Every finding on record at Westford Nursing and Rehabilitation Center

Based on interviews and record review, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#13), when he/she changed hospice providers and remained in the facility, out of a total sample of 22 residents.Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2024, indicated a SCSA comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. The RAI Manual further indicated a SCSA is required to be performed when a terminally ill resident changes hospice providers and remains a resident at the nursing home. Resident #13 was admitted to the facility in April 2025 with diagnoses including malnutrition and chronic obstructive pulmonary disease (a lung disease that causes difficulty breathing). Review of Resident #13's readmission practitioner note, dated 5/14/25, indicated:- Patient has been readmitted to the facility with previous hospice services (Hospice Vendor #1) however it was noted that patient did not wish to continue with these hospice services.- Patient endorsing wish to transfer services to different hospice group. - Consult Hospice Vendor #2 for further hospice evaluation. Review of Resident #13's Hospice Vendor #2 form titled 'Facility Notification of Hospice Admission', dated 5/15/25, indicated:- Date of hospice admission: [DATE]. Review of Resident #13's physician's order, dated 6/16/25, indicated:- Resident admitted to Hospice Vendor #2 on 5/15/25. Review of the Significant Change in Status (SCSA) MDS assessment, dated 6/26/25, indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. This MDS also indicated Resident #13 received hospice services. Review of this SCSA indicated it was completed on 7/11/25, which was 57 days after he/she was admitted to new hospice provider. During an interview on 7/15/25 at 10:48 A.M., Resident #13 said he/she was on hospice and was concerned with the communication between the facility staff and Hospice Vendor #2. Resident #13 said he/she's not sure who is responsible for different parts of his/her care but would like to know what's going on regarding his/her current health status. During a follow-up interview on 7/16/25 at 10:03 A.M., Resident #13 said he/she had not been offered or had a care plan meeting since being admitted to Hospice Vendor #2 but would have liked to have one and would like to be more involved in his/her plan of care. Review of Resident #13's progress notes, dated 5/15/25 to 7/16/25, failed to indicate any care plan meeting had been offered to the Resident/Resident Representative. During an interview on 7/16/25 at 10:11 A.M., Unit Manager #1 said she attends all resident care plan meetings. Unit Manager #1 said she did not recall attending any care plan meetings for Resident #13 and that Social Worker #1 is responsible for scheduling care plan meetings. During an interview on 7/16/25 at 10:15 A.M., Social Worker #1 said Resident #13 had not had any care plan meetings since shortly after he/she was first admitted to the facility in April 2025. Social Worker #1 said all residents/resident representatives should be invited to participate in a care plan meeting within seven days after the completion of an MDS assessment, including a SCSA. Social Worker #1 said there is no MDS Coordinator in house and it was expected that the facility staff communicate any need to schedule a SCSA with the Regional MDS Coordinator. Social Worker #1 was unaware that a change in hospice providers required a SCSA. Social Worker #1 said Resident #13 has had many concerns since his/her admission and would have benefitted from the team going over his/her entire plan of care together during a care plan meeting after his/her change in hospice providers, but one was not scheduled. During an interview on 7/16/25 at 10:28 A.M., the Regional MDS Coordinator said there is not an MDS Coordinator physically in the facility, and the expectation is that the facility staff communicate the need for any SCSA to her in order for them to be scheduled. The Regional MDS Coordinator said a SCSA is required to be completed when a resident changes hospice provider and remains in the facility. The Regional MDS Coordinator said Resident #13 should have had a SCSA completed within 14 days of 5/15/25 when he/she changed hospice providers, but it was never scheduled because she was not notified. The Regional MDS Coordinator said a care plan meeting with the Resident/Resident Representative is required within seven days of the MDS completion. The Regional MDS Coordinator said it wasn't identified as missed until the end of June, which resulted in no care plan meeting invitation being offered to Resident #13. During an interview on 7/16/25 at 11:05 A.M., the Director of Nursing (DON) said she expects the facility to follow the RAI manual guidelines for MDS assessment completion. The DON said a SCSA should have been completed for Resident #13 within 14 days of the change in hospice provider, but it was not.

Based on observation, record review and interview, the facility failed to ensure nursing implemented physician's orders and the recommendations made by therapy services for one Resident (#10) out of a total sample of 22 residents. Specifically, the facility failed to ensure Resident #10 was wearing a soft hand splint as ordered by the physician and as recommended by the therapy department.Findings include: Review of the facility policy titled Specialized Rehabilitation Services, dated and revised December 2009, indicated the following:- Policy Interpretation and Implementation: Once a resident has met his/her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his/her functional and physical status.Resident #10 was admitted to the facility in December 2024 with diagnoses including multiple sclerosis, hemiplegia and hemiparesis affecting right dominant side.Review of Resident #10's most recent Minimum Data Set Assessment, dated 5/20/25, indicated a Brief Interview Status for Mental Status score of 12 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for activities of daily living, does not reject care, and has impairment on one side. The surveyor made the following observations:- On 7/15/25 at 9:54 A.M., Resident #10 was lying awake in his/her bed. His/her right hand was in a fisted position. Resident #10 said he/she used to wear something on his/her hand, but has not in a long time.- On 7/15/25 at 2:10 P.M., Resident #10 was lying awake in his/her bed. His/her right hand was in a fisted position. No hand device was being worn on his/her right hand.- On 7/16/25 at 9:27 A.M., Resident #10 was lying awake in his/her bed. His/her right hand was in a fisted position. No hand device was being worn on his/her right hand. Resident #10 said he/she has not worn a hand splint in a long time and would like to if staff asked him/her to put it on. Resident #10 said he/she thinks he/she can move his/her hand better when a splint is on. The Resident asked the surveyor to look in his/her room for the splint but one was not located.Review of Resident #10's physician's order dated 3/3/24 indicated the following:- Soft splint to RUE (right upper extremity) as tolerated. On in AM (morning) and remove at HS (bedtime). Assess skin integrity on 3-11 shift. Remove as needed for careReview of Resident #10's care plans indicated the following:- Focus: ADLS (activities of daily living): Resident is at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting - dated 5/13/22Intervention: Soft Splint to RUE as tolerated. On in AM and remove at HS (at night) - dated 3/3/24.- Focus: The Resident has limited physical mobility r/t (related to) contractures, MS (multiple sclerosis), weakness - dated 8/25/24Goal: The resident will demonstrate the appropriate use of soft hand splint to right hand contracture as tolerated- revised 2/11/25Review of Resident #10's Kardex (a form indicating the level of care a resident needs) indicated the following:- Other Devices: Soft splint to RUE as tolerated. On in AM and remove at HS- Dressing/Grooming/Bathing: PERSONAL HYGIENE:Provide Resident #10 with EXTENSIVE TO TOTAL assist of ONE for personal hygiene (grooming). Review of the Certified Nursing Assistant (CNA) documentation for the month of July 2025, indicated that CNAs provided grooming care to Resident #10 daily. Review of Resident #10's Occupational Therapy Evaluation and Plan of Treatment dated 12/31/24 indicated the following: Musculoskeletal System Assessment: Functional Limitations present d/t contracture = yes. Functional limitations as result of Contracture: self-care, ROM (range of motion) ROM; is skilled therapy needed to address impairment? = No (patient has splint which staff has been educated on donning/doffing). During an interview on 7/16/25 at 11:19 A.M., CNA #2 said Resident #10 is totally dependent on staff for ADLs. CNA #2 said Resident #10 has had a right-hand contracture for a long time and that he/she always used to wear a splint, but she does not know what happened to it as she has not seen it in a long time.During an interview on 7/16/25 at 11:22 A.M., CNA #1 said she performs ADL care on Resident #10 since he/she is dependent on care. CNA #1 said Resident #10's right hand has always been in a fisted position and she does not remember seeing a hand splint on his/her hand.During an interview 7/16/25 at 11:34 A.M., Nurse #1 said Resident #10's right hand is contracted, and he/she wears a splint. Nurse #1 said the three o'clock shift is in charge of putting the splint on. The surveyor and Nurse #1 observed Resident #10 lying in his/her bed and he/she was not wearing a splint. Nurse #1 located the splint in the corner of the Resident's room on a chair under a pile of clothes. Nurse #1 and the surveyor reviewed Resident #10's physician's orders and she said the morning shift should be putting the splint on. Nurse #1 said all physician's orders should be followed as written.During an interview on 7/16/25 at 11:41 A.M., the Director of Rehab (DOR) said Resident #10 has had a right-hand contracture since 2023. The DOR said when Resident #10 was last seen by therapy, direct care staff were educated on how to don and doff the Resident's splint. The DOR said he/she should be wearing the hand splint as ordered.During an interview on 7/16/25 at 11:59 A.M., Unit Manager #2 said staff should be putting on Resident #10's splint in the morning, and if the resident refuses, then it needs to be documented. Unit Manager #2 said physician's orders should be followed as written.During an interview on 7/16/25 at 12:12 P.M., the Director of Nursing (DON) said Resident #10 should be wearing his/her hand splint every day as ordered by the physician. The DON said the Resident sometimes refuses but if so, then staff need to be documenting that in the medical record. The DON said that CNA's should be checking Resident #10's Kardex and if he/she is not wearing it then they need to let nursing know.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for one Resident (#10) out of a total sample of 22 residents. Specifically, the facility failed to ensure Resident #10's fingernails were cut short in his/her right contracted hand.Findings include:Review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised March 2018, indicated the following:- Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene.- Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, oral care)Resident #10 was admitted to the facility in December 2024 with diagnoses including multiple sclerosis, hemiplegia and hemiparesis affecting right dominant side.Review of Resident #10's most recent Minimum Data Set assessment dated [DATE] indicated a Brief Interview Status for Mental Status score of 12 out of 15, indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for activities of daily living, does not reject care and has impairment on one side. - On 7/15/25 at 9:54 A.M., Resident #10 was lying awake in his/her bed. His/her right hand was in a fisted position. Resident #10's pointer, middle and ring finger nails were roughly one inch in length and pressing into his/her palm. Resident #10 said someone normally comes in and cuts his/her nails but doesn't remember the last time it happened.- On 7/15/25 at 2:10 P.M., Resident #10 was lying awake in his/her bed. His/her right hand was in a fisted position. Resident #10's pointer, middle and ring finger nails were roughly one inch in length and pressing into his/her palm.- On 7/16/25 at 9:27 A.M., Resident #10 was lying awake in his/her bed. His/her right hand was in a fisted position. Resident #10's pointer, middle and ring finger nails were roughly one inch in length and pressing into his/her palm.Review of Resident #10's care plans indicated the following:Focus: ADLS: Resident is at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting - dated 5/13/22Intervention: Personal Hygiene: Provide Resident #10 with extensive to total assist of one for personal hygiene (grooming) - dated 1/18/22.Review of Resident #10's Kardex (a form indicating the level of care a resident needs) indicated the following:- Dressing/Grooming/Bathing: PERSONAL HYGIENE: Provide Resident #10 with extensive to total assist of one for personal hygiene (grooming). Review of the Certified Nursing Assistant (CNA) documentation for the month of July 2025, indicated that CNAs provided grooming care to Resident #10 daily. During an interview on 7/16/25 at 11:19 A.M., CNA #2 said Resident #10 is totally dependent on staff for ADLs. CNA #2 said Resident #10 needs help with cutting his/her nails and we should be cutting them if they are long.During an interview on 7/16/25 at 11:22 A.M., CNA #1 said she performs ADL care on Resident #10 since he/she is dependent on care. CNA #1 said CNA's cut residents' nails every week or if she notices they are long. CNA #1 and the surveyor observed Resident #10's fingernails on his/her right contracted hand. CNA #1 had to manually extend the Resident's fingers out of a fisted position to see his/her nails. CNA #1 said they are long and need to be cut. During an interview 7/16/25 at 11:34 A.M., Nurse #1 said Resident #10's right hand is contracted and CNAs should be performing ADL care for the Resident daily. Nurse #1 and the surveyor observed Resident #10's fingernails on his/her right contracted hand, Nurse #1 had to manually extend the Resident's fingers out of a fisted position to see his/her nails. Nurse #1 said they are long and need to be cut. Nurse #1 said they are starting to press into the Resident's palm.During an interview on 7/16/25 at 11:41 A.M., the Director of Rehab (DOR) said Resident #10 has had a right hand contracture since 2023. The DOR said staff should make sure Resident #10's fingernails are clipped short on his/her right contracted hand to maintain skin integrity. The DOR said if therapy staff notice long fingernails they would notify the Resident's nurse.During an interview on 7/16/25 at 11:59 A.M., Unit Manager #2 said Resident #10 is totally dependent on staff for ADL care. Unit Manager #2 said his/her fingernails should be cut short, especially on his/her contracted hands.During an interview on 7/16/25 at 12:12 P.M., the Director of Nursing (DON) said fingernails should be checked daily and if staff notice they are long, they should be cut. The DON said if a resident refuses any care then it needs to be documented in the medical record. The DON said staff should be checking on Resident #10's fingernails since his/her right hand is contracted.

Based on observation, interview, policy and record review, the facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication, also referred to as a feeding tube) for two Residents (#57 and #80), for two applicable residents, out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. For Resident #57, provide appropriate care and services to facilitate restoring oral eating skills as possible for the Resident. 2. For Resident #80, verify proper placement of a G-tube every shift to identify and prevent potential complications associated with enteral (passing through the gastrointestinal [GI] tract) feeding. Findings include: 1. Resident #57 was admitted to the facility in March 2024, with diagnoses including Gastrostomy, Dementia (loss of memory, language, problem-solving and other thinking abilities) and Dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #57: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of a total score of 15 -was dependent for all activities of daily living (ADL - bathing, grooming and dressing) -and had a G-tube Review of the GI Follow-up Progress Note dated 4/15/24, indicated that Resident #57's G-tube was placed on 3/7/24 during an inpatient admission after the Resident had failed multiple swallow evaluations. The GI Progress Note also indicated that the Resident had a repeat video swallow evaluation that had gone well, and his/her diet was advanced to mildly thick nectar liquids and pureed solids, and the Resident was to follow-up with Speech Therapy at the facility. Review of Resident #57's Care Plan for Tube Feedings, dated 3/14/24, indicated an intervention for Speech Therapy evaluation and treatment as ordered. Review of Resident #57's June 2024 Physician's orders indicated: -3/12/24 Speech evaluation and treat as needed -3/12/24 Nothing by mouth (NPO) -3/15/24 Enteral Feed Order every shift for nutrition: Glucerna 1.5 (nutritional liquid supplement low in calories and sugar, high in protein) at 50 milliliters per hour (ml/hr) continuous -3/25/24 Recommended Skilled Speech Therapy services: 12 visits x 30 days for Dysphagia management. Review of the Speech Therapist Notes, dated 4/5/24, indicated the following: -Resident demonstrated adequate oropharyngeal performance (a voluntary process that uses motor and sensory pathways to move food from the mouth to the oropharynx [middle section of the throat] triggering a series of reflexive movements). -With trials of soft sandwich requests adequate breakdown and timely appearing swallow, no to limited sign and symptom with trials, however Resident continued with significant GI concern with vomiting occurring post completion of small amounts of intake. -Was compliant with trials with Speech Therapy. During an interview on 6/11/24 at 10:01 A.M., Resident #57 said he/she has been asking to eat orally but was informed by the facility staff that he/she had to wait for the Speech Therapist. During an interview on 6/13/24 at 10:14 A.M., the Director of Rehabilitation Services said Resident #57 was discharged from Speech Therapy services on 4/24/24. During an interview on 6/13/24 at 4:59 P.M., the Speech Therapist (ST) said Resident #57 had been discharged from speech therapy sessions since 4/24/24, because the Resident had episodes of vomiting during the therapy sessions and needed to be evaluated by the Physician. The ST said she treated the Resident on three occasions and had brought the concerns about the Resident vomiting to the nursing staff and the Registered Dietitian (RD). During an interview on 6/13/24 at 5:15 P.M., the RD said she knew that Resident #57 had been discharged from speech therapy services. The RD said that she had spoken with the ST regarding concerns for Resident #57 having vomiting episodes after eating. The RD said if there were concerns for a Resident having vomiting relative to eating, the RD would alert the Director of Nursing (DON), and the DON would then notify the Physician or Nurse Practitioner (NP) so that the Resident could be assessed. The RD could not say whether she had informed the DON of Resident #57's vomiting after eating. During an interview on 6/14/24 at 7:59 A.M., the Infection Preventionist (IP) said Resident #57 would ask for food all the time but the IP knew that the Resident was working with Speech Therapy before his/her diet could be advanced. During an interview on 6/14/24 at 8:09 A.M., Resident #57's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself)) said Resident #57 was expected to be followed by Speech Therapy and that the G-tube was not supposed to be permanent. During an interview on 6/14/24 at 8:20 A.M., Nurse #1 said Resident #57 was working with Speech Therapy and that other staff could not provide oral feedings to the Resident until the Speech Therapist said that it was safe to do so. During an interview on 6/16/24 at 9:13 A.M., the Nurse Practitioner (NP) said the facility staff had not informed her that Resident #57 had been discharged from Speech Therapy sessions, that the Resident was expected to continue with oral feeding trials, and that the G-tube was not permanent. The NP said if she had been made aware of the Resident's vomiting, she would have made changes to the Resident's medications to ensure he/she tolerated the oral feedings. The NP further said she could have reached out to the GI Physician if a trial of medications to manage the vomiting had failed. The NP said that these interventions had not occurred because she was not made aware of the Speech Therapist's concern. During an interview on 6/14/24 at 10:38 A.M., the DON said she was not aware until the surveyor's inquiry that Resident #57 had been discharged from speech therapy sessions and that the discharge from speech therapy was due to vomiting. The DON said since she was not aware she had not informed the Physician or NP of any concerns that needed to be addressed for the Resident. 2. Resident #80 was admitted to the facility in February 2024 with diagnoses including Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment), Gastrostomy and Dysphagia. Review of the facility policy titled Enteral Tube Feeding via Gravity Bag, last revised March 2024, indicated: -Verify placement of feeding tube. -When correct tube placement has been verified, flush tubing with at least 30 ml of warm water. Review of the MDS assessment dated [DATE], indicated that Resident #80: -was severely cognitively impaired as evidenced by a BIMS score of 2 out of a total score of 15 -was dependent with ADL care -and had a G-tube Review of Resident #80's June 2024 Physician's orders included the following: -3/3/24 Enteral Feed Order: five times a day for hydration, water flush - 90 mls of warm water before and after every bolus (a method of tube feeding that involves delivering a large amount of formula or liquid food through a feeding tube in several doses throughout the day). -2/12/24 NPO -2/15/24 Enteral Feed Order: [NAME] times a day related to moderate protein-calories malnutrition, Jevity 1.5 (source of nutrition) Cal, administer 240 mls bolus (slowly administering large amounts of formula multiple times a day) via gravity five times a day. On 6/13/24 at 9:47 A.M., the surveyor observed Nurse #1 administer a bolus feeding to Resident #80. Nurse #1 did not check to verify proper placement of the G-tube prior to administering the bolus feeding. During an interview on 6/13/24 at 11:15 A.M., Unit Manager (UM) #1 said he was unsure whether the facility staff were required to check for placement of Resident #80's G-tube. During an interview on 6/13/24 at 11:30 A.M., Nurse #1 said she should have checked for G-tube placement, but she did not. During an interview on 6/13/24 at 11:45 A.M., the DON said there should have been a Physician's order to check for placement of Resident #80's G-tube when he/she was admitted to the facility. The DON also said that Nurse #1 should have checked to verify placement of the Resident's G-tube prior to administering the bolus feeding as required.

Based on record review and interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing, of a transfer or discharge for four Residents (#66, #43, #73, #51) out of a total sample of 23 residents. Specifically: 1. For Resident #66, the facility failed to notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred out of the facility to the hospital on 11/11/23, 12/22/23, 3/11/24 and 5/15/24. 2. For Resident #43, the facility failed to notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred to the hospital on 3/3/24. 3. For Resident #73, the facility failed to notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred out of the facility to the hospital on 11/4/23, 2/4/24, and 2/15/24. 4. For Resident #51, the facility failed to notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred out of the facility to the hospital on 3/3/24. Findings include: 1. Resident #66 was admitted to the Facility in June 2023 with diagnoses including Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs), Atrial Fibrillation (A-fib: irregular, rapid heartbeat that can lead to blood clots and other heart related complications) and Dementia (a group of conditions that impair brain functions such as memory and judgment). Review of Resident #66's clinical record indicated the following: -Resident #66 was transferred to the hospital on 11/11/23 and returned to the facility 11/12/23. -Resident #66 was transferred to the hospital on 12/22/23 and returned to the facility 12/23/23. -Resident #66 was transferred to the hospital on 3/11/24 and returned to the facility 3/13/24. -Resident #66 was transferred to the hospital 5/15/24 and returned to the facility 5/16/24. Further review of Resident #66's clinical record did not indicate any evidence that the Office of the State Long-Term Care Ombudsman had been notified in writing of any of the hospital transfers for Resident #66. During an interview on 6/13/24 at 11:16 A.M., the Social Worker (SW) said that she had worked in the facility since October 2023 and is responsible for providing bed hold and transfer notices to Residents and/or their Representatives upon transfer or discharge from the facility. The SW said that she could not provide any evidence the Office of the State Long-Term Care Ombudsman had been notified in writing when Resident #66 was transferred to the hospital on 11/11/23, 12/22/23, 3/11/24, and 5/15/24. The SW also said that she was unaware that the facility was required to notify the Office of the State Long-Term Care Ombudsman when residents were transferred or discharged from the facility. 2. Resident #43 was admitted to the facility July 2023 with diagnoses including Peripheral Vascular Disease (a circulatory condition in which blood vessels narrow causing reduced blood flow to the limbs) and Diabetes Mellitus 2 (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). Review of Resident #43's clinical record indicated that Resident #43 was transferred to the hospital on 3/3/24 and returned from the hospital to the facility on [DATE]. Further review of Resident #43's clinical record did not indicate any evidence that the Office of the State Long-Term Care Ombudsman had been notified in writing when Resident #43 was transferred to the hospital on 3/3/24. During an interview on 6/13/24 at 11:16 A.M., the SW said that she could not provide any evidence that the Office of the State Long-Term Care Ombudsman had been notified in writing when Resident #43 was transferred to the hospital on 3/3/24. The SW said that she was unaware that the facility was required to notify the Office of the State Long-Term Care Ombudsman when residents were transferred or discharged from the facility. 47901 3. Resident #73 was admitted to the facility in February 2023 with diagnoses including Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area), Atherosclerotic Heart Disease (build up of fats, cholesterol and other substances in the artery causing decreased blood flow to the heart) and Pulmonary Embolism (blood clot in the lungs). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15. Review of Resident #73's clinical record indicated the following: -Resident #73 was transferred to the hospital on 11/4/23 and returned to the facility on [DATE] -Resident #73 was transferred to the hospital on 2/4/24 and returned to the facility on [DATE] -Resident #73 was transferred to the hospital on 2/15/24 and returned to the facility on [DATE] Further review of Resident #73's clinical record did not indicate any evidence that the Office of the State Long-Term Care Ombudsman had been notified in writing of any of the hospital transfers for Resident #73. During an interview on 6/13/24 at 1:14 P.M., the SW said notification to the Office of the State Long-Term Care Ombudsman had not been done as required. 42761 4. Resident #51 was admitted to the facility in February 2024 with diagnoses including severe protein calorie malnutrition (condition where the body lacks enough protein and energy to function properly) and gastrostomy (G tube: tube inserted through the abdominal wall into the stomach, used to deliver nutrition) status. Review of Resident #51's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 total points. -The Resident was transferred to the hospital on 3/3/24 and his/her return to the facility was anticipated. Review of Resident #51's Transfer to Hospital Form dated 3/3/24, indicated the Resident was transferred from the facility to the hospital due to the Resident having removed his/her G tube. Review of Resident #51's clinical record indicated the following: -The Resident did not return from the hospital to the facility. -No evidence that the facility notified the Office of the State Long-Term Care Ombudsman in writing of the Resident's hospital transfer. During an interview on 6/14/24 at 10:30 A.M., the Director of Nursing (DON) said the facility could not provide any evidence that the Office of the State Long-Term Care Ombudsman was notified in writing of Resident #51's hospital transfer which occurred on 3/3/24.

Based on record review and interview, the facility failed to reassess one Resident (#99) out of a total sample of 23 residents, using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) at least once every three months. Specifically, the facility staff failed to complete a Quarterly Minimum Data Set (MDS) Assessment for Resident #99 when the MDS Assessment was due, which increased the Resident's risk for an unidentified change in status between assessments. Findings include: Resident #99 was admitted to the facility in October 2023 with a diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of Resident #99's clinical record indicated the following: -A Quarterly MDS Assessment, completed 1/30/24. -No evidence that any other Quarterly MDS Assessments had been completed after 1/30/24. During an interview on 6/13/24 at 2:19 P.M., the MDS Coordinator said the last MDS Assessment that had been completed for Resident #99 was done on 1/30/24, and the Resident should have had another Quarterly MDS Assessment since 1/30/24. The MDS Coordinator said that Quarterly MDS assessments were important because completing the assessments helped to identify changes in the residents' status between comprehensive assessments. The MDS Coordinator said a Quarterly MDS Assessment should have been completed for Resident #99 in April 2024, but the Quarterly MDS Assessment was not completed.

Based on observation, interview, and record review, the facility failed to complete assessments that accurately reflected the status of two Residents (#103 and #95) out of a total sample of 23 residents. Specifically, facility staff failed to complete: 1. an accurate assessment relative to wandering (aimless walking, getting lost, repetitive pacing) for Resident #103 2. an accurate assessment relative to cognition on the facility's Smoking Assessment for Resident #95. Findings include: 1. Resident #103 was admitted to the facility in February 2024 with diagnoses including Dementia (group of symptoms that affects memory, thinking and interferes with daily life) with Behavioral Disturbance. Review of Resident #103's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of 15 total points. -The Resident had exhibited wandering daily during the assessment period with the risk for getting into a potentially dangerous place. Review of Resident #103's Behavior Care Plan, initiated 2/18/24 and revised 6/11/24, indicated: -Resident #103 . wanders . intrusive at times . related to Dementia. Review of Resident #103's MDS Assessment, dated 5/21/24, indicated the following: -The Resident was severely cognitively impaired as evidenced by a BIMS score of four out of 15 total points. -The Resident exhibited no wandering behavior. Review of Resident #103's Certified Nurses Aide (CNA) Behavior Record for May 2024, indicated the Resident wandered with intrusive behavior during the observation assessment period for the MDS Assessment, dated 5/21/24, on six out of seven days as follows: 5/15/24 - 5/17/24 and 5/19/24 - 5/21/24. Review of Resident #103's Quarterly Nursing Assessment, dated 5/21/24, indicated the following: -The Resident was ambulatory. -The Resident had a history of elopement. -The Resident walked independently on the Unit. -The Resident wandered daily, and the wandering was not new. -The Resident had inattention and disorganized thinking. Further review of Resident #103's Quarterly Nursing Assessment did not indicate the Resident as being at risk for wandering and the section to identify interventions implemented for wandering was blank. During an interview on 6/13/24 at 11:30 A.M., CNA #1 said Resident #103 wandered daily and when the Resident wandered, staff were to provide the Resident with redirection and document the wandering behavior on the CNA Behavior Record. During an interview on 6/13/24 at 11:34 A.M., with Unit Manager (UM) #3 and the MDS Coordinator, UM #3 said Resident #103 wandered often and required redirection from staff when wandering occurred. The surveyor and UM #3 reviewed Resident #103's Quarterly Nursing assessment dated [DATE], and the May 2024 CNA Behavior Record. UM #3 said Resident #103 exhibited wandering behaviors at the time the Quarterly Nursing Assessment was completed, but she was not sure whether the Assessment should have indicated the Resident as being at risk for wandering or whether the interventions provided should have been included in the assessment. The MDS Coordinator said she would review Resident #103's clinical record and get back to the surveyor on whether wandering should have been coded under behaviors on the Resident's MDS Assessment, dated 5/21/24. During an interview on 6/13/24 at 12:10 P.M., the surveyor and the Director of Nursing (DON) reviewed Resident #103's Quarterly Nursing Assessment. The DON said the Assessment indicated the Resident wandered daily, and the Assessment should have indicated the Resident was at risk for wandering and should have included the interventions provided to Resident #103 for wandering. During a follow-up interview on 6/13/24 at 2:19 P.M., the MDS Coordinator said she reviewed Resident #103's clinical record and that the Resident did exhibit wandering behaviors during the observation assessment period for the MDS assessment dated [DATE]. The MDS Coordinator said wandering should have been coded on Resident #103's MDS Assessment, but it was not. 44337 2. Review of the facility policy titled Smoking-Residents last revised July 2017, indicated the following: -The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include current level of tobacco consumption, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision (per completed safe smoking evaluation). Resident #95 was admitted to the facility in May 2024, with a diagnosis of Wernicke's Encephalopathy (a degenerative brain disorder caused by the lack of thiamine [vitamin B1] that causes mental confusion, vision problems, and lack of muscle coordination). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #95 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a total score of 15. Review of Resident #95's current Smoking assessment dated [DATE], indicated the Resident smoked cigarettes and had no cognitive impairment. During an interview on 6/12/24 at 12:28 P.M., Unit Manager (UM) #1 said she performed smoking assessments on residents who smoked to determine if the residents were safe to smoke independently or if they required supervision to smoke. UM#1 said that she had completed a facility Smoking Assessment when Resident #95 was first admitted to the facility by observing him/her smoke in the designated smoking area and determined that Resident #95 could smoke independently. UM #1 also said that all residents who resided in the facility who smoke were independent smokers. During an interview on 6/12/24 at 12:47 P.M., the Administrator said that an MDS assessment dated [DATE], indicated Resident #95 scored a four on the BIMS assessment and a facility Smoking Assessment completed 5/28/24, indicated Resident #95 had no cognitive loss/impairment. The Administrator said that Resident #95 had cognitive loss because he/she had a BIMS score of four and that the Smoking Assessment done on 5/28/24 was inaccurate. The Administrator further said that a Resident with a BIMS score of four would most likely not be an independent smoker.

Based on interview, record and policy review, the facility failed to provide interdisciplinary team (IDT: professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs. An interdisciplinary team is not just a group of experts implementing separate treatments on a patient. They complement one another's expertise and actively coordinate to work toward shared treatment goals) review and revision of care plans after each Minimum Data Set (MDS) assessment for three Residents (#103, #55, and #61) out of a total sample of 23 residents. Specifically, the facility staff failed to provide IDT review and revision of: 1. Resident #103's care plan following an MDS Assessment completed for the Resident on 3/13/24. 2. Resident #55's care plan following MDS Assessments completed for the Resident on 8/10/23, 2/6/24, and 5/7/24. 3. Resident #61's care plan following MDS Assessments completed for the Resident on 1/12/24 and 4/10/24. Findings include: Review of the facility's policy, titled Care Planning - Interdisciplinary Team, dated March 2022, indicated the following: -Comprehensive, person-centered care plans are based on resident assessments and developed by an IDT. -Care plan meetings are scheduled at the best time of day for the residents and family when possible. 1. Resident #103 was admitted to the facility in January 2024 with a diagnosis of Dementia (group of symptoms that affects memory, thinking and interferes with daily life) with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). Review of Resident #103's clinical record indicated the following relative to MDS assessments: -One MDS Assessment, with an assessment reference date (ARD: the last date of the observation period which serves as the reference point for determining care and services captured on the MDS Assessment) of 2/22/24, was completed on 3/13/24. -One MDS Assessment, with an ARD of 5/21/24, was completed on 6/4/24. Further review of Resident #103's clinical record indicated no evidence that the facility's IDT reviewed and revised the Resident's care plan after the MDS Assessments were completed on 3/13/24 and 6/4/24. 2. Resident #55 was admitted to the facility in May 2019 with a diagnosis of Dementia with Behavioral Disturbance. Review of Resident #55's clinical record indicated the following relative to MDS assessments: -One MDS Assessment, with an ARD of 8/1/23, was completed on 8/10/23 -One MDS Assessment, with an ARD of 1/30/24, was completed on 2/6/24 -One MDS Assessment, with an ARD of 4/30/24, was completed on 5/7/24 Further review of Resident #55's clinical record indicated no evidence that the facility's IDT reviewed and revised the Resident's care plan after the MDS Assessments were completed on 8/10/23, 2/6/24, and 5/7/24. 50320 3. Resident #61 was admitted to the facility January 2022 with diagnosis of Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating the Resident had severe cognitive impairment. Review of the Resident's clinical record indicated the following relative to MDS assessments: -One MDS Assessment, with an ARD of 12/26/23, was completed on 1/12/24 -One MDS Assessment, with an ARD of 3/26/24, was completed on 4/10/24 Further review of Resident #61's clinical record indicated no evidence that the facility's IDT reviewed and revised the Resident's care plan after the MDS Assessments were completed on 1/12/24 and 4/10/24. During an interview on 6/12/24 at 11:15 A.M., the Social Worker (SW) said she was responsible for setting up and inviting Residents and their Representatives to care plan meetings based on the calendar of MDS Assessments due for Residents each month. The SW said she would contact Residents and their Representatives to inquire whether they wanted to have an IDT meeting to review the care plan, and if no IDT meeting was desired, the IDT did not meet collaboratively to review and revise the care plan, but would individually complete their specified sections of the care plan. The SW also said she did not realize that the IDT review of Residents' care plans was required to occur following completion of the MDS Assessments and that she thought the reviews could occur anytime during the month the MDS Assessments were scheduled to be completed. The SW further said she could not provide evidence that IDT care plan reviews and revisions occurred following MDS Assessment completions for Residents #103, #55, and #61 for the dates indicated.

Based on observation, interview, and policy review, the facility failed to provide an environment that was as free of accidents and hazards as possible for two Residents (#95, #44), out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. For Resident #95, secure a disposable lighter from the Resident after he/she returned from a smoking activity. 2. For Resident # 44, implement monitoring of the Resident during a smoking activity when the Resident had a diagnosis of Seizure Disorder (also known as Epilepsy, a brain condition that causes recurring seizures [sudden, uncontrolled burst of electrical activity in the brain that causes changes in behavior, movements, feelings and level of consciousness]) and was known to have seizures occur while smoking independently. Findings include: Review of the facility policy titled Smoking-Residents last revised July 2017 indicated the following: -The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include current level of tobacco consumption, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision (per completed safe smoking evaluation). -The staff shall consult with the attending Physician and the Director of Nursing (DON) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. -A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) as determined by staff. 1. Resident #95 was admitted to the facility in May 2024 with a diagnosis of Wernicke's Encephalopathy (a degenerative brain disorder caused by the lack of Vitamin B1 that causes mental confusion, vision problems, and lack of muscle coordination). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #95 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a total score of 15. Review of Resident #95's facility Smoking Policy Contract, signed by the Resident on 5/17/24, indicated that independent smokers are prohibited to have any lighters in their possession at any time except while smoking in the facility designated smoking area. On 6/11/24 at 9:21 A.M., the surveyor observed Resident #95 remove a red disposable lighter from his/her front pants pocket. During an interview at the time, Resident #95 said that he/she smoked and kept the lighter to light his/her cigarettes. Resident #95 said he/she went outside whenever he/she wanted to smoke. During an interview and observation on 6/11/24 at 9:46 A.M., Nurse #1 said residents are not permitted to keep disposable lighters in their possession because it was unsafe. Nurse #1 said that disposable lighters are supposed to be kept in a drawer at the nurse's station. The surveyor observed Nurse #1 asking Resident #95 if he/she had a disposable lighter in his/her pocket. Resident #95 was observed to remove the disposable lighter from his/her front pocket and gave it to Nurse #1. During an interview on 6/11/24 at 4:04 P.M., the Administrator said that all residents who smoked signed a facility Smoking Policy Contract which included a statement that smokers were prohibited to have disposable lighters in their possession. The Administrator said that residents who smoke are required to return disposable lighters to the nurse's station immediately after they attended a smoking activity, and that Resident #95 should not have had a disposable lighter in his/her pocket. 47901 2. Resident #44 was admitted to the facility in June 2023 with diagnoses including Seizure Disorder and Cerebrovascular Accident with left sided hemiparesis (stroke [interruption of blood flow to part of the brain] with left sided weakness). Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #44: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15. -with left upper and left lower extremities (a limb of the body, such as the arm or leg) impaired. -was wheelchair dependent. During an interview on 6/11/24 at 9:05 A.M., Resident #44 said that he/she had a seizure while he/she was smoking, slid out of the wheelchair to the floor and was sent out to the hospital. Resident #44 further said upon his/her return from the hospital the facility staff noted that he/she had obtained three skin tears on his/her left hand from the fall. Review of the Smoking Assessment completed on 12/23/23, indicated that Resident #44 was an independent smoker. Review of Resident #44's Care Plan indicated that during seizure activity, staff should document the type of seizure, duration, level of consciousness, any incontinence, whether the Resident slept or was dazed after seizure activity. Further review of the Resident's Care Plan indicated not to leave the Resident alone during seizure activity. The Resident's Care Plan also indicated to protect the Resident from onlookers but did not include any precautions for when the Resident was outside smoking by himself/herself. During an interview on 6/12/24 at 2:21 P.M., Unit Manager (UM) #1 said Resident #44 fell out of the wheelchair during seizure activity while the Resident was outside smoking. UM #1 said he was unsure of the seizure precautions in place for Resident #44 while he/she was outside smoking independently. During an interview on 6/12/24 at 4:43 P.M., the Nurse Evening Supervisor said she was informed by another Resident who was outside smoking that Resident #44 had fallen out of his/her wheelchair and on the ground while smoking. The Nurse said she was unsure how long Resident #44 had been on the floor but when she was notified, a staff member went to the smoking area to stay with the Resident until the Emergency Medical Services (EMS) arrived and Resident #44 was transferred to the hospital. During an interview on 6/12/24 at 4:53 P.M., the Social Worker (SW) said she had been assigned to supervise the smoking area as of 6/12/24 and that the facility had initiated a rotation schedule to supervise the Residents during smoking. During an interview on 6/13/24 at 10:15 A.M., Resident #44 said that he/she had to wait to be accompanied by a facility staff member when he/she was outside smoking moving forward.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for one Resident (#101) out of one applicable resident, out of a total sample of 23 residents, who required dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment. Specifically, the facility staff failed to provide the delivery of meals in coordination with Resident #101's dialysis treatment schedule to ensure that the Resident received meals and/or snacks on dialysis treatment days. Findings include: According to the National Institute of Diabetes and Digestive and Kidney Disease, revised September 2016: (https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis/eating-nutrition), a person's choices on nutrition and hydration while on hemodialysis can make a difference in how the person feels and can make the treatment work better. Resident #101 was admitted to the facility in May 2024, with diagnoses including End Stage Renal Disease (ESRD: the final and permanent stage of chronic kidney disease, kidneys are no longer able to function properly and meet the body's needs), Type 1 Diabetes (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), Nutritional Anemia (a condition where the body's hemoglobin concentration drops due to a deficiency in one or more nutrients), and Protein-Calorie Malnutrition (nutritional state that occurs when someone does not get enough food, calories, protein or other essential nutrients). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #101 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a total score of 15. On 6/11/24 at 10:47 A.M., the surveyor observed an untouched breakfast tray in Resident #101's room with the breakfast meal intact. The surveyor also observed that the Resident was not in the room. At 11:05 A.M., the surveyor observed a staff member enter the Resident's room and remove the breakfast tray. During an interview at the time, the staff member said Resident #101 was out of the facility for dialysis treatment. During an interview on 6/11/24 at 11:25 A.M., Resident #101 said he/she had just returned to the facility from his/her dialysis treatment. The Resident said his/her only concern was not eating breakfast before or after dialysis on dialysis treatment days. Resident #101 further said that he/she went to dialysis treatment four days a week. Review of the Physician's orders for May 2024 and June 2024 indicated that Resident #101 attended dialysis treatments on Mondays, Tuesdays, Thursdays, and Fridays and is picked up by 5:30 A.M. on treatment days. During an interview on 6/12/24 at 10:25 A.M., Unit Manager (UM) #1 said Resident #101 would leave the facility for dialysis treatments at 5:30 A.M UM #1 was unsure whether the Resident received breakfast or snacks before he/she left for dialysis treatments or upon returning from dialysis. During an interview on 6/12/24 at 5:14 P.M., the surveyor and the Director of Nursing (DON) reviewed the meal percentage intake and the DON said there was no indication that Resident #101 had received breakfast or snacks on the mornings of dialysis treatment days. During an observation on 6/13/24 at 8:43 A.M., the surveyor observed Resident #101's room and noted that there was a breakfast meal tray and the breakfast had been eaten. During a follow-up interview on 6/13/24 at 9:09 A.M., the DON said Resident #101 should have received breakfast and/or snacks on the mornings of the dialysis treatment days, but he/she had not. During an interview on 6/13/24 at 11:30 A.M., Resident #101 said the dialysis treatment went better today than any other day because he/she was given breakfast at 5:15 A.M., and that he/she finished eating the breakfast meal before he/she was picked up for his/her dialysis treatment.

Based on observation, record review and interview, the facility failed to ensure that nursing staff implemented and established systems to accurately reconcile controlled medications using acceptable standards of practice on two Units (Edgewood and [NAME]) of three units observed. Specifically, the facility failed to: 1. Maintain documentation of prescription numbers with the date of receipt of controlled substance medications and transfers. 2. Maintain professional standards of practice for discharging and transferring controlled medications within the narcotic book. Findings include: Review of the facility policy tiled Controlled Substances, revised April 2019, indicated the following: -The Nurse receiving the medication and the individual delivering the medication verify the name, dose and quantity of each medication. -Both individuals sign the controlled substance record of receipt. -An individual resident-controlled substance record contains: a) name of the resident b) name and strength of the medication c) quantity received d) prescription number e) name of issuing pharmacy f) date and time received . During medication storage review on 6/12/24 at 7:26 A.M., the surveyor observed the following in the Units Narcotic Books for Controlled Substance documentation logs: Edgewood Unit, Medication Cart #1: -On page 65, there was no prescription number documented for the Tramadol (used to treat pain) medication, no documented date of the receipt of the medications, and one Nurse had transferred the medications to page 100. -On page 69, one Nurse had transferred the Tramadol medication page to page 79, and another Nurse had signed the medication out as sent home with a patient. -On page 70, one Nurse had transferred the Clonazepam medication (used to treat anxiety disorder) for a resident to page 109, and on page 109, the surveyor found there was a different medication for a different resident documented. -On page 91, one Nurse had transferred Pregabalin medication (used to treat anxiety) to page 101. -On page 106, Clonazepam medication had no prescription number and no date as to when it was received. -On page 107, Oxycodone (used to treat pain) medication had no prescription number and no date as to when it was received. -On page 109, Tramadol medication had no prescription number and no date as to when it was received. -On page 111, Oxycodone medication had no prescription number and no date as to when it was received. Edgewood Unit, Medication Cart #2: -On page 75, Lacosamide medication (used to treat neuropathic pain/ seizures) had been transferred by one Nurse to page 94 -On page 76, Lorazepam medication (used to treat anxiety) had been transferred by one Nurse to page 98. -On page 77, Morphine Sulfate (used to treat pain) medication had no prescription number and no date as to when it was received. -On page 79, Oxycodone medication had been transferred by one Nurse to page 101. -On page 98, Tramadol medication had no prescription number and no date as to when it was received. -On page 100, Tramadol medication had no prescription number and no date as to when it was received. -On page 101, Oxycodone medication had no prescription number and no date as to when it was received. [NAME] Unit, Medication Cart #1: -On page 78, one Nurse transferred Buprenorphine medication (used to treat moderate to severe pain and opioid dependence) to page 87, there was no prescription number and no date the medication was received. -On page 92, Morphine Sulfate medication was removed from the emergency kit, there was no date or emergency kit number. -On page 93, Morphine Sulfate solution medication had no prescription number and no date as to when it was received. -On page 101, Tramadol medication had no prescription number and no date as to when it was received. -On page 102, Lorazepam medication had no prescription number and no date as to when it was received. -On page 103, Dilaudid medication (used to treat pain) had no prescription number and no date as to when it was received. -On page 105, Tramadol medication had no prescription number and no date as to when it was received. -On page 106, Tramadol medication had no prescription number and no date as to when it was received. -On page 107, Lorazepam medication had no prescription number and no date as to when it was received. -On page 108, Clonazepam medication had no prescription number and no date as to when it was received. -On page 109, Clonazepam medication had no prescription number and no date as to when it was received. -On page 110, Clonazepam medication had no prescription number and no date as to when it was received. During an interview on 6/12/24 at 10:14 A.M., the surveyor and Nurse #2 reviewed the Narcotic Book and Nurse #2 said the Nurses were expected to document prescription numbers and the date the facility received the medications in the Controlled Substance Narcotic Books, but they had not done this. During an interview on 6/12/24 at 10:27 A.M., the surveyor and Unit Manager (UM) #2 reviewed the Narcotic Book and UM #2 said the Nurses were expected to document when medications were received from the pharmacy and when the medications are transferred from one page to another, but they had not. UM #2 further said the Nurses were expected to document prescription numbers and dates received from the pharmacy on every page of the Controlled Substance Narcotic Books, but they had not. During an interview on 6/12/24 at 10:36 A.M., UM #1 said he was unsure about the number of Nurses that were required when documenting prescription numbers, dates, and when transferring controlled medications to different pages within the Narcotic Book. During an interview on 6/12/24 at 10:42 A.M., the Director of Nursing (DON) said every page of the Narcotic Book should have the prescription numbers for the controlled substances as well as the dates the Nurses received the medications. The surveyor and the DON reviewed the Narcotic Book, Book One on the Edgewood Unit and the DON said when controlled substance medications are sent home with a Resident upon discharge, two Nurses are expected to count the medication and sign that the medication was sent out with the Resident, but this was not done. The DON further said two Nurses are expected to witness and sign when medications are being transferred from one page to another, but this had not been done.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had diagnoses of paraplegia (paralysis of legs and lower body) and Stage IV (wound that has lost full thickness tissue, exposing bone, muscle, or tendon) pressure injury to sacral (lower back) region and required physical assistance from staff for Activities of Daily Living (ADL-bathing, dressing, grooming), the Facility failed to ensure they developed a baseline Care Plan which included minimal healthcare information related to the level of assistance he/she required to complete ADLs within forty-eight hours of admission as required, and per facility policy. Findings Include: The Facility Policy titled Care Plans-Baseline, with a revision dated of March 2022, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The Policy indicated a baseline Care Plan included instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. Resident #1 was admitted to the Facility in November 2023, diagnoses included Paraplegia (paralysis of the legs and lower body), Multiple Sclerosis, and Stage IV pressure injury of sacral region. Review of Resident #1's Medical Record indicated there was no documentation to support that a baseline Care Plan was developed related to his/her ADL care needs within forty-eight hours of his/her admission. During an interview on 05/07/24 at 2:48 P.M., the Director of Nurses (DON) said that there was no baseline ADL Care Plan developed for Resident #1 and said it should have been developed within twenty-four hours of his/her admission to the Facility. On 05/07/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by: A) 01/19/24 through 01/31/24, the Director of Nurses educated all licensed staff on the admission process, including baseline care plans. B) 01/19/24, the Director of Nurses educated all Unit Managers to bring resident charts to morning meeting to review New Admission Charts, Consents, Care Plans, and Physician's orders for accuracy. C) 01/19/24, daily audits were initiated related to the New Admission/Readmission resident charts, to verify Physician's orders for accuracy and to ensure care plans were in place. D) Daily audit results were reviewed daily at morning meetings by the Director of Nurses or designee. E) 01/19/24, weekly audits were initiated related to the New Admission/Readmission resident charts, to verify Physician's orders for accuracy and to ensure care plans were in place. F) Weekly audit results were reviewed on Mondays following the completion of the previous week by the Director of Nurses or designee. G) 02/01/24, initial results of the audits for New Admissions and Readmissions were brought to Quality Assurance Performance Improvement (QAPI) meeting. H) Monthly audits to be reviewed at QAPI meetings by QAPI committee and Director of Nurses or designee. I)The Director of Nurses and or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had diagnoses of paraplegia (paralysis of the legs and lower body) and Stage IV (wound that has lost full thickness tissue, exposing bone, muscle, or tendon) pressure injury to sacral (lower back) region, and required physical assistance from staff for mobility and positioning, the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets and Positioning Sheets, when daily documentation by CNAs was not consistently completed. Findings include: Review of the Facility's policy titled Charting and Documentation, with a revision date of July 2017, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Resident #1 was admitted to the Facility in November 2023, diagnoses included Paraplegia (paralysis of the legs and lower body), Multiple Sclerosis, and Stage IV pressure injury of sacral region. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 11/27/23, indicated that Resident #1 had impaired functional range of motion on both sides of his/her lower extremities and that he/she was dependent on staff for bathing, dressing, personal hygiene and to roll from lying on his/her back to his/her left/right side in bed. Review of Resident #1's Documentation Survey Report v2 (ADL Flow Sheets), completed by CNAs, dated 11/21/23 through 11/30/23, indicated that on the following shifts, documentation on the flow sheets were incomplete: -3:00 P.M. to 11:00 P.M.- 6 days (out of 9) all care areas were left blank -11:00 P.M. to 7:00 A.M.- 3 days (out of 9) all care areas were left blank Review of Resident #1's ADL Flow Sheets, completed by CNAs, dated 12/01/23 through 12/21/23, indicated that on the following shifts, documentation on the flow sheets were incomplete: -7:00 A.M. to 3:00 P.M.- 3 days (out of 19) all care areas were left blank -3:00 P.M. to 11:00 P.M. - 6 days (out of 19) all care areas were left blank -11:00 P.M. to 7:00 A.M.- 4 days (out of 19) all care areas were left blank Review of Resident #1's Positioning Sheet, completed by CNA's, dated 12/01/23 through 12/21/23, indicated for the following shifts, documentation on the positioning sheets were incomplete. -7:00 A.M. to 3:00 P.M.- 3 days (out of 19) positioning every two hours was left blank -3:00 P.M. to 11:00 P.M.- 8 days (out of 19) positioning every two hours was left blank -11:00 P.M. to 7:00 A.M.- 3 days (out of 19) positioning every two hours was left blank During an interview on 05/07/24 at 2:25 P.M., Certified Nurse Aide (CNA) #2 said all care provided to residents is documented electronically and should be completed at the end of their shift. During an interview on 05/07/24 at 2:48 P.M., the Director of Nurses (DON) said documentation had been a problem and the CNA ADL Flow Sheets and Positioning Sheets should not be incomplete, she said that the CNAs should be documenting all care provided to each resident. On 05/07/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by: A) 04/03/24 through 04/15/24, the Director of Nurses educated all Certified Nurse Aides (CNAs) to accurately document Activities of Daily Living care and behaviors in the Plan of Care (electronic) system. B) 04/03/24, the Director of Nurses completed an initial 30-day look-back audit of all CNA documentation. C) Weekly audits to be completed by the Director of Nurses or designee weekly for four weeks, then monthly for three months, or until substantial compliance is achieved. D) Quality Assurance Performance Improvement (QAPI) committee will assess results of audits to determine effectiveness of improvement plan. E) The Director of Nurses and or designee are responsible for overall compliance.

Based on policy review, interview, and record review, the facility failed to implement screening (assessing) for signs and symptoms of COVID-19 during a COVID-19 outbreak for one Resident (#3) out of a total sample of five residents. Specifically, for Resident #3, the facility failed to ensure that the Resident was being screened every shift for signs and symptoms of COVID-19 while the unit he/she resided on, was conducting outbreak testing. Findings include: Review of the facility policy titled Coronavirus Disease (COVID-19)-Testing Residents, revised 4/1/23, indicated the following: -During an outbreak, all residents on the unit with a positive COVID-19 individual are screened for COVID-19 signs and symptoms every shift to more rapidly detect those with new signs and symptoms. Resident #3 was admitted to the facility in September 2023. During the entrance conference on 12/5/23 at 7:55 A.M., the Director of Nurses (DON) said outbreak testing throughout the entire facility began on 11/16/23. During an interview on 12/5/23 at 11:17 A.M., Unit Manager (UM) #1 said the facility's procedure during outbreak testing was to monitor all residents for signs and symptoms of COVID-19 each shift, and this included assessing for a fever, taking oxygen saturations levels, and monitoring for changes in respiratory status. UM #1 said each Resident should have an order in place to monitor for signs and symptoms of COVID-19. She further said this information was to be documented on the Medication Administration Record (MAR) for each resident, each shift, after the Nurse assessed the resident. Review of Resident #3's November 2023 Physician's orders indicated no Physician's order in place from 11/16/23 through 11/30/23 to monitor the Resident for signs and symptoms of COVID-19. Review of Resident #3's November 2023 MAR indicated no documentation as required, that he/she was monitored for signs and symptoms of COVID-19 from 11/16/23 through 11/30/23. During an interview on 12/5/23 at 11:24 P.M., the surveyor and the Infection Preventionist (IP) reviewed Resident #3's medical record. The IP said she was unable to locate any documentation that the Resident was being monitored for signs and symptoms of COVID-19 from 11/16/23 through 11/30/23. She said it appeared the order to monitor for signs and symptoms of COVID-19 had fallen off [sic] from the Physician's orders and she was unsure why, but that it had been re-added on 12/1/23. The IP further said the Resident should have documentation to show that he/she was being monitored for signs and symptoms of COVID-19 each shift from 11/16/23 through 11/30/23, but there was no documentation as required.

Based on interview, record review, and policy review, the facility failed to offer the Pneumococcal Vaccination as required to one Resident (#4) out of a total sample of five residents. Specifically, for Resident #4, the facility failed to ensure the Resident was offered the Pneumococcal Vaccination at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia. Findings include: Review of the facility policy titled Pneumococcal Vaccine, revised March 2023, indicated the following: -Assessments of Pneumococcal Vaccination status are conducted within thirty (30) days of the resident's admission if not conducted prior to admission. -Administration of the Pneumococcal Vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. Review of the CDC Pneumococcal Vaccine Timing for Adults Schedule, dated 3/15/23, indicated the following: -Adults aged 19 to 64 with chronic health conditions who have not received any previous Pneumococcal Vaccination should receive the Pneumococcal Vaccine 20-Valent (PCV20) or the 15-Valent Pneumococcal Conjugate Vaccine (PCV15) followed a year later by the Pneumococcal Polysaccharide 23 Vaccine (PPSV23). -Chronic health conditions included those who smoked cigarettes. Resident #4 was admitted to the facility in June 2023, and was between the ages of 19 to 64. Review of the Smoking assessment dated [DATE], indicated Resident #4 was an independent smoker. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she was cognitively intact. During an interview on 12/5/23 at 10:50 A.M., Resident #4 said he/she had been residing at the facility for a few months, was a smoker, and was unsure if the facility had offered him/her a Pneumococcal Vaccination. He/she further said that he/she was unsure what the Pneumococcal Vaccination was and would like to learn more about the vaccine. Review of the Resident's medical record indicated no documentation that the Resident had any previous Pneumococcal Vaccination or that the Resident had been offered a Pneumococcal Vaccine at the time he/she was admitted to the facility, or shortly thereafter. During an interview on 12/5/23 at 12:26 P.M., the Infection Preventionist (IP) said that at the time a resident is admitted to the facility the Pneumococcal Vaccination consent form should be completed. The IP said she reviewed the Resident's medical record and was unable to find the Pneumococcal Vaccination consent form. She further said if at the time of admission the Resident was unable to complete the form, then the Resident should have been re-approached to complete the form and this had not happened as required.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was admitted to the Facility with a wound that required treatment, the Facility failed to ensure a baseline Care Plan that included minimal healthcare information with instructions related to his/her wound care and treatment needs, was developed and implemented within forty-eight hours of admission as required, and per facility policy. Findings Include: The Facility Policy titled Comprehensive Person-Centered Care Plan, undated, indicated the Facility must develop and implement a baseline Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The Policy indicated the baseline care plan must be developed within 48 hours of a resident's admission. The Policy indicated the baseline Care Plan must include the minimum healthcare information necessary to properly care for a resident that included but was not limited to initial goals based on admission orders. Resident #1 was admitted to the Facility in August 2023, diagnoses included diabetes mellitus, obesity, muscle weakness and a gangrenous wound (dead tissue caused by an infection or lack of blood flow) in the area of his/her genitalia. Review of Resident #1's Physician's Order Recap Report for the month of August 2023, indicated he/she had a Physician's Order for wound care and dressing changes to the gangrenous wound in the area of his/her genitalia, that was to be changed twice a day, once on the day (7:00 A.M. to 3:00 P.M.) shift and again on the evening (3:00 P.M. to 11:00 P.M.) shift, and as needed. Review of Resident #1's Medical Record indicated there was no documentation to support that a baseline Care Plan was developed or implemented related to his/her wound and wound care needs within forty-eight hours of his/her admission. During an interview on 10/25/23 at 2:29 P.M., Unit Manager #2 said she had been the Unit Manager on Resident #1's Unit when he/she was at the Facility. Unit Manager #2 said Resident #1's dressing was complicated to keep in place due to the location of his/her wound and said at times his/her dressing would fall off. Unit Manager #2 said that a baseline Care Plans had not been developed for Resident #1's wound, but should have been. During an interview on 10/25/23 at 3:54 P.M., the Assistant Director of Nursing (ADON) said a baseline Care Plan should have been developed for Resident #1's wound care upon admission. During an interview on 10/25/23 at 4:38 P.M, the Director of Nursing (DON) said there was no baseline Care Plan developed for Resident #1 and said a baseline Care Plan should have been developed for his/her wound within twenty-four hours of his/her admission by either a staff nurse, the Unit Manager, or the wound nurse.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was admitted to the Facility with a wound and had orders for wound care treatments, the Facility failed to ensure they maintained complete and accurate medical records related to nursing documentation for Resident #1's wound care and dressing changes in his/her Treatment Administration Record (TAR), when nurses signed off as having completed dressing changes, but had not, there were wound treatments not signed off on with the TAR left blank and wound care dressing change documentation by nurses did not consistently include descriptions of his/her wound. Findings Include: The Facility Policy titled Charting and Documentation, dated as revised July 2017, indicated treatments and services performed were to be documented in the resident's medical record. The Policy indicated documentation of procedures and treatments would include care-specific details, including: -The date and time of the procedure/treatment was provided. -The name and title of the individual who provided the care. -The assessment data and/or any unusual findings obtained during the procedure/treatment. -How the resident tolerated the procedure/treatment. -Whether the resident refused the procedure/treatment. -The signature and title of the individual documenting. The Facility Policy titled Wound Care, dated as revised October 2010, indicated information that should be documented in the resident's medical record included: -The date and time wound care was provided. -All assessment data such as wound bed color, size, and drainage, obtained when inspecting the wound. -If the resident refused the treatment and the reason why. Resident #1 was admitted to the Facility in August 2023, diagnoses included diabetes mellitus, obesity, muscle weakness and a gangrenous wound (dead tissue caused by an infection or lack of blood flow) in the area of his/her genitalia. Review of Resident #1's Physician's Order Recap Report for the month of August 2023, indicated he/she had a Physician's Order for wound care and dressing changes to the gangrenous wound in the area of his/her genitalia, that was to be changed twice each day, once on the day (7:00 A.M. to 3:00 P.M.) shift and again on the evening (3:00 P.M. to 11:00 P.M.) shift, and as needed. During an interview on 10/25/23 at 3:11 P.M., Nurse #2 said although she initialed and signed off on Resident #1's TAR that she had completed the dressing changes on his/her wound on 08/07/23, 08/09/23, 08/10/23, and 08/11/23, said she had not actually completed dressing changes on all of the dates she signed off on because Resident #1 said the previous shift had just changed the dressing. Nurse #2 said she did not know how many times she had actually completed Resident #1's dressing changes and said, of the dates she signed off on the TAR as having completed it, she did not know on which dates she did or did not change Resident #1's dressing. Further Review of Resident #1's TAR indicated there was no documentation to support that, although Nurse #2 said Resident #1 told her the dressing had just been changed by the previous shift nurse, that he/she had refused to allow Nurse #2 to change his/her wound dressing. Review of Resident #1's Treatment Administration Record (TAR), dated 08/15/23, indicated completion of his/her dressing changes were left blank and were not signed off as having had been completed on both the 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. shifts. During a telephone interview on 11/06/23 at 11:57 P.M., Nurse #3 said although she changed Resident #1's dressing on the 3:00 P.M. to 11:00 P.M. shift on 08/15/23, she was busy and did not sign his/her TAR to indicate she had changed his/her dressing. During a telephone interview on 11/06/23 at 12:11 P.M., Nurse #4 said he had changed Resident #1's dressing on the 7:00 A.M. to 3:00 P.M. on 08/15/23 but did not sign his/her TAR to indicate the dressing had been changed. During an interview on 10/25/23 at 2:29 P.M., Unit Manager #2 said she had been the Unit Manager on Resident #1's Unit when he/she was at the Facility. Unit Manager #2 said Resident #1's dressing changes should have been signed off on his/her TAR by the nurse completing the dressing change and said the TAR should not be left blank. Unit Manager #2 said if Resident #1's treatment was not done, nurses were supposed to sign it off on the TAR and then choose an additional option and document why the dressing change had not been completed. During an interview on 10/25/23 at 3:54 P.M., the Assistant Director of Nursing (ADON) said that every time a dressing is changed, nurses were supposed to document a description of the wound in the TAR because it helped identify the progression of a wound. The ADON reviewed Resident #1's TAR for August 2023 and said nurses had not documented the wound descriptions in Resident #1's TAR because the wound description template had not been chosen (part of the treatment order for wounds in the electronic medical record) when nursing initially transcribed his/her dressing change order into the computer. The ADON said as a result, the wound description section in Resident #1's TAR where staff should have documented wound descriptions with each dressing change never showed up (pre-populated as a treatment instruction) in the TAR. The ADON said if a treatment is not done, the TAR should be completed, but not signed as administered. The ADON said nurses were supposed to choose an option within the TAR (electronic medical record) with a corresponding explanation as to why a treatment had not been completed. During an interview on 10/25/23 at 4:38 P.M., the Director of Nursing (DON) said residents' TAR should not be left blank. The DON said the TAR must be signed by the nurses and must indicate whether the dressing was changed or if not, a reason why it had not been done. The DON said wound descriptions should be documented on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) and said the wound descriptions should be documented every time dressings were changed because it helped determine if a wound was getting better or worse. The DON reviewed Resident #1's electronic Medical Record and said she did not see wound descriptions regularly documented by nursing when Resident #1's dressings were changed.

Based on records reviewed and interviews for two of three sampled Employee Personnel Records (Certified Nurse Aide #1 and Certified Nurse Aide #2), the Facility failed to ensure that Massachusetts Nurse Aide Registry (NAR)checks were conducted as part of the employees background check upon hire, in accordance with Facility Policy. Findings include: Review of the Facility's Abuse, Neglect, exploitation and Misappropriation Prevention Program, revised April 2023, indicated to conduct employee background checks and not knowingly employ or otherwise engage any individual who had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. Review of Certified Nurse Aide (CNA) #1's Personnel File indicated she was hired on 04/10/23 and there was no documentation to support that a Massachusetts NAR check was completed upon hire. Review of CNA #2's Personnel File indicated she was hired on 09/21/23 and there was no documentation to support that a Massachusetts NAR check was completed upon hire. During an interview on 10/17/23 at 3:25 P.M., the Administrator said background checks upon hire included the Massachusetts NAR check. The Administrator said the Facility could not locate Massachusetts NAR checks for CNA #1 and CNA #2, and was unable to provide any additional documentation to support that NAR checks were completed upon hire.

Based on observation and interview the facility failed to ensure staff performed hand hygiene when indicated on three of three resident care units and wore proper Personal Protective Equipment (PPE) appropriately while on a COVID-19 positive unit, during a COVID-19 outbreak at the facility. Findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 3/23, indicated This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at last 62% alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: Before preparing or handling medications; Before donning gloves; After removing gloves; Before and after entering isolation precaution settings. Hand Hygiene is the final step after removing and disposing of personal protective equipment. Review of the facility's policy titled, Coronavirus Disease (COVID-19) Using Personal Protective Equipment, dated 5/12/23, indicated Disposable respirators are removed and discarded after exiting the resident's room or care area. Hand hygiene is performed after removing the respirator or face mask. Eye protection is applied upon entry to the resident room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Gloves are removed and discarded before leaving the resident room or care area, and hand hygiene performed immediately. During an interview on 7/24/23 at 7:05 A.M., the Director of Nursing (DON) said that the facility had been in a COVID-19 outbreak since 6/29/23. The DON said that five residents in the facility were presently COVID-19 positive on the [NAME] Unit. The DON said the PPE expectation on the [NAME] Unit, where the positive residents reside, would be eye protection and a N95 mask for anyone entering the unit. 1. During observations made on 7/24/23 on the [NAME] Unit the surveyor made the following observations: - On 7/24/23 from 7:38 A.M. to 8:02 A.M., the housekeeper on the [NAME] Unit was observed to not be wearing eye protection. The housekeeper was then observed to enter multiple resident rooms on the unit. - On 7/24/23 from 7:58 A.M. to 8:05 A.M., the laundry services staff person was observed entering the [NAME] Unit with a surgical mask on and without eye protection, he then entered the dirty utility room touching the door handle and then exited the dirty utility room without performing hand hygiene. Without performing hand hygiene, the laundry services staff person exited the unit with a linen cart, pushing the door with his hand, potentially contaminating the door's surface. - On 7/24/23 from 8:05 A.M. to 8:23 A.M., Certified Nurse Aide (CNA) #1 on the [NAME] Unit was observed to have two face masks on, one surgical mask partly down at the neckline and partly under the N95 mask. During an interview and observation on 7/24/23 at 8:25 A.M., Nurse #1 said that the CNA should not be double masked ever, and said she was not sure why the CNA had two masks on. - On 7/24/23 from 8:11 A.M. to 8:13 A.M., CNA #1 on the [NAME] Unit was observed to exit a resident room with gloves on both hands. CNA #1 then with the same gloved hands was observed in the hallway touching the dirty linen cart, and touched the dirty utility room handle. CNA #1 then touched the handrail on the wall in the hallway with the same gloved hands, then removed the gloves without performing hand hygiene. - On 7/24/23 from 8:40 A.M. to 8:41 A.M., CNA #1 on the [NAME] Unit was observed to remove her N95 mask in the hallway directly in front of a resident room, CNA #1 did not perform hand hygiene and then placed the same N95 mask on without performing hand hygiene or changing her mask. During an interview on 7/24/23 at 10:13 A.M., the Infection Control Preventionist Nurse (ICP) said the expectation is that staff are to wear one mask and not to double mask. The ICP Nurse further said gloves should never be worn in the hallway and hand hygiene should always be performed after glove removal or after touching a contaminated surface. The ICP Nurse said laundry services should also have performed hand hygiene going in and out of the COVID unit and said hand hygiene should always be performed after touching things in the dirty utility room. During an interview on 7/24/23 at 11:17 A.M., the DON said a CNA should not remove their mask without performing hand hygiene and said if the mask is removed it should be replaced with a new mask. 36431 2. During observations on 7/24/23 on the Poe's Corner Unit the surveyor made the following observations: -At 7:53 A.M., A housekeeper cleaning the men's room removed her gloves and without performing hand hygiene entered the janitor room touching the keypad, the door handle and removed a mop. The housekeeper returned to the housekeeping cart and donned gloves without performing hand hygiene and proceeded to mop the room. -The housekeeper removed her gloves and without hand hygiene moved the housekeeping cart further down the hall and stopped in front of the staff restroom. The housekeeper donned gloves without performing hand hygiene, then cleaned the room. The housekeeper doffed her gloves, failed to perform hand hygiene, touched the mop, the housekeeping cart, the keypad and door handle for the dirty utility room, then donned gloves without performing hand hygiene and began to clean the dirty utility room. Upon completing the cleaning of the dirty utility room, the housekeeper removed her gloves and without performing hand hygiene touched the keypad and the door handle to the soiled utility room two times, then donned gloves without hand hygiene. During an interview on 7/24/23 at 8:15 A.M., Nurse #2 said all staff are to perform hand hygiene before entering and exiting resident rooms and before donning gloves and when doffing gloves. 3. During an observation on the Edgewood Unit on 7/24/23 the surveyor made the following observations: -At 8:27 A.M., CNA #2 entered a resident room with out hand hygiene and placed a cup of juice on the residents tray table, then exited the room without performing hand hygiene. CNA #2 then picked up a breakfast tray off a cart in the hall and delivered the tray to the same resident and set up the tray, then exited the room without performing hand hygiene carrying a plate cover. CNA #2 placed the plate cover on a cart, moved the cart, then went to the nursing desk, picked up two pitchers of juice and placed them on a cart. In doing so, and without hand hygiene CNA #2 potentially contaminated the pitchers of juice. CNA #2 then went to the nourishment kitchen to prepare tea for a resident. At no time during the observation did CNA #2 perform hand hygiene before and after entering and exiting rooms, delivering breakfast trays, and encountering the resident's environment, carts in the hall and areas on the unit. -A Nurse prepared medications at the medication cart then without performing hand hygiene, picked up the medicine cup, a cup of water and two boxes (containing medication) and entered a resident's room and placed the boxes on the dresser. The resident said she did not wish to take the medication at this time. The Nurse without performing hand hygiene exited the resident's room, placed the medication cup, water cup and boxes on top of the medication cart, then pulled open a drawer and placed the prepared medication into the drawer, thus potentially contaminating the top of the medication cart and inside of the medication cart. During an interview on 7/24/23 at 10:39 A.M., the ICP Nurse said all staff should be completing hand hygiene before entering and after exiting a resident room. The ICP Nurse said the prepared medication should not have been placed back on the medication cart after being placed in the resident's room without the Nurse performing hand hygiene.

Based on policy review, record review, and interview, the facility failed to ensure its staff provided the appropriate care and services related to a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one Resident (#151) out of three sampled closed records. Specifically, the facility failed to ensure its staff (1.) immediately implemented interventions to prevent further skin breakdown, (2.) implemented recommendations from the Wound Care Physician, (3.) revised the care plan to include goals and interventions related to the pressure ulcer and (4.) failed to obtain timely consent from the Resident's Representative for Physician recommended wound debridement (removal of dead tissue). Findings include: Review of the facility policy, Pressure Ulcers/Skin Breakdown, dated April 2018, indicated the following: -The nurse shall document/report a full assessment of the pressure ulcer including location, stage, length, width and depth, presence of exudates or necrotic tissue. -Current treatments, including support surfaces. -The Physician will order pertinent wound treatments, including pressure reduction surfaces Resident #151 was admitted to the facility in August 2022. 1. Review of the Norton Pressure Sore Risk Assessment Scale, dated 11/8/22, indicated the Resident was at high risk for pressure ulcer as evidence by a score of 11. Review of a Progress Note, dated 11/28/22, indicated the Resident continued to have pressure (the note did not specify the location or any other details). Review of the November 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated no treatment orders were put into place for the pressure area until 11/30/22. 2. Review of the Wound Consult, dated 11/29/22, indicated the following: -Stage 3 pressure wound (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) of the left sacrum full thickness. Duration is greater than 6 days. Wound size is 2.5 centimeters (cm) x 1cm x 0.1 cm. Granulation (new) tissue = 100 % -Dressing Treatment Plan: Alginate calcium with silver (highly absorbent anti-microbial dressing), apply twice daily followed by a gauze island dressing with border and skin prep (used to form a barrier between skin and an adhesive dressing) to surrounding skin. -Recommendations: Off-load wound. Turn side to side and front to back every 1-2 hours. Low air loss mattress. Review of the Physician Order Summary Report from 9/1/22 through 11/1/22 indicated the following order, initiated on 11/30/22 (two days after it was first mentioned in a progress note), Apply silver alginate to wound and cover with border dressing to open area on the sacrum every day until resolved. Review of the Wound Consult, dated 12/6/22, indicated the following: -Unstageable (due to necrosis) of the left sacrum, duration is greater than 13 days. Wound size is 2.5 cm x 2 cm x 0.2 cm. Thick adherent devitalized necrotic tissue = 70 % Slough (yellow/white material in the wound that consists of dead cells) = 10 % Granulation tissue = 20 % Wound Progress: Deteriorated Dressing Treatment Plan: Discontinue Alginate Calcium with Silver and change to Alginate Calcium and Santyl (used to debride a wound) apply twice a day, skin prep to surrounding skin and cover with a gauze island dressing with border. Recommendations: Low air loss mattress, obtain consent for debridement. Vitamin C 500 milligrams (mg) by mouth twice daily and Multivitamin by mouth once daily. Coordination of Care: The patient's care was discussed with another health care provider Nursing Staff Member during this visit. Reason for no debridement: Unable to obtain consent from patient or surrogate and unable to contact primary care physician at this time. Review of the Wound Consult, dated 12/13/22, indicated the following: -Unstageable (due to necrosis) of the left sacrum full thickness. Wound size is 4.0 cm x 3.5 cm x 0.2 cm Thick adherent devitalized necrotic tissue = 70 % Slough = 10% Granulation tissue = 20 % -Wound progress: Deteriorated -Dressing Treatment Plan: Continue same treatment and add Mupirocin (antimicrobial) ointment. -Recommendations: Low air loss mattress. Obtain consent for debridement. Vitamin C 500 milligrams (mg) by mouth twice a day and Multivitamin by mouth once a day. Coordination of Care: The patient's care was discussed with another health care provider Nursing Staff Member during this visit. -Reason for no debridement: Unable to obtain consent from patient or surrogate and unable to contact primary care physician at this time. Review of the Physician Order Summary Report from 9/1/22 through 11/1/22, indicated no orders were obtained for the low air loss mattress, Vitamin C 500 mg, Multivitamin, or the Mupirocin as recommended as interventions by the Wound Care Physician. 3. Review of the care plan indicated the Resident was at risk for skin breakdown, the goal was for the Resident to not show signs of skin breakdown throughout next review (2/5/23). Further review indicated there were no new interventions added since 8/5/22 and the care plan did not indicate the Resident had an unstageable pressure ulcer to the sacrum. 4. Review of the clinical record indicated consent for debridement of the wound was not obtained until 12/15/22 (nine days after the initial recommendation was made by the Wound Care Physician on 12/6/22). During an interview on 2/07/23 at 10:58 A.M., Unit Manager (UM) #2 said she was familiar with Resident #151 as he/she had resided on her Unit. UM #2 said the Resident had an area on his/her sacrum for quite a while (she was unable to provide a date but indicated to the surveyor that it was about one month) and the staff had treated the area with barrier cream and a protective dressing. The surveyor and UM #2 reviewed the MAR and TAR for November 2022 and UM #2 said there was no order in place or documentation about the use of the barrier cream and protective dressing, but there should have been because that is how they cared for the area. UM #2 said that when the area took a turn for the worse they contacted the Wound Care Physician and the Resident was evaluated by the Wound Care Physician on 11/29/22. The surveyor asked UM #2 what the process was when a wound was identified and she said a full assessment including measurements should be done. UM #2 looked through the clinical record and said she was unable to find an intial wound assessment for the sacral wound. She said that when the Wound Care Physician came in, either she or another nurse would accompany him on rounds so that he could review the plan of care with nursing staff. UM #2 said it was the responsibility of the nurse to follow through with the recommendations the Wound Care Physician provided. The surveyor asked UM #2 if the Resident had an air mattress in place as recommended by the Wound Care Physician from the initial visit on 11/29/22. UM #2 said the Resident had an air mattress. The surveyor asked what the process was for the use of air mattresses and UM #2 said they would get a Physician's order for the use of the air mattress including settings (individualized according to the Resident's needs). UM #2 reviewed the Physician's orders and MAR/TAR for December 2022 and said she could not find an order for the use of an air mattress or what settings it should have been on, if it had been in place. The surveyor asked why the consent for debridement was never obtained from the Resident's Representative. UM #2 said she called the Resident's Representative and left a message but the Resident's Representative never returned the call. UM #2 said she did not try again and she did not document that she called. The surveyor asked if anyone else had attempted to get consent for the debridement and UM #2 said no. UM #2 said she did get consent on 12/15/22 (nine days after the Wound Care Physician's initial recommendation). UM #2 said the Resident was then sent to the hospital on 12/16/22 so the debridement did not occur. The surveyor asked UM #2 if the Vitamin C, Multivitamin or Mupirocin were ever implemented as recommended by the Wound Care Physician. UM #2 reviewed the Physician's orders and December 2022 MAR/TAR and said none of the interventions had been put into place and they should have been. UM #2 reviewed the Resident's care plan and said it was up to the nursing staff to update the care plan and that it was not done for this Resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a [DIAGNOSES REDACTED].#1's Physician or Nurse Practitioner was notified about his/her weight gain, per weight gain parameters ordered by his/her Physician on several occasions between 12/9/19 and 12/31/19, and as a result Resident #1 did not receive appropriate treatment in a timely manner. Resident #1 was transferred to the Hospital Emergency Department on 1/2/20 where he/she was treated and admitted for an acute exacerbation of his/her [MEDICAL CONDITION]. Findings include: Resident #1 was admitted to the Facility in July of 2018 and had a [DIAGNOSES REDACTED]. Resident #1's physician's orders [REDACTED].#1 was to be weighed daily related to his/her [DIAGNOSES REDACTED]. During an interview on 2/11/20 at 11:26 A.M., the Nurse Practitioner said Resident #1 had a physician's orders [REDACTED]. Review of the Weight and Vital Sign Summary, dated 12/2019, indicated that Resident #1 experienced weight gain as follows: -12/9/19-12/10/19 weight gain of 3.7 lbs, -12/25/19-12/27/19 weight gain of 6.0 lbs, -12/26/19 no weight documented for this date, -12/30/19-12/31/19 weight gain of 2.0 lbs. Review of Resident #1's Medical Record, including review of nursing progress notes, indicated that there was no documentation to support that the Physician or the Nurse Practitioner was notified of his/her weight gain in December. The Nurse Practitioner said that neither she nor the Physician were notified that Resident #1 had gained any weight The Nurse Practitioner said if she was notified that Resident #1 gained 2 lbs in a day, she would typically have ordered to increase the dosage of Resident #1's diuretic medication (promotes the removal of excess fluid from the body) and said if she was notified that Resident #1 gained more than five pounds she would typically have had the Facility transfer Resident #1 to the Cardiology Office so that they could administer an intravenous diuretic medication. A Hospital Transfer Form, dated 1/2/20, indicated that Resident #1 was transferred to the Hospital Emergency Department due complaints of chest tightness, shortness of breath, respiratory distress, and his/her oxygen saturation level was 80% (level of oxygen in the blood, average is 95-100, less than 90% is considered low). A Nurse Progress Note, dated 1/2/20, indicated that Resident #1 was admitted to the Hospital for [MEDICAL CONDITION] exacerbation. During an interview on 2/6/20 at 3:01 P.M., the Unit Manager said it was the responsibility of the 7:00 A.M. to 3:00 P.M. (day shift) nurse to review Resident #1's previous weights. The Unit Manager said when daily weights were obtained, she expected nurses to look back at the previous weight, that nurses should also check what the weights were for a week and to notify the Physician according to the ordered weight gain parameters. During an interview on 2/11/20 at 2:18 P.M., Nurse #6 said that she worked the day shift on 12/10/19 as Resident #1's nurse and said she did not notify Resident #1's Physician or Nurse Practitioner about his/her weight gain of 3.7 lbs. Nurse #6 said she did not notify Resident #1's Physician or Nurse Practitioner about his/her weight gain of 2 lbs when she worked the day shift on 12/31/19. During an interview on 2/12/20 at 12:58 P.M., Nurse #7 said that he worked the day shift on 12/27/19 as Resident #1's nurse and said he did not call Resident #1's Physician about his/her 6 lb weight gain. During an interview on 2/11/20 at 10:59 A.M., Nurse #4 said that the nurse on the day shift was responsible for looking at Resident #1's weight and comparing it to the prior weights in his/her Medical Record to determine if he/she gained weight. Nurse #4 said, when she worked during the day shift on 1/1/20 as Resident #1's nurse and said she did not look in Resident #1's Medical Record, said she was not aware of his/her weight gain of more than 8 lbs in the past week, and said she did not notify Resident #1's Physician or Nurse Practitioner about his/her weight gain during the day shift on 1/1/20. During an interview on 2/11/20 at 1:37 P.M., Nurse #5 said that, at approximately 6:00 A.M. on 1/2/20, Resident #1 experienced shortness of breath and said he/she was unable to talk without stopping to take breaths. Nurse #5 said Resident #1's change in condition was an emergency situation so she called 911 and Resident #1 was transferred to the Hospital Emergency Department. The Unit Manager said if she observed concerns related to weight loss parameters she would tell nurses to call to notify the Physician and said, when she worked the 11:00 P.M. to 7:00 A.M. shift on 12/31/19 into 1/1/20, before she left at the end of her shift, she told Nurse #4, who came in to work the day shift, that Resident #1 had a weight gain that had not yet been reported to his/her Physician. During an interview on 2/6/20 at 3:47 P.M., the Director of Nurses (DON) said that the Unit Manager reviewed Resident #1's Medical Record and discovered that there were weights taken for Resident #1 that were not reported to Resident #1's Physician that should have been by nursing, because of the parameters ordered by the Physician.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a [DIAGNOSES REDACTED].#1's physician's orders [REDACTED].#1's weights were obtained daily and that weight gains were reported per the ordered parameters. - When in December 2019, Resident #1 experienced weight gain (indicative of acute [MEDICAL CONDITION]), this was not reported to the Physician, orders for necessary treatment were not obtained, and as a result of Resident #1 not being treated in a timely manner, he/she was transferred to the Hospital Emergency Department on 01/02/20 due to respiratory distress and required Hospital admission related to an exacerbation of his/her [MEDICAL CONDITION]. Findings Include: Resident #1 was admitted to the Facility in July of 2018 and had a [DIAGNOSES REDACTED]. Resident #1's physician's orders [REDACTED].#1 was to be weighed daily related to his/her [MEDICAL CONDITION] and his/her Physician (Cardiologist) or the Nurse Practitioner was to be notified for a weight gain of two (or more) pounds (lbs) in one day or five lbs (or more) in a week. During an interview on 2/11/20 at 11:26 A.M., the Nurse Practitioner said Resident #1 had a physician's orders [REDACTED]. Review of the Weight and Vital Sign Summary Report for Resident #1, dated 12/2019, indicated there were no documentation to support that a daily weight was obtained by nursing, as ordered for the following dates; -12/01/19 no weight documented for this date, -12/02/19 no weight documented for this date, -12/08/19 no weight documented for this date, -12/12/19 no weight documented for this date, -12/13/19 no weight documented for this date, -12/14/19 no weight documented for this date, -12/22/19 no weight documented for this date, -12/24/19 no weight documented for this date, -12/26/19 no weight documented for this date. Review of the Weight and Vital Sign Summary, dated 12/2019, indicated that Resident #1 experienced weight gain as follows: -12/9/19-12/10/19 weight gain of 3.7 lbs, -12/25/19-12/27/19 weight gain of 6.0 lbs, -12/30/19-12/31/19 weight gain of 2.0 lbs. Review of Resident #1's Medical Record, including review of nursing progress notes, indicated that there was no documentation to support that the Physician or the Nurse Practitioner was notified of his/her weight gain in December. The Nurse Practitioner said that neither she nor the Physician were notified that Resident #1 gained any weight as indicated in the weight gain parameter orders in December. The Nurse Practitioner said if she was notified that Resident #1 gained 2 lbs in a day, she would have ordered to increase the dosage of Resident #1's diuretic medication (promotes the removal of excess fluid from the body) and said if she was notified that Resident #1 gained more than five pounds she would typically have had the Facility transfer Resident #1 to the Cardiology Office so that they could administer an intravenous diuretic medication. Review of Resident #1's Medical Record indicated that there was no documenation to support that nursing had obtained changes to medication or treatment orders from the Physician or Nurse Practitioner to treat his/her weight gain in December. A Hospital Transfer Form, dated 1/2/20, indicated that Resident #1 was transferred to the Hospital Emergency Department due to complaints of chest tightness, shortness of breath, respiratory distress, and his/her oxygen saturation level was 80% (level of oxygen in the blood, average is 95-100, less than 90% is considered low). A Nurse Progress Note, dated 1/2/20, indicated that Resident #1 was admitted to the Hospital for [MEDICAL CONDITION] exacerbation. A Hospital Discharge Summary, dated 1/9/20, indicated that Resident #1 was admitted on [DATE] with medical [DIAGNOSES REDACTED]. During an interview on 2/11/20 at 10:59 A.M., Nurse #4 said that Resident #1 was weight daily because he/she had a [DIAGNOSES REDACTED]. Nurse #4 said nurses who worked on the 7:00 A.M. to 3:00 P.M., (day shift) were responsible for comparing Resident #1's weights from day to day and notifying his/her Physician of weight gain or with any concerns. Nurse #4 said she thought Resident #1's weight gain parameter orders were to notify the Physician with a two or three pound weight gain. Nurse #4 said she was not aware that Resident #1 had gained more than 8 lbs in a week from 12/25/19-1/1/20. Nurse #4 said did not check Resident #1's Medical Record to look at his/her previous weights and said she did not notify Resident #1's Physician or Nurse Practitioner about his/her weight gain during her day shift on 1/1/20. During an interview on 2/11/20 at 2:18 P.M., Nurse #6 said that when she worked on the day shifts on 12/10/19 and 12/30/19, she was not aware if Resident #1 had gained weight on either of those days and said she could not recall what Resident #1's weight gain parameters were. Nurse #6 said that it was the responsibility of the Certified Nurse Aide (CNA) to inform her of weight gain because nobody had informed her that Resident #1 had gained weight. During an interview on 2/12/20 at 12:58 P.M., Nurse #7 said that he worked on the day shift on 12/27/19 and said he saved his notes from that day. Nurse #7 said Resident #1's weights were supposed to be monitored because he/she had heart issues. Nurse #7 said he was told what Resident #1 weighed that morning but said he was not told that Resident #1 had a weight gain that required notifying his/her Physician. Nurse #7 said he thought that Resident #1's weight gain parameters were to call his/her Physician with weight gains of greater than three pounds. Nurse #7 said he did not look at Resident #1's previous weights that day to determine actual amount of his/her weight gain. During an interview on 2/11/20 at 1:37 P.M., Nurse #5 said that, at approximately 6:00 A.M. on 1/2/20, Resident #1 experienced shortness of breath and said he/she was unable to talk without stopping to take breaths. Nurse #5 said Resident #1's change in condition was an emergency situation so she called 911 and Resident #1 was transferred to the Hospital Emergency Department. During an interview on 2/6/20 at 3:01 P.M., the Unit Manager said that Resident #1 was typically weighed each morning by the 11:00 P.M. to 7:00 A.M.( night shift) staff. The Unit Manager said it was the responsibility of the day shift nurses to review Resident #1's weights going back for a week and to notify his/her Physician according to the ordered weight gain parameters.

Based on observation, record review and interview the facility staff failed to follow their policy regarding weight loss and failed to assess and address severe and significant weight losses for 6 residents, (#67, #49, #22, #108, #34, #89) out of a total of 24 sampled residents. Findings include: Review of the facility's Weight and Height Policy, revised 3/15/19, indicated the following: - If a patient's weight is less than or greater than five pounds from the previous weight, the patient will be re-weighed and the weight verified by a licensed nurse to determine accuracy. - The licensed nurse will notify the physician and dietitian of significant weight changes. - The licensed nurse will notify the physician of the dietitian recommendations. - If a physician does not implement the dietitian's recommendations, the licensed nurse will document physician's refusal and add it to the 24-hour summary report. Review of the facility's Nutrition/Hydration Management, dated 12/1/2006, indicated the following: - Consult with the dietitian may be indicated for any of the following conditions: Unplanned weight loss or gain of greater than 5% in one month, 7.5% in three months, 10% in six months; inadequate oral intake, potential need or order for oral supplements, refusal of ordered supplements. - Review Dietitian recommendations. Obtain orders per recommendations. - Develop service plan for enhancing oral intake and promoting adequate nutrition and hydration. Include dietitian recommendations. Review of the facility's Food and Nutrition Services Policy, revised 6/15/18, indicated the following: -Dietitian or non-dietitian designee visits each patient/resident as part of the assessment process. -Nutrition assessment is completed by the Dietitian or the non-dietitian designee upon admission and with changes in nutritional status. The Dietitian completes a comprehensive or further assessment for any patients/residents determined to be of nutrition concern. 1. For Resident #67, the facility staff failed to assess and address significant and severe weight losses of 5% or greater of his/her total body weight. Resident #67 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set (MDS), dated [DATE], indicated Resident #67 is severely cognitively impaired and requires assistance with bathing and dressing. During initial observations of the breakfast meal on 4/2/19, the surveyor observed Resident #67 feeding himself/herself with a spoon. Resident #67 appeared thin and frail. Review of Resident #67 Nutrition care plan, initiated 11/28/16, indicated the following: - Focus: Resident is at nutritional risk related to weight loss, fair intake. - Initiated 11/28/16 - Interventions: Provide rehab eating devices: lip plate during meals. -Initiated 3/1/18 - Weigh as ordered and alert Dietitian and Physician to any significant loss or gain. -Initiated 11/28/16 - Monitor for changes in nutritional status and report to food and nutrition/Physician as indicated. - Initiated 11/28/16 - House Supplement as ordered. -Initiated 11/28/16 Review of Resident #67 weights indicated the following: - 5/3/18: 108.6 lbs. (pounds) - 6/18/18: 101.2 lbs. (A significant weight loss of 7.45 lbs. or 9% of his/her total body in less than 3 months.) There was no evidence in the clinical record that the dietitian or physician were notified of Resident #67 weight loss or assessed the Resident for weight loss. Additionally, there was no evidence of a re-weigh being completed per facility policy. Review of the Nurse Practitioner (NP) note, dated 6/21/18, indicated the following: Resident #67 is on increased supplements. We will continue to monitor. Review of Resident #67 physician's orders [REDACTED]. Further review of Resident #67 weights indicated the following: - 7/5/18: 103.9 lbs. - 8/10/18: 97.5 lbs. (A significant weight loss of 6.45 lbs. or 6.1% in 1 month and 11.1 lbs. or 10% in 3 months.) Review of the dietary note dated 8/15/2018 indicated that Resident #67 was assessed by a dietitian intern and was not further comprehensively assessed by a registered dietitian per facility policy. Additionally, no interventions were implemented to address the weight loss and there was no evidence that a re-weigh was completed or that the physician was notified, per policy. Review of the nurse practitioner (NP) note, dated 8/23/18, indicated the following: Weight has remained stable. The NP note did not indicate that she was informed of the weight loss. Further review of Resident #67 weights indicated the following: - 1/8/19: 98.1 lbs. - 2/13/19: 93 lbs. (A significant weight loss of 5% of his/her total body weight in 1 month.) There was no evidence in the clinical record that a re-weigh was completed or that Resident #67's physician was notified of the significant weight loss. Review of the Dietitian assessment dated [DATE] indicated the following: - Significant weight loss at 1 & 3 months. Speech therapy recommends puree solids. Will monitor weight, intake, coordinate care with interdisciplinary team, and adjust nutrition as needed. Review of Resident #67 physician's orders [REDACTED]. No new interventions were implemented to address the weight loss. During an interview on 4/8/19 at 11:28 A.M., Unit Manager #3 said that nursing staff take the residents weights and should be documenting them in the electronic medical record. She said that if there is a 5 lb change in weights, the physician and the dietitian should be notified. She said that she does not call Resident #67's physician and that she would speak with his NP instead, as the NP is in the building daily. During an interview with the NP on 4/5/19 at 11:37 A.M., she said that she sees residents on a monthly basis and if she is aware of any weight changes, she would review medications, initiate house supplements, and may refer the resident to hospice. She said that any interventions to address weight loss which include fortified foods or changes in diet would be made by the dietitian. The NP said she was not aware of Resident #67's significant weight losses and did not know why recommendations or interventions were not implemented in response to his/her weight loss. 2. Resident #49 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. Resident #49 was severely cognitively impaired with a Brief Interview Mental Status (BIMS) score of 9 out of 15 and required extensive assistance of two persons for most activities of daily living. Resident #49 required supervision for eating. During an observation 4/2/19 at 11:20 A.M., Resident #49 was seated in a wheelchair out in the hallway. He/she had headphones on and was watching a movie on a tablet. Resident #49 appeared frail. During an interview 4/2/19 at 11:25 A.M., Resident #49 said the food is good but sometimes my appetite is not good. My family brings me food also. Unit Manager (UM) #1 said during an interview on 4/8/19 at 1:30 P.M., that the facility policy for resident weight monitoring is as follows: - Upon admission, the resident is weighed and weights are obtained weekly for 4 weeks. The UM of each unit reviews the weights for their residents. Should a re-weight be needed because of a weight change of 5 pounds or greater, the weight must be completed within 24 hours. All weights are entered into the electronic medical record. The Facility Nurse Practitioner reviews all resident weights in the electronic medical record. When a weight loss has occurred the UM sends an email to the dietitian. The dietitian will then review all related information via the electronic medical record. The dietician will email the UM with recommendations as needed. The resident record indicated the following for Resident #49: - Week #1 Admission weight 11/5/18 - 184.2 lbs. (pounds) - Week #2 weight 11/15/18 - 173.4 lbs. (10.8 pounds or 5.86% significant weight loss in 1 week) - Week #3 no weight obtained - Week #4 weight 12/1/18 - 157.7 lbs. (26.5 pounds or 14.39% significant weight loss in 1 month) Record review 4/4/19 at 8:30 A.M. indicated Resident #49 had a significant weight loss during his/her stay at the facility and there was no evidence of reweights to confirm the weights per facility policy. The meal percentage documentation indicated Resident #49 consistently ate 75-100% of all meals. Review of the Nutritional assessment dated [DATE] (almost 1 month after the initial significant weight loss was identified), indicated that the dietitian recommended a house supplement 3 times per day. A nutritional risk care plan was developed 12/11/18 by the dietitian. 3. Resident #22 was admitted in 04/2014 with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS), dated [DATE], Resident #22 was severely cognitively impaired with a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS). During observation on 4/2/19 at 8:00 A.M., Resident #22 was eating breakfast in bed. Resident #22 appeared thin and frail. Review of weight record as follows: - 7/10/18: 120.1 lbs. (pounds) - 8/20/18: 110.5 lbs. (pounds) (significant weight loss of 9.6 lbs. or 7.9% in 1 month) - 9/17/18: 111.9 lbs. (pounds) During interview on 4/9/19 at 2:34 P.M., Unit Manager (UM) #2 said that weights are obtained by the Certified Nursing Aides (CNA's) and the unit manager verifies the weights. A re-weigh is obtained if the weight is over or under five pounds from the previous weight. The weight is then put into the electronic medical record and the physician and dietitian are notified. Review of the dietary note dated 7/21/18 indicated that Resident #22 was assessed by an intern and not a Registered Dietitian per facility policy. The dietary intern indicated that Resident #22 had experienced a weight loss trend over the last four months and that the house supplement was recently discontinued. No interventions were recommended at this time. Review of the weight change note, dated 8/21/18, after the significant weight loss had been identified, indicated that UM #2 confirmed the significant weight loss and updated the Dietitian. Review of the dietary note dated 9/19/18, which was 1 month after the significant weight loss was identified, indicated that Resident #22 had a significant weight loss over the last 6 months and Resident #22 was refusing supplements. The Dietitian noted that Resident #22 had declined any further interventions. Review of the Nurse Practitioner progress note, dated 9/26/18, confirmed Resident #22's weight loss and increased house supplements to twice a day. During interview on 4/18/19 at 10:58 A.M., the regional dietitian said that some of the interventions that could be used for weight loss include supplements, fortified (high calorie/high protein) or specific/preferable food items, referrals to other disciplines, and weekly weights. When asked why Resident #22 had not been evaluated until 9/19/18, the Regional Dietitian said she could not speak to that time period. 4. Resident # 108 was admitted in 06/2018 with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS), dated [DATE], Resident #108 was mildly cognitively impaired with a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS). Review of weight record as follows: - 12/20/18: 113 lbs. (pounds) - 1/16/19: 105.8 lbs. (pounds) (6.3 significant weight loss in 1 month) - 2/14/19: 101.2 lbs. (pounds) - 2/18/19: 99.8 lbs. (pounds) (11.6% significant weight loss in 2 months) Review of the weights indicated a significant weight loss from: - 12/20/18 to 1/17/19: 5.8% total body weight in one month from 113 lbs. to 106.5 lbs. (pounds) - 1/17/19 to 2/18/19: 6.3% of total body weight in one month from 106.5 lbs. to 99.8 lbs. (pounds) Review of the nursing documentation: A weight change note, dated 1/24/19, indicated that UM #2 verified the weight loss and documented that supplements were to be continued three times a day. The medical record failed to indicate a nutrition evaluation was completed by the Registered Dietician at this time. A weight change note, dated 2/16/19, indicated that the physician and dietitian were notified and weekly weights would be put in place. The medical record failed to indicate a nutrition evaluation was completed by the Registered Dietician at this time. A weight change note, dated 3/13/19, was entered indicating that Resident #108 was to be signed into hospice services and consumed 100% of supplements three times a day. Review of the dietary note, dated 3/25/19, more than 2 months after the significant weight loss was identified, indicated that Resident #108 was to be signed into hospice services and no further interventions were necessary. During interview on 4/18/19 at 10:58 A.M., the Regional Dietitian said that she could not speak to Resident #108 being evaluated more than 2 months after the significant weight loss was identified. 5. Resident #34 was admitted in 01/2019 with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS), dated [DATE], Resident #34 was cognitively intact with a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS). Review of weight record as follows: - 1/9/19: 176.4 lbs. - 2/15/19: 169 lbs. - 2/19/19: 162.1 lbs. (significant weight loss of 14.3 lbs or 8% in less then 3 months) - 3/13/19: 161 lbs. - 4/5/19: 156.8 lbs. (significant weight loss of 19.6 lbs or 11.1% in 3 months) Review of the nursing weight change notes indicated a significant weight loss on 2/19/19. There was no indication that the Physician or Dietitian were notified. The medical record failed to indicate a nutrition evaluation was completed by the Registered Dietician at this time. Review of the Nurse Practitioner notes dated 3/7/19 and 3/21/19 does not mention any weight loss or indicate that any interventions would be put in place. Review of the Physician orders [REDACTED]. Review of the dietary notes indicated that Resident #34 was seen by the Dietitian on 3/25/19, more than 1 month after the significant weight loss occurred, and an intervention of house supplements one time per day was implemented at that time. During interview on 4/18/19 at 10:58 A.M., the Regional Dietitian said that she could not speak to that time period when asked why Resident #34 had not been assessed at the time of the significant weight loss. 6. Resident #89 was admitted in 09/2018 with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS), dated [DATE], Resident #89 was severely cognitively impaired with a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS). Review of weight record as follows: - 9/6/18: 207 lbs. - 10/6/18: 184 lbs. (significant weight loss of 23 lbs. or 11% in 1 month) - 11/1/18: 177.9 lbs. (significant weight loss of 29.1 lbs. or 14% in 2 months) Review of the weight change note, dated 10/11/18, indicated that the Unit Manager had verified the weight and notified the Nurse Practitioner. The Unit Manager (UM # 2) indicated that this was a post [MEDICAL TREATMENT] weight. Review of the weight change note, dated 11/14/18, indicated that the Nurse Practitioner was aware of the weight loss and that Resident #89 had a poor appetite. UM #2 also indicated that Resident #89 was receiving house supplements twice a day. Review of the Physician order [REDACTED]. Review of the dietary note dated 11/26/18, (more than 1 month after the significant weight loss was identified), indicated that the house supplements would be increased to three times a day. During an interview with the Regional Dietitian and the Administrator on 4/5/19 at 12:00 P.M., the Regional Dietitian said that residents should be evaluated by a Dietitian, if a resident has weight loss and the assessment should be done as soon as possible. She said that the Dietitians are reliant on nursing staff to be notified of any changes in resident's status. The Regional Dietitian said she could not speak to any residents with weight loss for the described time period. During an interview with the Medical Director on 4/8/19 at 1:56 P.M., he said that he was not aware that weight loss was an issue across the board.

Based on interviews and records reviewed, for one of three sampled residents, (Resident #1), the Facility failed to ensure staff followed the comprehensive plan of care for falls prevention, when on 9/1/17 Resident #1's chair alarm was not in place, and as a result Resident #1 fell out of his/her wheelchair, sustained a left [MEDICAL CONDITION] and which required surgery to repair. Findings include: The policy titled Falls Management, dated 3/15/16, indicated residents identified at risk for falls would receive interventions to reduce risk and minimize injury, and the resident's fall risk status would be communicated to care givers. Resident #1 was admitted to the Facility 12/21/16, his/her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 8/1/17, indicated Resident #1 was completely dependent and required assistance of two staff members for transfers. The MDS indicated Resident #1's Brief Interview for Mental Status (BIMS) score was of 2 out of 15 (score of 00-07 indicates severe cognitive impairment). The Care Plan, dated 1/11/17, indicated Resident #1 was at risk for falls, and interventions included a chair alarm to alert staff to his/her need for assistance. The physician's orders [REDACTED].#1 was to have a chair alarm and check every shift. Resident #1's Treatment Administration Record (TAR), dated 9/1/17, indicated his/her order for the chair alarm was circled, which indicated his/her alarm was not in place. The Facility's Investigation Synopsis, undated, indicated Resident #1 did not have a chair alarm in place at the time of the fall on 9/1/17. The Nurse Practitioner's Progress Note, dated 9/1/17, indicated Resident #1 was found, at 2:30 P.M., in his/her room lying on his/her left side and complained that his/her head hurt. The Note indicated Resident #1 was transferred to the Hospital. The Emergency Department Report, dated 9/1/17, indicated Resident #1 was found to have a left [MEDICAL CONDITION] resulting from a fall from his/her wheelchair at the Facility. The Operative Report, dated 9/2/17, indicated Resident #1 required surgery to repair his/her left [MEDICAL CONDITION]. The Surveyor interviewed the Director of Rehabilitation at 3:14 P.M. on 11/1/17. The Director said that around 2:30 P.M. on 9/1/17, she heard Resident #1 call for help, and she found Resident #1 in his/her room, lying on his/her left side on the floor. The Director said she did not hear Resident #1's safety alarm sounding, and there was no alarm on Resident #1's chair at the time. The Surveyor interviewed Hospice Certified Nurse Aide (CNA) #1 at 11:13 A.M. on 11/1/17. Hospice CNA #1 said she provided care to Resident #1 earlier in the morning on 9/1/17, but had not provided any care for Resident #1 after he/she went to breakfast. The Hospice CNA #1 said although she wrote in her statement that Resident #1 did not have an alarm in place on 9/1/17, the statement was untrue, and said she had in fact placed Resident #1's chair alarm on his/her chair that morning. The Witness Statement, dated 9/1/17, and signed by Hospice CNA #1, indicated Resident #1 did not have a chair alarm in place on 9/1/17. The Surveyor interviewed CNA #1 at 3:48 P.M. on 11/1/17. CNA #1 said the Facility used a Safety Rounds Book and staff did rounds three times per shift with the Safety Rounds Book to check that residents who required alarms had the alarms in place. The Surveyor interviewed CNA #2 at 4:06 P.M. on 11/1/17. CNA #2 said he had used the Safety Book the previous day, on 10/31/17 to do rounds. During the survey Facility staff were unable to provide the Surveyor with the Safety Books for review. The Surveyor interviewed Unit Manager #1 at 4:15 P.M. on 11/1/17. Unit Manager #1 said the Facility had not used the Safety Book for approximately two months. The Surveyor interviewed Nurse #1 at 1:16 P.M. on 11/2/17. Nurse #1 said she was Resident #1's nurse on 9/1/17, that it was the first time she worked on the unit where Resident #1 lived, and said she was not familiar with Resident #1. Nurse #1 said she could not recall if she had checked for placement of Resident #1's chair alarm that day. Nurse #1 said she was unsure of the Facility's protocol for ensuring staff were aware of residents' interventions for preventing falls, and said sometimes it was communicated during shift change report, sometimes it was listed on the Treatment Administration Record (TAR), and she said there used to be a Safety Book which listed residents at risk and their interventions. Nurse #1 said the Facility was not consistent with how use of alarms was communicated to staff. The Surveyor interviewed the Regional Clinical Director at 4:25 P.M., on 11/1/17. The Regional Clinical Director said the Facility did not have a policy that addressed the use of personal safety alarms. The Surveyor interviewed the Director of Nurses at 4:25 P.M. on 11/1/17. The Director of Nurses said the Facility had not used the Safety Books for approximately one or two months, and any resident with an order for [REDACTED].

Based on interviews and records reviewed, on 9/1/17, for one of three sampled residents (Resident #1), who was at increased risk for falls, the Facility failed ensure his/her safety device, personal chair alarm, was in place and functioning properly, and as a result Resident #1 fell out of his/her wheelchair, sustained a left hip fracture which required surgical intervention to repair. Findings include: The policy titled Falls Management, dated 3/15/16, indicated residents identified at risk for falls would receive interventions to reduce risk and minimize injury. Resident #1 was admitted to the Facility 12/21/16, his/her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 8/1/17, indicated Resident #1 was completely dependent and required assistance of two staff members for transfers. The MDS indicated Resident #1's Brief Interview for Mental Status (BIMS) score was 2 out of 15 (score of 00-07 indicates severe cognitive impairment). The Care Plan, dated 1/11/17, indicated Resident #1 was at risk for falls, and interventions included a chair alarm to alert staff to his/her need for assistance. The physician's orders [REDACTED].#1 was to have a chair alarm, check every shift. Resident #1's Treatment Administration Record (TAR), dated 9/1/17, indicated his/her order for the chair alarm was circled, which indicated his/her alarm was not in place. The Nurse Practitioner's Progress Note, dated 9/1/17, indicated Resident #1 was found, at 2:30 P.M., in his/her room lying on his/her left side and complained that his/her head hurt. The Note indicated Resident #1 was transferred to the Hospital. The Emergency Department Report, dated 9/1/17, indicated Resident #1 was found to have a left hip fracture resulting from a fall from his/her wheelchair at the Facility. The Operative Report, dated 9/2/17, indicated Resident #1 required surgery to repair his/her left hip fracture. The Surveyor interviewed the Director of Rehabilitation at 3:14 P.M. on 11/1/17. The Director said that around 2:30 P.M. on 9/1/17, she heard Resident #1 call for help, and she found Resident #1 in his/her room, lying on his/her left side on the floor. The Director said she did not hear Resident #1's safety alarm sounding and there was no alarm on Resident #1's chair at the time. The Surveyor interviewed Nurse #1 at 1:16 P.M. on 11/2/17. Nurse #1 said she was Resident #1's nurse on 9/1/17, that it was the first time she worked on the unit where Resident #1 lived, and said she was not familiar with Resident #1. Nurse #1 said at the time Resident #1's fall was discovered, she was at the nurses' station, and did not hear an alarm sound. Nurse #1 said she could not recall if she had checked for placement of Resident #1's chair alarm that day. The Surveyor interviewed the Director of Nurses at 1:29 P.M. on 11/1/17. The Director of Nurses said Resident #1 should have had a chair alarm in place, as indicated in his/her Care Plan.

Based on record review and interview, the facility staff failed to provide adequate interventions to prevent falls for 3 residents (#5, #9 and #23) of 13 applicable residents reviewed for falls, in a total sample of 23 residents. Findings include: 1. For Resident # 23, the facility staff failed to implement the use of bed alarm when the resident was in bed. Review of the facility's Fall Management Policy, revision date 3/15/16, indicated the following; -Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive the appropriate interventions to reduce risk and minimize injury. -Communicate patient's fall risk status to caregivers. -Develop individualized plan of care. -Review and revise care plan regularly. Resident # 23 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. Review of the resident's Fall Care Plan, date initiated 5/10/16, indicated the following intervention; -The resident will need contact guard for transfers and ambulation. -Provide verbal cues for proper pacing and energy conservation. -Monitor for and assist with toileting needs. Review of Nurse's Notes (dated 5/7/16, 5/8/16, 5/9/16), and 5/11/16 indicated the resident had bed and chair alarms. Review of the Admission Minimum Data Set (MDS) Assessment, dated 5/12/16, indicated the resident had moderate cognitive impairment as evidenced by a score of 12 out of 15 on the Brief Interview of Mental Staus (BIMS), required extensive assistance for bed mobility, transfers, walking in the room, dressing, toileting, hygiene and bathing, and had falls in the previous 6 months prior to admission. Review of the Nursing Assessment-Expanded, dated 5/12/16, indicated the resident was a high fall risk as evidenced by a score of 20 on the assessment (form indicated High Risk). Review of the facility's Risk Management Form, date 5/13/16, indicated the resident had an unwitnessed fall in his/her room at 4:00 P.M. The report indicated the resident was found on the floor near the bathroom and had not complained of pain. Further review of the report indicated the facility staff had called 911 prior to the fall due to critically high lab work. The resident was transported to the hospital and admitted . Review of the facility's Long Term Care Fax Report form, undated, indicated no safety precautions were in place at the time of the occurrence. Review of a hospital Computerized Tomography (CT) scan report of the cervical (C) spine, dated 5/13/16, indicated the resident had a C5 and C6 fractures. Review of a Nurse's Note, dated 5/13/16, indicated the resident had sustained 2 cervical fractures from the fall and was admitted to the hospital. Further review of the facility's fall investigation indicated 2 Individual Performance Improvement Plan forms, both dated 5/13/16. The forms indicated both nurses failed to ensure the resident's bed alarm was turned on after providing care at the time of the fall. During an interview on 9/13/16 at 10:00 A.M., Unit Manager (UM) #1 and Nurse #3 said when the resident was admitted to the facility, he/she was noted to be a high fall risk. They said the resident was put in a room close to the Nursing Station and alarms (bed and chair) were instituted. Both nurses said the resident's bed alarm was not on and sounding when the resident sustained [REDACTED]. During the same interview, UM #1 also said the bed and chair alarms should have been noted on the resident's Treatment Administration Record (TAR) and the Fall Care Plan when the resident was admitted , but were not. During the interview on 9/13/16 at 10:00 A.M., the Director of Nurses (DON) said there was a communication and documentation breakdown for this resident relative to the use of the bed and chair alarm. She said the alarms should have been noted on the Certified Nursing Assistant (CNA) Kardex, the fall care plan and TAR when the resident was admitted and they were instituted by the nursing staff. She said all staff have been educated on checking alarms and documenting them on the TAR, care plan and Certified Nursing Assistant (CNA) Kardex. 2. For Resident # 9, the facility staffed failed to ensure use of a chair alarm, as care planned, for 2 of 3 applicable falls the resident sustained [REDACTED].>Resident #9 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. Review of the CNA Kardex, dated 9/16/15, indicated the following interventions for safety; -Bed alarm to bed to alert staff members of resident's need to ambulate. -Chair alarm to chair/wheel chair to alert staff members of resident's need to ambulate. Review of the Fall Care Plan, date initiated 9/16/15, indicated the resident was at a risk for falls due to impaired mobility. Interventions included the following; -Assist resident with ambulation providing one assist using a rolling walker to meals, bathroom, activities and anytime requested. -Bed alarm to bed. -Chair alarm to chair/wheel chair . Review of the Admission MDS Assessment, dated 9/22/15, indicated Resident #9 had mild cognitive impairment as evidenced by a score of 12 out of 15 on the BIMS, required limited assistance with ambulation, required extensive assistance with bed mobility, transfers, dressing, toilet use, bathing and hygiene and had no falls since admission. Review of a Nurse's note, dated 2/3/16, indicated the resident had an unwitnessed fall in the bathroom while trying to self transfer. The resident sustained [REDACTED]. Review of the Risk Management System Form, dated completed 2/11/16, indicated there was not an alarm assigned to the resident at the time of the fall. Review of a Nurse's note, dated 2/27/16, indicated the resident had a witnessed fall when attempting to self transfer from a seated position while in the bathroom. The resident sustained [REDACTED]. Review of the facility's Risk Management Form, dated completed 2/27/16, indicated an alarm was not assigned to the resident at the time of the fall, and the new intervention added was to implement a chair alarm. Review of the Quarterly MDS Assessment, dated 3/5/16, indicated the resident had moderate cognitive impairment as evidenced by a score of 9 out of 15 on the BIMS, required extensive assistance for bed mobility, transfers, dressing, toilet use, hygiene and bathing, and had one fall with no injury since the last assessment. Review of the a Nurse's note, dated 3/5/16, indicated the resident had an unwitnessed fall in the bathroom when attempting to self transfer. The resident was uninjured. Review of the Risk Management System Form, dated completed 3/8/16, did not indicate the alarm was sounding and indicated there was not an alarm assigned to the resident. The new intervention added was for a chair alarm to be on the wheelchair at all times when out of bed, care planned for since 9/16/15, and alarm box to be placed out of the resident's reach. Review of a Nurse's Note, dated 4/26/16, indicated the resident was heard yelling for help at 1:10 A.M The resident was found on the bathroom floor beside the wheelchair with blood coming his/her nose and mouth, a laceration below the right eye and a hematoma (bruise) on the right forehead. The note indicated 911 was called and the resident was transferred to the hospital for evaluation. Review of the Risk Management System Form, dated 4/26/16, including witness statements did not indicate an alarm was sounding at the time of the fall. Review of the facility's Long Term Care Fax Report form, dated 4/27/16, indicated no safety precautions were in place at the time of the occurrence. During an interview of 9/9/16 at 7:15 A.M., the DON said the patient was not always compliant with the alarm. She said she did not know why the investigations for the falls on 3/5/16 and 4/26/16 did not indicate the alarms were assigned to the resident and sounding at the time of the falls. She said the chair alarm should have been on during the fall of 3/5/16 and 4/26/16, as care planned. 3. For Resident #5, the facility staff failed to provide adequate supervision for the resident for 1 of 3 falls the resident sustained [REDACTED].>Resident #5 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. Review of the Fall Care Plan, date initiated 2/2/16, indicated the resident was at risk of falls due to impaired mobility. The care plan indicated the following interventions; -Patient requires assist of one at all times for Activities of Daily Living (ADL) and transfers, and toileting with a rolling walker as tolerated. -Supervised areas at all times while awake (initiated 2/24/16). Review of the Admission MDS Assessment, dated 2/8/16, indicated the resident had severe cognitive impairment as evidence by a score of 3 out of 15 on the BIMS, required limited assistance for bed mobility, transfers, toilet use and hygiene, required extensive assistance for dressing and bathing, one fall with no injury since admission and had falls during the 6 months prior to admission. Review of a Nursing Assessment-Expanded, dated 2/8/16, indicated a fall category score of 17, indicating a high fall risk. Review of the clinical record indicated the resident had unwitnessed falls on 2/16/16 and 2/23/16. Review of the facility's Risk Management System Form, dated completed 3/2/16, indicated the new intervention added was to keep the resident in a supervised area when out of bed, and toilet upon awakening. Review of the clinical record indicated the resident had an unwitnessed fall on 4/25/16 at 7:45 A.M. in his/her room. The resident was uninjured. Review of the Risk Management System Form, dated 4/26/16, indicated the resident fell while rising from the chair/wheelchair. Further review of the report indicated the staff was to be re-educated to encourage the resident to be in a supervised area when he/she was out of bed. During an interview on 9/13/16 at 11:00 A.M., UM #3 said she was unsure why the resident was in his/her room at the time of the fall because he/she was supposed to be in a supervised area when out of bed as care planned.

Based on record review and interviews, for one of three sampled residents (Resident #2), the Facility failed to provide Resident #2 with an advanced dysphagia diet as ordered by the physician. Resident #2 had a history of [REDACTED].#2 was placed on an advanced dysphagia diet and was not to be served pancakes. On 10/20/14, the Facility provided Resident #2 with pancakes, in error, and Resident #2 choked on the pancakes, his/her airway became occluded, and required staff to administer abdominal thrusts in order to dislodge the pancakes from Resident #2's airway. Findings include: The Nurse's note, dated 3/28/14, indicated Resident #2 choked on a pancake and staff successfully performed the abdominal thrust on Resident #2, to clear his/her airway. The Interdisciplinary Therapy Screen, dated 3/28/14, indicated Resident #2's diet included "no pancakes," and a diet slip was sent to the kitchen to maintain this diet. The Speech Therapy notes, dated 3/31/14, indicated Resident #2 was on an advanced dysphagia diet, which included no pancakes. Resident #1's Swallowing Care Plan, initiated 4/1/14, indicated Resident #2 was at risk for impaired swallowing, and one of the interventions included, "no pancakes." The Surveyor interviewed Speech Therapist #1 at 10:35 A.M. on 11/24/14. Speech Therapist #1 said she evaluated Resident #2, on 3/31/14, after Resident #2 choked on pancakes on 3/28/14. Speech Therapist #1 said Resident #1 presented with mild oral dysphagia and was edentulous (had no teeth). Speech Therapist #1 said Resident #2 was appropriate for an advanced dysphagia diet, which included "no pancakes." Speech Therapist #1 said a meal slip was sent to the kitchen, and an order was written to reflect these diet changes for Resident #2. The Surveyor interviewed the Food Services Director at 3:15 P.M. on 11/25/14. The Food Service Director said after the first incident, on 3/28/14, of Resident #2 choking on pancakes, his/her diet was changed and included no pancakes and no rolls. The physician's orders [REDACTED].#2's advanced dysphagia diet included, "no pancakes." The Quarterly Minimum Data Set (MDS), completed 8/6/14, indicated Resident #1 had severe cognitive impairment, and his/her [DIAGNOSES REDACTED]. The Nurse's note, dated 10/20/14, indicated Resident #1 choked on a pancake and staff successfully performed the abdominal thrust on Resident #2 to clear the airway. The Surveyor interviewed Nurse #1 at 2:15 P.M. on 11/24/14. Nurse #1 said she would check residents' trays to ensure they were correct, and would pass on reports to the certified nurse aides. Nurse #1 said, prior to 10/20/14, she thought Resident #1 was not on a special diet (this is not consistent with the orders, medications records, speech therapy evaluations, from 3/31/14, and dietary records from April 2014). The Speech Therapist #1 said she evaluated Resident #2 again on 10/20/14, after Resident #2 choked on pancakes a second time (on 10/20/14). Speech Therapist #1 said Resident #2 was to continue with an advanced dysphagia diet, which included no regular texture pancakes, but Resident #2 was able to have pureed pancakes. The Food Service Director said he had to "write up" a staff member in the kitchen for not reading Resident #2's diet/meal ticket properly in regards to Resident #2's choking incident on 10/20/14. The Surveyor interviewed the Director of Nurses (DON) at 3:00 P.M. on 11/24/14. The DON said Resident #2 received pancakes on 10/20/14, which were cut up small. When the Surveyor pointed out Resident #2's physician's orders [REDACTED]. would be carried out.

Based on observation, record review, and interviews, the facility failed for 1 sampled resident (#2) of 3 applicable residents with pressure sores out of a total sample of 21 residents, to keep the resident from developing pressure sores. The facility also failed to ensure that necessary treatment and services were provided to promote healing. Findings include: For Resident #2, the facility failed to provide pressure relief, and the resident developed a stage two pressure ulcer to his/her right heel which progressed to an unable to stage pressure ulcer. Review of the facility Skin Integrity Care Delivery Process, dated 10/1/10, indicated the following: All residents will have a Norton Plus Pressure Ulcer Scale completed on admission/readmission, weekly for the first month, quarterly and with any significant change in condition to identify risk. Evaluate for presence of specific risk factors and develop plan of care to address individual risk factors. Intervention guidelines: Employ methods to offload heels despite bed surface for individuals at risk. Resident #2 was admitted to the facility in 2/2013 with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment, dated 3/4/13, indicated that the resident required extensive assistance with bed mobility, transfer from one surface to another, and ambulation. The skin conditions section of the MDS was coded "0" for the presence of pressure ulcer. Review of the resident's admission Norton Plus Pressure Ulcer Scale, dated 2/26/13, indicated that the resident scored an 8, which indicated that the resident is at high risk for skin breakdown. Review of the resident's 3/2013 Skin Integrity Report indicated the following: 3/5/13 - Stage 2 pressure ulcer right heel- 2 centimeter(cm) by 2 cm blister/serous(clear liquid within blister). 3/13/13 - Stage 2 pressure ulcer right heel- 3.5 cm by 3.5 cm - open (no further description). 3/20/13 - Unable to stage pressure ulcer right heel - 3 cm by 3 cm - 100% eschar (black,necrotic tissue). 3/27/13 - Unable to stage pressure ulcer right heel- 2 cm by 3 cm - 100% eschar (black, necrotic tissue). Review of the resident's 2/2013 and 3/2013 Treatment Administration Records (TAR) indicated the following: *Skin prep to heels twice a day for 7 days, (2/27/13 through 3/7/13). *Observe blister to right heel every shift (3/5/13 through 3/11/13, 11:00 P.M. - 7:00 A.M. shift). *Elevate both heels while in bed (3/5/13 through 3/11/13, 11:00 P.M. - 7:00 A.M. shift). * There were no treatment orders documented on the 3/2013 TAR (3/11/13, 7:00 A.M. - 3:00 P.M. shift through 3/13/13, 7:00 A.M. - 3:00 P.M. shift). *Cleanse area on right heel with skin integrity, apply wound gel and protective dressing daily, until healed (3/13/13 through 3/15/13). *Off load heels while in bed (3/13/13 through present). *Cleanse area on right heel with normal saline, apply Santyl (a [MEDICATION NAME] agent) and [MEDICATION NAME] dressing daily and as needed (prn) until healed (3/16/13 through 3/20/13). *Skin prep to right heel twice daily (3/20 through present). A care plan, dated 2/26/13, was developed for at Risk for Skin Breakdown with a goal of "will show no signs of skin breakdown for 90 days" The care plan was revised on 3/11/13. Interventions included: * Apply barrier cream with each cleansing. * Assist in positioning as needed due to generalized weakness/fatigue due to multiple medical issues. * Monitor skin for signs/symptoms of skin breakdown, i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. * Observe skin condition with Activities of Daily Living (ADL) care daily and report abnormalities. * Pressure redistribution surfaces to bed as per protocol. * Weekly skin assessment by licensed nurse. * Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation (resolved 3/11/13). * Norton/Braden assessments per policy (resolved 3/11/13). * Evaluate for skin risk factors per protocol (resolved 3/11/13). During observation, the following was revealed: On 3/27/13 at 10:00 A.M., resident was observed lying in bed, both feet were resting on the mattress. On 3/29/13 at 7:45 A.M., resident was observed lying in bed, both feet were resting on the mattress. For Resident #2, the facility failed to follow their skin care policies, which included off loading of heels, to prevent the development and worsening of a pressure ulcer.