alarm did not function at the time of the fall. The resident was unsupervised and the alarm was considered ""not dependable" by staff. The care plan was updated 8/19/11 to include: -If patient becomes restless, offer snacks/fluids and ambulation, -and Bring patient into on-unit dining room for safety during shift changes if patient is up in wheelchair, Change of Condition Documentation, and Investigation of 8/20/11 at 7:15 P.M. indicated that the resident was sitting at a restorative dining table, and staff were in the room at another table. Staff noted the resident sitting on the floor in front of the wheelchair on buttocks. The alarm had a delay in sounding. The chair pad alarm was replaced. There was no injury to the resident and the Investigation noted the resident to be incontinent. There was no mention of the alarmed seat belt administration. On 8/21/11, the Physician ordered and the care plan was updated 8/22/11 to provide a "Lap tray to W/C (Wheelchair), remove every 2 hours and with structured activities." The Resident's Treatment Administration Record (TAR) from 8/2/11 to 8/31/11 and from 9/1/11 to 9/7/11 indicated the Lap Tray was checked every shift rather than every 2 hours, as ordered. Nursing Notes of 9/4/11 at 9:00 P.M. revealed staff utilized a Tabs alarm for the resident rather than the chair pad alarm, as planned . On 9/7/11, the Physician changed the Lap Tray order to read: "lap tray while in wheelchair due to impulsivity secondary to dementia. Check every hour and release and reapply with meals and activities." The Resident's Treatment Administration Record (TAR) from 9/8/11 to 9/21/11 revealed the Lap tray was checked every shift rather than every hour, as ordered. Documentation indicated the Lap tray was not utilized as ordered on: -9/8/11 (all shifts), -9/9/11 (day and night shifts), -9/10/11 (night shift), -9/11/11 (day and night shift), -9/12/11 (day and night shift), -9/13/11 (all shifts), -9/14/11 (night shift), -9/15/11 (all shifts), -9/16/11 (all shifts), -9/17/11 (all shifts), -9/18/11 (all shifts), -9/19/11 (all shifts), -9/20/11 (all shifts), and 9/21/11 (day and night shifts). Observation of the resident on 9/20/11 at 11:32 A.M. revealed the resident seated in a wheelchair without anti-tippers in the hallway across from the Nursing Station, with glasses on, and a Tabs alarm attached to the resident's red sweatshirt. There was no Lap tray or chair pad alarm on the wheelchair, as planned. At 12:30 P.M., the resident was observed seated in a wheelchair without anti-tippers at the restorative dining room table after completing the lunch meal. No chair pad alarm or Lap Tray were observed after the meal. Interview with the resident's assigned daytime CNA #1 on 9/20/11 at 2:30 P.M. revealed the resident was alert and confused, liked to stay in bed in the morning, utilized a bed pad alarm, was placed by 1 person assist in the wheelchair with Tabs alarm attached only, wandered throughout the unit corridor, sat usually in restorative dining or in the hallway near the Nursing Station, frequently attempted to self-transfer which was an indication to toilet or ambulate the resident. The resident was incontinent of bladder, eats well at meals, was combative at times, and ambulated with gait belt, assist and a trailing wheelchair. The CNA was unsure about supervision periods or history of falls. Observation revealed on 9/20/11 at 4:00 P.M. the resident seated in a wheelchair without anti-tippers in the hallway across from the Nursing Station, with glasses on, a Tabs alarm attached to the resident's red sweatshirt, and no Lap tray or chair pad alarm on the wheelchair, as planned. At 4:30 A.M., the resident was seated at a table in the restorative dining room, agitated at another resident, without a Lap Tray attached, and no staff available for supervision. At 11:30 A.M. on 9/21/11, the resident was observed seated in a wheelchair in the hallway across from the Nursing Station, with glasses on, a Tabs alarm attached to the resident's red sweatshirt, and no Lap tray or chair pad alarm attached on the wheelchair, as planned and ordered. At 1:30 P.M., the resident was observed wandering down the south corridor without a Lap Tray attached or supervision by staff. The resident ended up at the corridor doorway leading outside the facility, the resident leaned forward to push the door repeatedly with no results. No staff intervened. At 1:40 P.M., staff approached the resident's area, but made no attempt to re-direct the resident. At 1:45 P.M., the resident had turned around the wheelchair, Tabs alarm attached, and proceeded beyond the Nursing Station, bumping into the back of another resident's wheelchair. Staff now re-directed the resident to the Nursing Station location in the hallway. At 2:00 P.M., the resident was observed attempting to stand up without assist. No alarm sounded. At 2:05 P.M., staff ambulated the resident with walker and gait belt, and then, placed the resident back in the wheelchair with Tabs alarm and a "side table" in front of the resident with a box of dominos from a busy box. Interview with UM #2 on 9/21/11 at 4:15 P.M. and 9/26/11 at 1:30 P.M., and the DON on 9/26/11 at 2:00 P.M. acknowledged the facility had not followed the resident's care plan to prevent repeated falls, due to non-functioning bed and chair alarms, the lack of anti-tippers to the wheelchair, inconsistent transfers, ambulation and toileting assistance, inconsistent supervision during periods of restlessness, wandering, and shift changes, as well as scheduled toileting, and uneven device administration. Staff confirmed that there was no order for the facility's use of an alarmed seat belt, that the Lap Tray had not been checked every 1 or 2 hours as ordered.. Additionally, the care plan did not indicate the use of a Tabs alarm as a replacement for a chair pad alarm. Both the UM #2 and DON acknowledged the care plan was ineffective and/or not followed to prevent repeated falls. Please refer to F 274, Example 1 and F 323, Example 2. 3. For Resident #13, the Facility failed to provide functioning chair and bed pad alarms, supervision and assistance for transfers, ambulation and toileting, as planned to prevent repeated falls, as well as following Physician orders for a Neurological Consult. Resident # 13 was admitted to the facility in 4/11. [DIAGNOSES REDACTED]. A. Falls: The resident's admission Patient Care Referral Form of 4/6/11 indicated the resident had fallen 4 times since 4/1/11, and had gone from "unsteady gait to not walking without help". Admission Nursing Notes indicated the resident also had frequency of voiding and required "a wheelchair with pad alarm." The initial plan of care to have no significant injury related to falls due to impulsivity, impaired balance and unsteady gait, 4/12/11 to present, had the following interventions: -Bed pad alarm, check for placement and functionality, -Assist resident getting in and out of bed with 1 assist using roll walker, -and Assist resident with ambulation providing 1 assist using roll walker. The initial care plan for communicating toileting needs to staff as needed, dated 4/12/11 to present, had the following intervention: -Toileting-one person continual supervision and physical assist for safety. Nurses' Notes and Investigation of 6/14/11 at 9:20 A.M. indicated the resident self transferred from a chair in the unit dining room, and fell to the floor with the walker. The fall was witnessed, and no injury was noted. Although the admission CAA for Falls (dated 4/19/11) had recommended a chair pad alarm, it was not in place at the time of the fall to alert staff of the resident's unsafe transfer. A chair alarm was now "put on (the resident's) chair for safety." Nursing Notes and Investigation of 7/12/11 at 3:55 P.M. indicated the Physical Therapist was providing close supervision to the resident and instructed the resident to walk independently to a chair with the walker in the bedroom. The resident let go of the walker, lost balance and fell to the floor landing on the right side. No injury was noted, and the Investigation noted an "improper procedure" was used for the resident's ambulation (not following the care plan for supervision and 1 person assist while ambulating with walker.) The Investigation and Change of Condition Documentation for a fall on 7/15/11 at 9:00 P.M. noted the resident was found on the floor, after ambulating from a chair without assistance. No injury was noted, however the chair alarm was not in place, as planned. Apparently no bed alarm was in place as this device was also recommended as an intervention after the fall. Nurses' Notes, Change in Condition Documentation, and Investigation of 8/15/11 at 11:45 A.M. revealed the resident was found lying on the hallway floor on his/her back. The resident had been placed on the toilet, handed a call light string, and told to ring when the resident was finished. The wheelchair was placed in front of the resident in the bathroom. Staff then left the resident alone in the bathroom, and 5 minutes later found the resident on the floor. The resident complained of posterior head pain. Staff had not followed the care plan for toileting by leaving the resident alone rather than providing supervision and physical assist while toileting the resident. This intervention was re-written on both the Falls and Toileting care plans. Resident was observed on 9/26/11 at 7:30 A.M., sitting in a wheelchair, with chair pad alarm, at a table in the unit dining room. The resident was observed 9/26/11 at 9:30 A.M. sleeping in the same location. On 9/26/11 at 2:15 P.M., the resident's falls were discussed with UM #2 and with the Director of Nurses (DON) at 2:30 P.M. Both the Unit Manager #2 and the DON acknowledged that the resident's care plans to prevent falls and for toileting had not been followed regarding functioning bed and chair pad alarms, and staff assistance and supervision for transfers, ambulation and toileting. B. Physician Orders: Nursing Notes of 6/30/11 and 7/5/11 noted increased resident confusion and lethargy. The resident was admitted to the local hospital 7/5/11 to "rule out [MEDICAL CONDITION] disorder." Because the hospital's Neurologist was unavailable to assess the resident, the hospital's discharge notes of 7/9/11 recommended a "FU (Follow Up) Appointment Neurologist ASAP" (As Soon As Possible). The resident's Physician ordered "Neuro (Neurological) Consult (with) Dr. A (Neurologist's name)" on 7/12/11 Record review revealed no evidence of a Neurological consult. Interview with Unit Manager #2 on 9/26/11 at 2:15 P.M. acknowledged the facility had not obtained a Neurological Consult as ordered. Please refer to F 157 and F 323, Example 3. Based on record review, interviews and observations, the facility failed to insure that the physician orders and care plans were followed for 4 residents (#3, #6, #11, and #13) out of a total sample of 18 residents. Findings included: 1. For Resident #6, the facility failed to follow the care plan for falls regarding locking the wheelchair prior to transfers, insuring proper footwear was worn, insuring that alarms were applied, and/or were working, and failed providing adequate supervision/assistance during transfers and wheelchair mobility. The facility failed to apply an ankle foot brace before transferring the resident. The resident experienced multiple falls and a [MEDICAL CONDITION] ankle. Resident #6 was admitted to the facility in April of 2008 with [MEDICAL CONDITION], a history of [MEDICAL CONDITIONS] with [MEDICAL CONDITION], hypertension, [MEDICAL CONDITIONS] disorder, [MEDICAL CONDITION] and history of [MEDICAL CONDITION]. Review of the care plan in effect 9/28/10 indicated the resident was a fall risk related to cognitive and physical deficits, [MEDICAL CONDITION] with left [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. The interventions included: -Naps after lunch, supervise and assist mobility. Provide assistive devises as needed, uses walker. -Monitor behavior. Keep call bell within reach of resident. -Provide assist of 1 for transfers with walker and ambulate up to 25 feet. -Use non-skid footwear/socks. Explain all care/activities prior to initiating. Scoop Mattress, pressure bed alarm. Do not leave alone in bathroom. Non-skid strips to floor on left side of bed. Wheelchair alarm under chair and out of reach of resident. Bilateral half side rails when in bed. Wheelchair and walker beside bed when in bed. Review of the Nurse's Note of 9/29/10 indicated that at 9:45 P.M., the resident was observed in her/his room walking without footwear and without a walker to the bathroom. The resident fell to the floor. Review of the Nurse's Note of 10/4/10 indicated the resident was ambulated with a staff person to the bathroom when the resident's leg gave out and the resident was lowered to the floor. Review of the investigation did not indicate if the resident wore footwear when ambulating to the bathroom. Review of the Physical Therapy Evaluation of 10/5/10 indicated that the resident demonstrated very poor safety awareness and noted that the resident's wheelchair was too small to accommodate the resident. This assessment indicated the resident had multiple falls. Review of the care plan 10/5/10 indicated that new interventions included: -Assist resident getting in and out of bed with two assists and a rolling walker. -Assist resident with ambulation with 1 assist using a rolling walker and a gait belt. Review of the Nurse's Note of 10/8/10 indicated the resident was found on the floor in the resident's bathroom. The resident hit the front of his/her head and sustained a pink/purple hematoma above the resident's nose. Staff did not assist the resident to the bathroom as care planned. Review of the Nurse's Note of 10/11/10 indicated the resident was found with a laceration of the left calf. The area was cleansed and a clean dressing was applied. The cause of the laceration was unknown. However, the care plan was updated on 10/11/10 to include: -Resident to utilize self release alarmed seat belt for added safety. -Resident will be given verbal cues and praise for calling for help before ambulating. Review of the Physical Therapy note of 10/22/10 indicated the resident received a left ankle brace and that the resident was very happy with the device. Review of the Physical Therapy note of 11/9/10 indicated the resident had been provided with an AFO (an ankle/foot orthotic) brace. Review of the Nurse's Note of 11/30/10 indicated the resident was found on the floor in the resident's room. The resident hit his/her head but sustained no injury. The investigation indicated the resident was not wearing shoes or non-skid socks as care planned and did not call for help before transferring. Review of the Investigation of the fall indicated the resident was found on the floor in the resident's room at 10:45 P.M. Review of the investigation indicated that the alarm was on and functioning. However, review of a statement from a staff person indicated "went into resident's room and me and another aid (sic) found resident sitting upright on the floor. I should also add that the resident's alarm was not on and the bedroom door was closed". This statement was from the staff person who found the resident on the floor. Review of the Nurse's Note of 12/15/10 indicated the resident was found on the floor in the resident's room at 10:30 P.M. The note indicated the resident attempted self transfer, did not have shoes or socks on as care planned and sustained an abrasion to the right knee. Review of the Nurse's Note of 1/11/11 indicated the resident was observed ambulating from the toilet without assistance (as care planned) and fell . Review of the Falls Investigation indicated the resident fell at 12:00 P.M., while attempting to ambulate alone. Review of the Nurse's Note of 1/21/11 indicated that the resident fell during staff assistance to bed. The note indicated that the bed brakes were not working and the bed rolled during resident transfer. Review of the Nurse's Note of 1/31/11 indicated the resident was found on the floor in the resident's room. The alarms were not on as care planned. Review of the Nurse's Note of 3/16/11 indicated the resident fell during transfer from the wheelchair to the bed. Review of the investigation indicated the wheelchair was not locked prior to transfer as care planned. Review of the Nurse's Note of 3/24/11 indicated the new interventions added to the care plan to prevent falls included increased toileting and placing a yellow barrier strip with a door alarm tab to the room entrance to alert staff of resident's attempts to enter room alone. Review of the Nurse's Note of 3/31/11 indicated the resident fell . The alarm was observed to be on but not functioning correctly as care planned. Review of the Nurse's note of 4/7/11 indicated the resident was found on the floor. The resident fell as the resident attempted to leave the bathroom without staff assistance as care planned. Review of the Nurse's Note of 5/11/11 indicated that the resident continued to demonstrate poor safety awareness, had an unsteady gait secondary to an old [MEDICAL CONDITION], and was at risk of additional falls. This note indicated that all alarms were kept out of resident's reach. Review of the Nurse's Note of 5/20/11 indicated the resident was found on the floor in another resident's room. The resident was not provided with assistance with wheelchair transfers as care planned. Review of the Nurse's Note of 5/22/11 (no time given) indicated the resident had another fall that was reported to staff by another resident. The alarm was observed to be " functional but did not sound". Review of the Nurse's Note of 6/3/11 indicated the resident fell . This note indicated another resident approached the staff to tell them that a resident was on the floor. The resident was found on the floor in his/her room with the wheelchair near the bathroom. A small abrasion was observed on the right back. The resident complained of a backache. Review of the Falls Investigation indicated the alarm did not sound. This investigation indicated staff were educated on the need to check alarms. Review of the Nurse's Note of 6/29/11 indicated that the resident was found on the floor in the resident's bathroom (no time of fall given); but this note indicated the Physician was informed at 12:50 P.M. The resident was found with slippers on but did not have the left lower extremity AFO on as care planned. Review of the Nurse's Note of 8/2/11 indicated the resident was lowered to the floor during a transfer into a chair van at the facility at 8:50 A.M. The resident did not have the left lower extremity AFO on as are planned. An X-ray was ordered which indicated a [MEDICAL CONDITION]. Observation of the resident on 9/26/11 at 1:40 P.M. was of the resident in a wheelchair in the hallway. Another resident, NS#1 was observed wheeling resident #6 to his/her room and leaving the resident in his/her room next to the bed. The resident was not assisted by staff with mobility as care planned. During interview on 9/26/11 at 1:30 P.M., the DON acknowledged that the care plan interventions involving the use of the AFO, locking the wheelchair, wearing non-skid socks, use of alarms, assisting the resident with transfers and ambulation were not always followed for this resident. Please refer to F323, Example 1. 4. For Resident #3, the facility failed to ensure that Intake and Outputs were completed for this resident with a G (Gastrostomy) tube. Resident #3 was admitted to the facility in 7/11. The resident's [DIAGNOSES REDACTED]. According to the 7/1/11 written care plan, Resident #3 has increased nutritional risk due to feeding tube, unresponsive/comatose state, and weight loss. An intervention included on this care plan identified to monitor the Resident's Intake and Output every shift. The 7/23/11 Nursing Note indicated that Resident #3 became ill, the physician was notified, and the resident was sent to the hospital to be evaluated. Resident #3 was diagnosed with [REDACTED]. The resident received various treatments including blood [MEDICAL CONDITION], and returned back to the facility on [DATE]. The Physician's order (8/3/11) indicated to obtain Intake and Outputs every shift. Review of the daily Intake and Output records (on 9/21/11 at 3:38 P.M.) revealed that Intake and Outputs were not obtained on the following dates/shifts: - 7/28/11 Day shift, not obtained. - 7/29/11 Night and Day shift not obtained. - 8/1/11 through 8/14/11. All three shifts did not obtain the resident's Intake and Output. - 8/15/11 Day shift not obtained. - 8/16/11 Night shift (did not document total intake of tube feeding formula received). - 8/16 and 8/17/11 Day Shift not obtained. - 8/18/11 Evening Shift (did not document total intake of water received). - 8/18, 8/19, 8/20, 8/21/11 Day Shift not obtained. - 8/22/11 Day and Evening Shift not obtained. - 8/24, 8/25, 8/26/11 Day Shift not obtained. - 8/27/11 Evening Shift not obtained. - 8/28, 8/29, 8/30, 8/31, 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11/11 Day Shift not obtained. During interview with Nurse #2 and UM (Unit Manager) #1 on 9/21/11 at 3:38 P.M., Nurse #2 indicated that each shift fills out a "worksheet," and that it is up to the 11:00 P.M. to 7:00 A.M. shift nurse to place all amounts from the worksheets on the Intake and Output Sheets. Nurse #2 stated that the worksheets are tossed out and a new one is completed for the following days. Nurse #2 showed the surveyor that Licensed Nurses initial on the MAR (Medication Administration Record) for each shift, to indicate that the resident received tube feeding formula at 65 cc (cubic centimeters) per hour, 350 cc water flushes every shift, and an entry indicating that 30 cc of water was administered before and after each medication was administered. Nurse #2 indicated that this was all that was needed. The surveyor pointed out that the Care Plan identified for the facility to monitor the resident's Intake and Output every shift, and that this resident had been sent to the hospital on [DATE], was admitted , and diagnosed at the hospital with dehydration. Nurse #2 and UM #1 acknowledged that although the resident's dehydrated state could have been contributed by volume depletion from the [MEDICAL CONDITION], requiring blood [MEDICAL CONDITION], that monitoring the resident's Intake and Outputs were an essential part of the care plan that was not followed for Resident #3.

2. For Resident #11, the Facility failed to provide effective devices, interventions and/or supervision to prevent 12 falls with injury. Resident #11 was admitted to the facility in 2/11. [DIAGNOSES REDACTED]. . The initial plan of care to have no significant injury related to a fall due to impulsivity, impaired balance, unsteady gait, decreased safety awareness, and medications, dated 2/12/11 to 4/7/11, had the following interventions: -Place call light within easy reach of resident, -Remind resident to use call light prior to ambulating or transfer, -Remove all objects near bed to prevent injury if resident falls from bed, -Ensure environment is free of clutter, -and Encourage resident to communicate needs/ask for assistance. Nursing Notes of 2/14/11 (time unknown) indicated the resident was non-compliant with safety measures. On 2/17/11 at 4:30 P.M., the resident was ambulating with rolling walker and mild confusion, and "wanders without regard to...own safety." The admission MDS (Minimum Data Set) assessment of 2/24/11 indicated that the resident was severely impaired cognitively, had no mood or behavioral issues, required limited assist for bed mobility, transfers, and ambulation with in the room, extensive assist for bathing, was independent for eating, had no balance issues in transitions or walking, was occasionally incontinent of bladder, and had no pain or falls. Nurse's Notes of 3/2/11 at 10:30 A.M., 3/4/11 (evening shift), and 4/3/11 at 7:10 P.M. indicated the resident was "alert and confused, needed frequent cueing as to where the bathroom and bed were located... forgot to take walker...when ambulating...needed close supervision for safety, and needs reminder to use RW" (Rolling Walker.) Nursing Notes of 4/7/11 on the "7-3 shift" revealed the "pt. (patient) fell in Dining Room." No apparent injury until 4/8/11 at 7:00 A.M. when the resident complained of shoulder pain, There was no evidence the resident was provided close supervision. The care plan was updated to now provide: -Bed and chair alarms for safety, -and Ambulate with rolling walker, gait belt and stand by assist. Nursing Notes of 4/27/11 at 10:10 P.M. noted the resident getting out of bed without help, alarm rings. Nursing Notes, Change of Condition Documentation, and Investigation of 5/4/11 at 5:00 P.M. indicated the resident's alarm was sounding, and staff found the resident on the floor, lying on back with feet facing the bedside chair. The resident complained of hip pain and had a small left wrist bruise (dime-size). The care plan was updated to include supervising the resident in restorative dining area from 3:00 P.M. to bedtime. Nursing Notes of 5/18/11 at 2:30 P.M. indicated the resident was ambulating in the bedroom without the walker, became weak, and was lowered to the floor by a CNA (Certified Nursing Assistant). No injury was noted. The resident was referred to Rehabilitation. The care plan was updated to include: -toilet patient every 2-3 hours on each shift to reduce impulsivity related to toileting needs. Rehabilitation Notes of 5/20/11 indicated the resident had continued shoulder pain, and the last fall was when the resident was attempting to get to the toilet. Nursing Notes, Change of Condition Documentation, and Investigation of 5/23/11 at 2:00 P.M. indicated the resident was ambulating in the hallway with distant supervision (rather than close supervision or use of a gait belt and stand-by assist, as care planned). The resident changed direction, but did not change the walker position, and fell . The resident hit his/her upper back and head on the hallway wall. Physical Therapy Notes of 5/26/11 indicated the resident presents with "decreased initiation, very slow shuffling gait pattern. Requires maximum cues for safety, use of walker and negotiating through obstacles especially when approaching chair or turning. Pt. with very poor safety awareness putting him/her at high fall risk. Recommend close supervision at all times when ambulating. Patient with decreased balance reactions...requires increased caregiver dependency/supervision." The quarterly MDS assessment of 6/1/11 indicated that the resident wandered, now required extensive assist with bed mobility, transfers and ambulation, had balance issues with transitions and walking, utilized a walker, was frequently incontinent of bladder, had pain issues and fallen. Nursing Notes, Change of Condition Documentation, and Investigation of 6/19/11 at 11:35 A.M. indicated the resident quickly stood up from chair in restorative dining, set off alarm, took a step forward and tripped on the chair, falling face forward. The resident hit his head on the floor, sustaining 2 lacerations (one to the mid-forehead that was irregular, 1 inch wide and 0.1 cm. (centimeter) deep, and one to the upper right eyebrow area that was 1/2 inch wide and 0.1 cm. deep). Steri-strips were applied to the lacerations. There was no evidence the resident was kept in close supervision or provided assist when the resident self-transferred, as planned. The care plan was updated to: -Keep in view of staff-encourage resident to sit in hallway to supervise, -and Anti-tippers on wheelchair to decrease falls. Nursing Notes of 7/15/11 at 2:45 P.M. (near shift change) indicated the resident had an unwitnessed fall in the dining room when the resident got up out of the wheelchair and fell . Staff noted the "chair alarm on later," (delayed in sounding.) There was no evidence of "close" supervision of the resident, nor was the resident placed in the hallway to supervise, as planned. Nursing Notes, Change of Condition Documentation, and Investigation of 8/2/11 at 9:05 P.M. indicated staff were called to the resident's room and found the resident sitting on buttocks on side of bed with back leaning up against bed. The fall was unwitnessed (no supervision prior to bedtime) and the bed alarm was removed as it was non-functional. No injury was noted. The resident was not wearing any footwear (non-skid socks) There was no evidence the resident had been toileted every 2-3 hours to reduce impulsivity, as planned. Nursing Notes, Change of Condition Documentation, and Investigation of 8/3/11 at 8:30 A.M., like that of 8/2/11's fall, indicated staff found the resident on the floor, incontinent and crawling to the bathroom. The bed alarm did not sound, and the resident had no footwear on. No injury was noted, and the Multidisciplinary Screening Notes of 8/3/11 now recommended toileting the resident every 2 hours. The care plan was updated to include: -safety floor mats on sides of bed, -and Alarm seat belt (self-releasing). Nursing Notes indicated on 8/5/11 an alarmed seat belt was placed in use on the resident's wheelchair daily. Change of Condition Documentation and Investigation of 8/9/11 at 2:30 P.M. indicated the resident was in a wheelchair in the hallway at the Nurses' Station, attempted to get up and slid under the self-releasing seat belt onto the floor. No injury was noted. The alarm did not sound. There was no evidence that the resident had been toileted, was continent or incontinent at the time of the fall, or was receiving close supervision at the time near shift change. Nursing Notes, Change of Condition Documentation, and Investigation of 8/17/11 at 9:15 A.M. indicated the resident was in a wheelchair in the hallway at the Nurses' Station, attempted to get up and fell on to buttocks on the floor. Like the 8/9/11 fall, staff were present but not close enough to the resident to intervene. It was recommended that the resident be toileted after meals, ambulated every 2 hours while awake, use items in the busy box to provide an activity for the resident, and keep the resident in a supervised area. Nursing Notes and Investigation of 8/19/11 at 7:20 A.M. indicated that the resident had an unwitnessed fall from the wheelchair at the Nursing Station. No injury was noted, the resident was incontinent, and the alarm did not function at the time of the fall. The resident was unsupervised and the alarm was considered ""not dependable" by staff. The care plan was updated 8/19/11 to include: -If patient becomes restless, offer snacks/fluids and ambulation, -and Bring patient into on-unit dining room for safety during shift changes if patient is up in wheelchair, Change of Condition Documentation, and Investigation of 8/20/11 at 7:15 P.M. indicated that the resident was sitting at a restorative dining table, and staff were in the room at another table. Staff noted the resident sitting on the floor in front of the wheelchair on buttocks. The alarm had a delay in sounding. The chair pad alarm was replaced. There was no injury to the resident and the Investigation noted the resident to be incontinent. On 8/21/11, the Physician ordered and the care plan was updated 8/22/11 to provide a "Lap tray to W/C (Wheelchair), remove every 2 hours and with structured activities." The Resident's Treatment Administration Record (TAR) from 8/2/11 to 8/31/11 and from 9/1/11 to 9/7/11 indicated the Lap Tray was checked every shift rather than every 2 hours, as ordered. Nursing Notes of 9/4/11 at 9:00 P.M. revealed staff utilized a Tab alarm for the resident rather than the care planned chair pad alarm. On 9/7/11, the Physician changed the Lap Tray order to read: "lap tray while in wheelchair due to impulsivity secondary to dementia. Check every hour and release and reapply with meals and activities." The Resident's Treatment Administration Record (TAR) from 9/8/11 to 9/21/11 revealed the Lap Tray was checked every shift rather than every hour, as ordered. TAR documentation indicated the Lap tray was not utilized as ordered on: -9/8/11 (all shifts), -9/9/11 (day and night shifts), -9/10/11 (night shift), -9/11/11 (day and night shift), -9/12/11 (day and night shift), -9/13/11 (all shifts), -9/14/11 (night shift), -9/15/11 (all shifts), -9/16/11 (all shifts), -9/17/11 (all shifts), -9/18/11 (all shifts), -9/19/11 (all shifts), -9/20/11 (all shifts), and 9/21/11 (day and night shifts). Observation of the resident on 9/20/11 at 11:32 A.M. revealed the resident seated in a wheelchair without anti-tippers, in the hallway across from the Nursing Station, with glasses on, a Tabs alarm attached to the resident's red sweatshirt, and no Lap tray or chair pad alarm on the wheelchair. At 12:30 P.M., the resident was observed at the restorative dining room table after completing the lunch meal. No chair pad alarm or Lap Tray were observed. Interview with the resident's assigned daytime CNA #1 on 9/20/11 at 2:30 P.M. revealed the resident was alert and confused, liked to stay in bed in the morning, utilized a bed pad alarm, was placed by 1 person assist in the wheelchair with Tabs alarm attached only, wandered throughout the unit corridor, sat usually in restorative dining or in the hallway near the Nursing Station, frequently attempted to self-transfer which was an indication to toilet or ambulate the resident. The resident was incontinent of bladder, eat well at meals, was combative at times, and ambulated with gait belt, assist and a trailing wheelchair. The CNA was unsure about supervision periods or history of falls. Observation revealed on 9/20/11 at 4:00 P.M. the resident seated in a wheelchair without anti-tippers in the hallway across from the Nursing Station, with glasses on, a Tabs alarm attached to the resident's red sweatshirt, and no Lap tray or chair pad alarm on the wheelchair, as planned. At 4:30 A.M., the resident was seated at a table in the restorative dining room, agitated at another resident, without a Lap Tray attached, and no staff available for supervision. On 9/21/11, from 7:20 A.M. to 8:53 A.M., the resident was observed asleep in a low bed with bed pad alarm attached/functioning and mats on either bedside. At 11:30 A.M., the resident was seated in a wheelchair in the hallway across from the Nursing Station, with glasses on, a Tabs alarm attached to the resident's red sweatshirt, and no Lap tray or chair pad alarm attached on the wheelchair. At 1:30 P.M., the resident was observed wandering down the south corridor without a Lap Tray attached or supervision by staff. The resident ended up at the corridor doorway leading outside the facility, the resident leaned forward to push the door repeatedly with no results. No staff intervened. At 1:40 P.M., staff approached the resident's area, but made no attempt to re-direct the resident. At 1:45 P.M., the resident had turned around the wheelchair, Tabs alarm attached, and proceeded beyond the Nursing Station, bumping into the back of another resident's wheelchair. Staff now re-directed the resident to the Nursing Station location in the hallway. At 2:00 P.M., the resident was observed attempting to stand up without assist. No alarm sounded. At 2:05 P.M., staff ambulated the resident with walker and gait belt, and then, placed the resident back in the wheelchair with Tabs alarm and a "side table" in front of the resident with a box of dominos from a busy box. Interview with UM #2 on 9/21/11 at 4:15 P.M. and 9/26/11 at 1:30 P.M. and the DON on 9/26/11 at 2:00 P.M. acknowledged the facility had not followed the resident's care plan to prevent repeated falls, due to non-functioning bed and chair alarms, inconsistent transfers, ambulation and toileting assistance, inconsistent supervision during periods of restlessness, wandering, and shift changes, as well as uneven device administration (no anti-tippers to the wheelchair). Staff confirmed that there was no order for the facility's use of an alarmed seat belt, that the Lap Tray had not been checked every 1 or 2 hours as ordered, nor had the facility obtained a physician's orders [REDACTED]. Additionally, the care plan did not indicate the use of a Tabs alarm as a replacement for a chair pad alarm. Staff acknowledged that the frequent reminders for the resident to call for assist or to use the walker, or the call bell were not effective given the resident's memory loss and cognitive deficits. Staff acknowledged in conversations with the UM #2 and DON that the resident had declined after repeated falls. Please refer to F 274, Example 1 and F 282, Example 2. 3. For Resident #13, the Facility failed to provide effective devices, interventions and/or supervision to prevent 7 falls. Resident #13 was admitted to the facility in 4/11. [DIAGNOSES REDACTED]. The resident's admission Patient Care Referral Form of 4/6/11 indicated the resident had fallen 4 times since 4/1/11, and had gone from unsteady gait to not walking without help. Admission Nursing Notes indicated the resident also had frequency of voiding and required a "wheelchair with pad alarm." The initial plan of care to have no significant injury related to a fall due to impulsivity, impaired balance and unsteady gait, 4/12/11 to present, had the following interventions: -Bed pad alarm, check for placement and functionality,, -Assist resident getting in and out of bed with 1 assist using roll walker, -Assist resident with ambulation providing 1 assist using roll walker, -Encourage resident to use handrails or assistive devices properly, -Ensure environment is free of clutter, -Encourage resident to communicate needs/ask for assistance, and Educate resident on Safety Risks. The initial care plan for communicating toileting needs to staff as needed, dated 4/12/11 to present, had the following intervention: -Toileting-one person continual supervision and physical assist for safety. The CAA (Care Area Assessment) for Falls, dated 4/19/11, indicated the resident had frequency of back pain, memory loss, utilized a walker, and required assist with transfers and ambulation. Nurse's Notes and Investigation, dated 4/28/11 at 11:45 P.M., revealed the alarm sounded and staff found the resident on the floor with feet near the bathroom doorway. The resident stated "I needed to go to the bathroom." The resident was incontinent, had no injury, and was not wearing non-skid footwear at the time of the fall. The Investigation recommended that staff remind the resident to call for assistance to the bathroom, despite the resident's identified memory loss, and to have slipper socks on at bedtime. The admission MDS assessment of 4/30/11 indicated that the resident was moderately impaired cognitively (8/15 score on BIMS), required limited assist for ambulation, locomotion and toilet use, and was occasionally incontinent of bladder, continent of bowel, had pain constantly and had fallen without injury prior to admission. Nurse's Notes of 5/7/11 at 8:35 P.M. indicated the resident was alert and disoriented, was going to the bathroom without assist and unsteady gait was noted. Staff reeducated the resident and reminded the resident to request help. Nurse's Notes and Investigation of 6/14/11 at 9:20 A.M. indicated the resident self transferred from a chair in the unit dining room, and fell to the floor with the walker. The fall was witnessed, and no injury was noted. Although the admission CAA for Falls had recommended a chair pad alarm, there was none in place at the time of the fall.. A chair alarm was now "put on (the resident's) chair for safety." Nursing Notes and Investigation of 7/12/11 at 3:55 P.M. indicated the Physical Therapist was providing close supervision to the resident and instructed the resident to walk independently to a chair with the walker in the bedroom. The resident let go of the walker, lost balance and fell to the floor landing on the right side. No injury was noted and the Investigation noted "improper procedure" used for the resident's ambulation. The Investigation and Change of Condition Documentation for a fall on 7/15/11 at 9:00 P.M. noted the resident was found on the floor, after ambulating from a chair without assistance. No injury was noted, however the chair alarm was not in place, as planned. Apparently no bed alarm was in place as this device was also recommended as an intervention after the fall. Nursing Notes of 7/17/11 at 1:00 P.M. noted the resident was having a difficult time ambulating with 2 assist in the hallway 10 feet...Pt. (Patient) pushing walker too far away from body-pt. stopped and let ...knees buckle. I can't make it, (said the resident.) Wheelchair provided." Investigation and Change of Condition Documentation for a fall on 7/18/11 at 4:00 P.M. indicated the resident was heard yelling "Whoa!" Alarm began sounding at the same time. Upon entering the resident's bedroom, staff found the resident sitting on buttocks in front of wheelchair. No apparent injuries were noted. The quarterly MDS assessment of 7/29/11 indicated that the resident was now severely impaired cognitively (score of 3/15 on the BIMS, required extensive assist with ambulation, locomotion, and toilet use, was always incontinent of bladder, frequently incontinent of bowel, had pain daily and had fallen since the last assessment. Nurse's Notes, Change in Condition Documentation, and Investigation of 8/15/11 at 11:45 A.M. revealed the resident was found lying on the hallway floor on he/she's back. The resident had been placed on the toilet, handed a call light string, and told to ring when the resident was finished. The wheelchair was placed in front of the resident in the bathroom. Staff then left the resident alone in the bathroom, and 5 minutes later found the resident on the floor. The resident complained of posterior head pain. Staff had not followed the care plan for toileting by leaving the resident alone rather than providing supervision and physical assist for the resident while toileted. This intervention was re-written on both the Falls and Toileting care plans. Nursing Notes, Change of Condition Documentation, and Investigation of 9/4/11 at 11:30 A.M. revealed the resident was sitting in a wheelchair in the hallway, when the resident dropped sewing materials to the floor, leaned forward, attempting to pick it up before staff could intervene. The resident slid out of the wheelchair, No injury was noted. A reacher was provided to the resident with "instruction on use...care plan updated with reminder to use reacher." The quarterly MDS assessment of 9/5/11 indicated that the resident still required extensive assist with ambulation, locomotion, and toilet use, was always incontinent of bladder and now was always incontinent of bowel. Observation of the resident on 9/26/11 at 7:30 A.M. noted the resident to be seated in a wheelchair with chair pad alarm at a table in the unit dining room, and at 9:30 A.M. to be asleep in the same location. On 9/26/11 at 2:15 P.M., the resident's falls were discussed with UM #2 and with the Director of Nurses (DON) at 2:30 P.M. Both the Unit Manager #2 and the DON acknowledged that the resident's care plan had been rendered ineffective for fall prevention interventions, including non-functioning or non-existent chair and bed pad alarms, assistance and supervision for transfers, ambulation and toileting. Staff acknowledged the resident had had a significant decline in functionality. Please refer to F 274, Example 2 and F 282, Example 3. Based on record review, interview and observations the facility failed for 3 residents (#s 6, 11, and 13) of 8 residents with falls out of a total sample of 18 residents to ensure the residents' environment was free of accident hazards and that each resident received adequate supervision and assistive devices to prevent accidents. Findings included: 1. For Resident #6, the facility failed to maintain bed locks in good repair, failed to insure the wheelchair was locked before transfers, failed to insure that the resident wore proper footwear, failed to insure that alarms were applied properly and were working and failed to provide adequate supervision for transfers to prevent falls. The facility failed to apply a ankle foot brace before transferring the resident. The resident experienced multiple falls and a fracture of the left ankle. Resident #6 was admitted to the facility in April of 2008 with Alzheimer's Disease, a history of cerebral vascular accident (CVA) with hemiparesis, hypertension, coronary artery disease, seizure disorder, peripheral vascular disease and history of [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment of 8/31/10 indicated the resident was coded as having short and long term memory problems with impaired decision making ability. The resident was coded as transferring and ambulating with supervision, required extensive assistance for toilet use, had experienced falls in the past 30 days and 31 to 180 days. Review of the care plan in effect 9/28/10 indicated the resident was a fall risk related to cognitive and physical deficits, cerebral vascular accident with left hemiparesis and seizure disorder. The interventions included: -Naps after lunch, supervise and assist mobility. Provide assistive devises as needed, uses walker. -Monitor behavior. Keep call bell within reach of resident. -Provide assist of 1 for transfers with walker and ambulate up to 25 feet. -Use non-skid footwear/socks. Explain all care/activities prior to initiating. Scoop Mattress, pressure bed alarm. Do not leave alone in bathroom. Non-skid strips to floor on left side of bed. Wheelchair alarm under chair and out of reach of resident. Bilateral half side rails when in bed. Wheelchair and walker beside bed when in bed. Review of the Nurse's Note of 9/29/10 indicated that at 9:45 P.M., the resident was observed in her/his room walking without footwear and without a walker to the bathroom. Staff observed resident lower self to the floor and was assisted back to bed with the assistance of 4 staff. This note indicated safety precautions were reviewed with resident. Review of the investigation did not address or indicate whether or not the chair alarm sounded to alert staff that resident had attempted independent transfer/ambulation. No new interventions were added to the care plan, however the goal was updated to include "resident will call for assistance before ambulating". Review of the Nurse's Note of 10/4/10 indicated the resident was ambulated with a staff person to the bathroom when the resident's leg gave out and the resident was lowered to the floor. The resident was transferred back to bed with the assistance of a Hoyer lift. The resident indicated that his/her right leg was hurting prior to the fall. Review of the investigation did not indicate if the resident wore footwear when ambulating to the bathroom. Review of the Physical Therapy Evaluation of 10/5/10 indicated that the resident demonstrated very poor safety awareness and noted that the resident's wheelchair was too small to accommodate the resident. This assessment indicated the resident had multiple falls. Review of the care plan indicated that new interventions included: -Assist resident getting in and out of bed with two staff and a rolling walker. -Assist resident with ambulation with 1 assist using a rolling walker and a gait belt. Review of the Nurse's Note of 10/8/10 indicated the resident was found on the floor in the resident's bathroom. The resident hit the front of his/her head and sustained a pink/purple hematoma above the resident's nose. Review of the Investigation of the incident indicated it occurred at 2:00 P.M. This investigation was incomplete as it was blank under the question "was alarm in use and functioning". The investigation indicated the resident was found on the floor, crying, in the bathroom during rounds. A staff person indicated that the resident had attempted to transfer self from the toilet to the wheelchair. This investigation did not indicate how the resident got into the bathroom. Review of the Nurse's Note of 10/11/10 indicated the resident was found with a laceration of the left calf. The area was cleansed and a clean dressing was applied. The cause of the laceration was unknown. However, the care plan was updated on 10/11/10 to include: -Resident to utilize self release alarmed seat belt for added safety. -Resident will be given verbal cues and praise for calling for help before ambulating. Review of the Physical Therapy Note of 10/12/10 indicated the nursing staff was concerned that the resident's ankle inversion was contributing to frequent falls. The resident was assessed for an assistive device to aid in aligning the ankle. Review of the Physical Therapy Note of 10/22/10 indicated the resident received the left ankle brace and that the resident was very happy with the device. Review of the Physical Therapy Note of 11/9/10 indicated the resident had been provided with an AFO (an ankle/foot brace used to improve anatomical positioning/alignment). A new wide bariatric wheelchair was ordered for the resident to improve the resident's ability to safely use a wheelchair. Review of the late entry Nurse's Note (of 11/20/10 at 11:00 P.M.) indicated the resident was lowered to the floor with no injury. This note indicated the bed alarm was not functioning. Review of the Investigation of the fall indicated that the resident was assisted to the floor (11/19/10 at 3:00 A.M.) after staff found the resident ambulating alone to the bathroom. The witness statement indicated the staff heard the resident walking in the resident's room and that one staff assisted the resident to the bathroom. However this statement indicated the resident could not sustain walking was lowered to the floor by a staff person. The falls investigation concluded that the resident removed the bed alarm. The intervention to prevent further falls was to "Rediscuss safety precautions". Review of the Nurse's Note of 11/19/10 indicated staff discussed bed and wheelchair alarms with the resident and the resident expressed understanding of the discussion. However, the note also stated that although the resident has expressed understanding in the past, the resident continued to shut off alarms. Review of the quarterly MDS of 11/29/10 indicated the resident was coded as moderately impaired cognitive status as evidenced by a Brief Interview of Mental Status (BIMS) score of 9/15, and coded as experiencing behavioral indicators. The resident was coded as requiring extensive assistance with transfers, ambulation and required extensive assistance for toilet use. The resident was coded as being unable to determine fall history since last assessment. The existing care plan was continued. Review of the Nurse's Note of 11/30/10 indicated the resident was found on the floor in the resident's room. The resident hit his/her head but sustained no injury. The investigation indicated the resident was not wearing shoes or non-skid socks as care planned and did not call for help before transferring. Review of the Investigation of the fall indicated the resident was found on the floor in the resident's room at 10:45 P.M. The resident told staff that he/she was trying to get to the closet when his/her feet slipped. Review of the investigation indicated that the alarm was on and functioning. However, review of a statement from a staff person indicated "went into resident's room and me and another aid (sic) found resident sitting upright on the floor. I should also add that the resident's alarm was not on and the bedroom door was closed". This statement was from the staff person who found the resident on the floor. This staff statement was not addressed in the Investigation of this fall. The intervention to prevent further falls was to "remind resident to ring for help" despite the resident's previous demonstrated non-compliance or inability to comply with this request. Review of the Nurse's Note of 12/15/10 indicated the resident was found on the floor in the resident's room at 10:30 P.M. The note indicated the resident attempted self transfer, did not have shoes or socks on as care planned and sustained an abrasion to the right knee. Review of the investigation indicated the plan was to have the resident maintain non-skid socks on at all times in bed. However, the intervention of wearing non-skid socks was already on the care plan. The investigation concluded that this cognitively impaired resident was not compliant with ringing for help or wearing non-skid socks. Review of the Physical Therapy note of 12/15/10 indicated that the Physical Therapist spoke with the Maintenance Department about fixing the brakes on the bed of Resident #6. This note indicated the Maintenance person would look into it. Review of the Physical Therapy Note of 12/28/10 indicated the Maintenance person indicated the bed brakes broke all the time and would not support the weight of the resident. Review of the Nurse's Note of 1/11/11 indicated the resident was observed ambulating from the toilet without assistance and fell . Review of the Falls Investigation indicated the resident fell at 12:00 P.M., while attempting to ambulate alone. This investigation was incomplete as it did not address why the resident was in the bathroom, on the toilet alone. This investigation included no witness statement, what safety equipment was in use, etc. The cause of the fall was determined to be resident non-compliance Review of the Nurse's Note of 1/21/11 indicated that the resident fell during staff assistance to bed. The note indicated that the bed brakes were not working and the bed rolled during resident transfer. The Nurse's Note of 1/21/11 indicated that the maintenance man put new brakes on the bed. Review of the Falls investigation (Screening form completed by Rehabilitation Department 1/23/11) indicated that the resident had been previously evaluated for safety and environment modifications (12/8/10 to 1/20/11). This note indicated the fall was an "equipment issue" and further Rehabilitation was not indicated. Review of the Nurse's Note of 1/31/11 indicated the resident was found on the floor in the resident's room. Review of the Investigation of the fall indicated the resident fell in the resident's room. The investigation indicated the resident was attempting to transfer self from the wheelchair to the bed. The investigation indicated the alarms were not on and not functioning. The investigation does not state why the alarms were not on. The care plan was updated 2/1/11 to include keeping the bed in the highest position wit