**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was a Diabetic, had experienced an acute episode of hypoglycemia (low blood sugar) and required administration of glucose gel for treatment, the Facility failed to ensure Resident #1 was provided nursing care and treatment in accordance with professional standards of practice, when on 11/29/23, after Nurse #1 administered the glucose gel, she failed to recheck Resident #1's blood glucose level, left him/her unattended in his/her bed and later found Resident #1 (who was unable to transfer or ambulate without the physical assistance from staff) lying on the bathroom floor. Resident #1 was later diagnosed with hypoglycemia, acute right pubic bone fractures and was admitted to the Hospital. Findings include: Review of the Facility Policy titled, Diabetic Management Protocol, dated as revised April 6, 2018, indicated the following: -residents who have diabetes will receive care according to accepted standards of care focused on maintaining blood glucose control and preventing both acute and chronic complications; -upon admission, initiate diabetic management physician order set; -perform fingerstick blood glucose monitoring as ordered; -administer insulin/oral hypoglycemic medication as ordered; -assess for and respond to any change in condition; -treat hypoglycemic episode according to hypoglycemic protocol; Review of the Facility's Policy titled, Hypoglycemia Protocol, undated, indicated the following: -hypoglycemia is defined as a blood glucose of less than 70 mg (milligrams)/dl (deciliter) with or without symptoms; -assess for signs and symptoms of hypoglycemia which could include the following: sweating, facial pallor, shakiness, tremors, increased appetite, nausea, dizziness or light-headedness, sleepiness, tingling around the mouth and tongue, change in level of consciousness ranging from confusion to coma, weakness, rapid heart rate, headache, seizures; -Treatment of blood sugar (BS) 50 mg/dl or less, conscious, able to swallow, able to take food by mouth, remain with patient if symptomatic and provide 30 grams of carbohydrates; 8 ounces of juice or soda (regular, not sugar free or diet) or; 1 cup of applesauce or; 12 saltines or; 2 tablespoons of sugar, jelly, honey or; 16 ounce cup of milk -skim, low-fat or whole; or provide 30 grams of glucose gel (two tubes), and retest blood glucose in 15 minutes, -if blood glucose less than 70, provide another 15 grams of carbohydrates; -repeat blood glucose every 15 minutes until two blood glucose levels above 70 and no symptoms; -add order to check blood glucose level one time at 2:00 A.M., in addition to any other MD orders for blood glucose check; -notify MD per Physician Notification Pamphlet of hypoglycemic event, using Situation Background Assessment Recommendation (SBAR) include vitals, symptoms, time of last food intake, time/dose of diabetic meds, response to therapy, and ask for change in regime if appropriate; -document on SBAR: event, times of glucose checks, signs and symptoms of hypoglycemia, treatment, resolution, assessment, correspondence with MD/NP prior to administering the next insulin or oral diabetes agent for medication and glucose monitoring orders; -post hypoglycemic event: review insulin regime with MD/NP within 24 hours of event. Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 defined Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in January 2023, diagnoses spinal stenosis of lumbar region, hypertensive urgency, acute kidney failure, weakness, hypoglycemia, major depressive disorder, dementia and diabetes mellitus with ketoacidosis. Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 had severe cognitive impairment. The MDS indicated Resident #1 required maximum assistance from staff with transfers and moderate assistance from staff with ambulation. Review of the Facility's Internal Investigation, dated 11/29/23, indicated that at approximately 8:00 A.M. Resident #1 had a low blood glucose level of 39 mg/dl, was confused, unable to answer questions appropriately and was given glucose gel 15 grams. The Investigation indicated that Nurse #1 waited a bit (exact amount of time unknown) for his/her condition to improve, he/she became more alert, was forming words, so she left Resident #1 in bed and checked in on him/her 15 minutes later. The Investigation indicated Resident #1 was improving and was able to answer questions. The Investigation indicated that 20 minutes later, Nurse #1 went to check in on Resident #1 and found him/her on the floor in the bathroom with his/her pants halfway down with urine and feces on the floor. The Investigation indicated Resident #1 was crying and complaining of pain in his/her right hip and leg and Nurse #1 was unable to perform Range of Motion to his/her right leg due to pain. The Investigation indicated that Resident #1 was transferred to the Hospital ED. Review of Resident #1's Physician Order, dated 1/27/23, indicated he/she had a Physician's order for the following: -check blood glucose level before meals and at bedtime, notify MD/NP/PA when blood glucose is less than 70 mg/dl and greater than 350 mg/dl and -the orders included parameters in the event of a low blood sugar, for nursing to administer one from the following for blood glucose less than 51 mg/dl: - 30 gm glucose gel (2 tubes); - 8 ounces of juice or soda; - 1 cup of apple sauce; - 12 saltines; - 2 tablespoons of sugar or jelly. -remain with resident if symptomatic; -repeat above every 15 minutes until two blood glucose levels above 70 mg/dl and asymptomatic. Review of Resident #1's Nurse Progress Note, dated 11/29/23 at 2:41 P.M., (written by Nurse #1), indicated that Resident #1 had a CBG (capillary blood glucose) level of 39 mg/ml this morning, speech unremarkable, confused, unable to answer questions accurately, orange juice was attempted but he/she was unable to sit up properly and swallow thin liquids. The Note indicated that glucose gel 15 gm (gram) was given, waited for his/her status to change and he/she started to form words. However, Resident #1's Physicians orders indicated to administer 30 gm of glucose gel for a CBG less than 51 mg/dl, (not 15 gm, as documented by Nurse #1). The Progress Note further indicated that 15 minutes later, Resident #1 was able to answer questions accurately, form words and 20 minutes later, Resident #1 was found on the floor in his/her bathroom with his/her pants down and urine and feces noted on the floor. The Note indicated that Resident #1 was crying, unable to perform Range of Motion (ROM) to his/her right leg and cried out in pain when he/she tried to move his/her right leg. The Note indicated that Resident #1 was transferred to the Hospital ED. During a telephone interview on 1/04/24 at 12:30 P.M., Nurse #1 said that she obtained Resident #1's CBG between 7:45 A.M. and 7:50 A.M. on 11/29/23 and it was 39 mg/dl. Nurse #1 said she attempted to give Resident #1 orange juice, but he/she was confused, not making any sense, was unable to sit up or swallow and did not eat anything that morning. Nurse #1 said she gave Resident #1 one packet of glucose gel (15 gm) and after a few minutes she checked in on him/her, he/she was still confused and not making any sense. Nurse #1 said that a few minutes later, she checked in on Resident #1 and he/she was able to form words and was more alert. Nurse #1 said around 10:00 A.M., she went to check on Resident #1 again and found him/her on the floor in the bathroom complaining of right leg pain. Nurse #1 said Resident #1 was transferred to the Hospital ED. Nurse #1 said that she did not check Resident #1's Physician orders, but said she should have. Nurse #1 said she was not aware that Resident #1 had specific Physician orders with parameters in the event of a hypoglycemic incident. Nurse #1 said she administered just one packet of glucose gel (for a total of 15 gm, not 30 gm per physician's orders). Nurse #1 said she never rechecked Resident #1's blood sugar after she administered the packet of glucose gel, but said she should have. Nurse #1 said that she did not follow Resident #1's Physician Orders or facility policy for the treatment of Resident #1's hypoglycemia. During an interview on 12/27/23 at 4:10 P.M., Certified Nurse Aide (CNA) #2 said that on 11/29/23 at approximately 8:00 A.M., she went to give Resident #1 his/her breakfast tray and the Nurse told her not to give Resident #1 his/her breakfast tray because his/her blood sugar was low. CNA #2 said that Resident #1 was talking to him/herself, was out of it and was not making any sense. CNA #2 said that she went back in to check on Resident #1 sometime between 8:30 A.M. and 8:45 A.M., and that Resident #1 was still out of it, was not making any sense, and was not him/herself. During an interview on 12/28/23 at 11:05 A.M., Unit Manager #1 said that at approximately 9:15 A.M. on 11/29/23, she went into Resident #1's room to obtain a COVID sample and said Resident #1 was not his/her usual self and his/her behavior was not at his/her baseline. Unit Manager #1 said that Resident #1 required emergent transfer to the Hospital Emergency Department for evaluation that day and when Emergency Medical Services (EMS) arrived (exact time unknown), she heard Nurse #1 tell EMS that Resident #1's blood sugar was low and heard EMS ask Nurse #1 if she rechecked Resident #1's blood sugar and that Nurse #1 had stated no to EMS. Unit Manager #1 said that Nurse #1 did not inform her that Resident #1 had a hypoglycemic episode that morning. Unit Manager #1 said that it was her expectation that nurses notify her of any change in a resident's condition. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 presented to the Hospital ED after an episode of hypoglycemia and an unwitnessed fall at the Nursing Home. The Summary indicated that Resident #1 was found to have a blood sugar of 38 mg/dl this morning at the Nursing Home and upon arrival at the ED, Resident #1 was found to be hypoglycemic with a blood sugar of 43 mg/dl. The Summary indicated that Resident #1 was given D 10 bolus (dextrose used to treat severe hypoglycemia) 100 milliliters (ml) intravenously. The Summary indicated that Resident #1's blood sugar was rechecked and was 29 mg/dl and he/she was given D 50 25 ml (used for rebound hypoglycemia) intravenously and D 5 in Ringers lactate solution (crystalloid isotonic intravenous fluid of balanced electrolytes) at 125 ml/hr. intravenously. The Summary indicated that a CT scan of Resident #1's right hip revealed acute right pubic (pelvic) bone fractures and that the fall was probably due to hypoglycemia. During an interview on 12/28/23 at 11:40 A.M., the Director of Nurses (DON) said it was her expectation that nursing stay with Resident #1 until his/her blood sugar levels were 70 mg/dl or above. The DON said it was her expectation that Nurse #1 checked Resident #1's blood sugar level every 15 minutes until they were 70 mg/dl or above. The DON said Nurse #1 did not recheck Resident #1's blood sugar level and did not follow Resident #1's Physician orders or the Facility's Policy related to Hypoglycemic Protocol. On 12/28/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A) 11/29/23, Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and treatment of hypoglycemia and injury as a result of an unwitnessed fall. B) 11/29/23, Nurse #1 was immediately educated by the Director of Nurses (DON) to follow the Facility's hypoglycemia protocol and to ensure re-testing and re-assessment of resident's who are hypoglycemic. C) 12/06/23 and 12/07/23, Nursing Staff were in-serviced on the Facility's Diabetic Management Policy and Hypoglycemia Protocol by the Staff Development Coordinator (SDC) and the Director of Nurses (DON). D) 12/07/23, Nursing Staff were in-serviced on the Facility's Falls Management Policy by the Staff Development Coordinator (SDC). E) 12/13/23 - 12/15/23, A Facility wide audit of all diabetic resident's blood glucose results was completed by the Regional Director of Clinical Services. F) 12/15/23, Unit Manager #1 and Nurse #1 were in-serviced on the proper policy and procedure of their positions and compliance with standards of practice by the SDC. G) DON and Unit Managers will conduct daily audits of all diabetic resident's blood glucose results to ensure the Hypoglycemic Protocol and Diabetic Management Policy were followed. H) Audits will be conducted daily for three weeks, then weekly for three months or until substantial compliance is achieved. I) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months for patterns, trends and continued recommendations for process monitoring and improvement. J) The DON and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, required physical assistance from staff for transfers and mobility, and who had been administered medication by nursing to treat an acute episode of hypoglycemia (low blood sugar), the Facility failed to ensure he/she was provided adequate supervision by nursing in an effort to maintain his/her safety to prevent an incident/accident resulting in an injury. On 11/29/23, Nurse #1 administered glucose gel to Resident #1 to treat his/her low blood sugar, however Nurse #1 failed to recheck his/her blood glucose level, left him/her unattended in his/her bed and later found Resident #1 lying on the bathroom floor crying out in pain when range of motion was attempted to his/her right leg. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation of his/her injury, was diagnosed with hypoglycemia, acute right pubic bone fractures and was admitted to the Hospital. Findings include: Review of the Facility Policy titled, Falls Management Program Practice Guidelines, undated, indicated the following: -four most common risk factors are: impaired cognition - some practitioners cite dementia as the top risk factor for falls, medications-affect balance, orientation, gait and mobility, medical conditions-affect vision, balance, strength, gait and mobility, and urinary incontinence-urine on the floor, attempting to get to the bathroom without assistance due to urgency; Review of the Facility Policy titled, Falls Risk Reduction, dated as revised 11/02/23, indicated the following: -all residents will be assessed for falls risk factors; -those determined to have risk factors will receive individualized interventions based on risk factors in order to reduce risk for falls and minimize the actual occurrence of falls; -ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents; -complete Fall Risk Assessment; -identify resident's specific risk factors to determine which risk factors need further assessment and/or require intervention. Review of the Facility's Policy titled, Hypoglycemia Protocol, undated, indicated the following: -hypoglycemia is defined as a blood glucose of less than 70 mg (milligrams)/dl (deciliter) with or without symptoms; -assess for signs and symptoms of hypoglycemia which could include the following: sweating, facial pallor, shakiness, tremors, increased appetite, nausea, dizziness or light-headedness, sleepiness, tingling around the mouth and tongue, change in level of consciousness ranging from confusion to coma, weakness, rapid heart rate, headache, seizures; -repeat blood glucose every 15 minutes until two blood glucose levels above 70 and no symptoms; Resident #1 was admitted to the Facility in January 2023, diagnoses spinal stenosis of lumbar region, hypertensive urgency, acute kidney failure, weakness, hypoglycemia, major depressive disorder, dementia and diabetes mellitus with ketoacidosis. Review of Resident #1's Fall Risk Assessment, dated 10/30/23, indicated that he/she was at increased risk for falls. Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 had severe cognitive impairment. The MDS indicated Resident #1 required maximum assistance from staff with transfers and moderate assistance from staff with ambulation, hygiene and toileting. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, dated 11/06/23, indicated he/she required the physical assistance of one staff member with ambulation, mobility, transfers, and toileting. Review of Resident #1's Urinary Incontinence Care Plan, dated 11/07/23, indicated he/she had chronic and intractable urinary incontinence related to dementia and could not perform personal hygiene or manage clothing, interventions included to toilet resident during their individual morning and evening care, before and after meals, before going back to bed, if resident appears restless or if requested. Review of Resident #1's Certified Nurse Aide (CNA) Care Plan, (used as a reference guide by CNA's), undated, indicated Resident #1 required the physical assistance of one staff member with transfers, ambulation, dressing, toileting, bathing and hygiene and was incontinent of bladder. Review of a Fall Incident and Root Cause Analysis Report, dated 11/29/23, indicated that at 10:00 A.M., Resident #1 was found on his/her buttocks on the bathroom floor and urine was noted on the floor. The Report indicated Resident #1 was unable to recall incidents leading up to the fall, was confused and forgetful. The Report indicated Resident #1's blood sugar was 39 mg/dl at 8:00 A.M. The Report indicated that Resident #1 sustained an injury to his/her right leg/hip area. Review of the Facility's Internal Investigation, dated 11/29/23, indicated that at approximately 8:00 A.M. Resident #1 had a low blood glucose level of 39 mg/dl, was confused, unable to answer questions appropriately and was given glucose gel 15 grams. The Investigation indicated that Nurse #1 waited a bit (exact duration of time unknown) for his/her condition to improve, he/she became more alert, was forming words, so she left Resident #1 in bed and checked in on him/her 15 minutes later. The Investigation indicated Resident #1 was improving and was able to answer questions. The Investigation indicated that 20 minutes later, (at approximately 10:00 A.M.) Nurse #1 went to check in on Resident #1 and found him/her on the floor in the bathroom with his/her pants halfway down with urine and feces on the floor. The Investigation indicated Resident #1 was crying and complaining of pain in his/her right hip and leg and Nurse #1 was unable to perform Range of Motion to his/her right leg due to pain. The Investigation indicated that Resident #1 was transferred to the Hospital ED. Review of Resident #1's Nurse Progress Note, dated 11/29/23 at 2:41 P.M., (written by Nurse #1), indicated that Resident #1 had a CBG (capillary blood glucose) level of 39 mg/ml this morning, speech unremarkable, confused, unable to answer questions accurately, orange juice was attempted but he/she was unable to sit up properly and swallow thin liquids. The Note indicated that glucose gel 15 gm (gram) was given, waited for his/her status to change and he/she started to form words. The Note indicated that 15 minutes later, Resident #1 was able to answer questions accurately, form words and 20 minutes later, Resident #1 was found on the floor in his/her bathroom with pants down and urine and feces noted on the floor. The Note indicated that Resident #1 was crying, unable to perform Range of Motion (ROM) to his/her right leg and cried out in pain when he/she tried to move his/her right leg. The Note indicated that Resident #1 was transferred to the Hospital ED. During a telephone interview on 1/04/24 at 12:30 P.M., Nurse #1 said that she obtained Resident #1's CBG between 7:45 A.M. and 7:50 A.M. on 11/29/23 and it was 39 mg/dl. Nurse #1 said she attempted to give Resident #1 orange juice, but he/she was confused, not making any sense, was unable to sit up or swallow and did not eat anything that morning. Nurse #1 said she gave Resident #1 one packet of glucose gel (15 gm) and after a few minutes, she checked in on him/her, he/she was still confused and not making any sense. Nurse #1 said that a few minutes later, she checked in on Resident #1, he/she formed words and was more alert. Nurse #1 said that when she went to check on Resident #1 again, which was approximately at 10:00 A.M., she found him/her on the floor in the bathroom complaining of right leg pain. Nurse #1 said she never rechecked Resident #1's blood glucose level after she administered the packet of glucose gel but should have. Nurse #1 said Resident #1 was transferred to the Hospital ED for evaluation. Based on Nurse #1's Progress Note and interview, regarding the sequence of events on 11/29/23 related to Resident #1 hypoglycemic episode, there was no documentation to support Nurse #1 rechecked his/her blood glucose level every 15 minutes until he/she had two blood glucose levels of 70 mg/dl and had no symptoms, therefore leaving him/her unattended and at risk for falls. During an interview on 12/27/23 at 4:10 P.M., Certified Nurse Aide (CNA) #2 said that on 11/29/23 at approximately 8:00 A.M., she went to give Resident #1 his/her breakfast tray and the Nurse told her not to give Resident #1 his/her breakfast tray because his/her blood sugar was low. CNA #2 said that Resident #1 was talking to him/herself, was out of it and was not making any sense. CNA #2 said that she went back in to check on Resident #1 between 8:30 A.M. and 8:45 A.M., and Resident #1 was still out of it, not making any sense, and was not him/herself. CNA #2 said that she never gave Resident #1 his/her breakfast tray that morning because he/she was not alert enough to feed him/herself or be fed by staff. During an interview on 12/28/23 at 11:05 A.M., Unit Manager #1 said that at approximately 9:15 A.M. on 11/29/23, she went into Resident #1's room to obtain a COVID sample and said Resident #1 was not his/her usual self and his/her behavior was not at his/her baseline. Unit Manager #1 said that approximately 20 minutes later, Nurse #1 informed her that Resident #1 was on the bathroom floor in his/her room. Unit Manager #1 said that she went into Resident #1's room, he/she was sitting on the bathroom floor crying and pointed to his/her right hip area and said that it hurt. Unit Manager #1 said that she called 911 and when Emergency Medical Services (EMS) arrived, she heard Nurse #1 tell EMS that Resident #1's blood sugar was low, heard EMS ask Nurse #1 if she rechecked Resident #1's CBG and that Nurse #1 had stated no to EMS. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 presented to the Hospital ED after an episode of hypoglycemia and an unwitnessed fall at the Nursing Home. The Summary indicated that Resident #1 was found to have a blood sugar of 38 mg/dl this morning at the Nursing Home and upon arrival at the ED, Resident #1 was found to be hypoglycemic with a blood sugar of 43 mg/dl. The Summary indicated that Resident #1 was given D 10 bolus (dextrose used to treat severe hypoglycemia) 100 milliliters (ml) intravenously. The Summary indicated that Resident #1's blood sugar was rechecked and was 29 mg/dl and he/she was given D 50 25 ml (used for rebound hypoglycemia) intravenously and D 5 in Ringers lactate solution (crystalloid isotonic intravenous fluid of balanced electrolytes) at 125 ml/hr. intravenously. The Summary indicated that a CT scan of Resident #1's right hip revealed acute right pubic (pelvic) bone fractures and that the fall probably due to hypoglycemia. The Summary indicated that Resident #1 was admitted to the Hospital for hypoglycemia and acute right pubic bone fractures. During an interview on 12/28/23 at 11:40 A.M., the Director of Nurses (DON) said it was her expectation that nursing stay with Resident #1 until his/her blood sugar levels were 70 mg/dl or above. The DON said it was her expectation that Nurse #1 recheck Resident #1's blood sugar level every 15 minutes until they were 70 or above and said Nurse #1 did not recheck Resident #1's blood sugar level. The DON said that Resident #1's low blood sugar level, change in condition and transferring him/herself to the bathroom contributed to his/her fall. On 12/28/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A) 11/29/23, Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and treatment of hypoglycemia and injury as a result of an unwitnessed fall. B) 11/29/23, Nurse #1 was immediately educated by the Director of Nurses (DON) to follow the Facility's hypoglycemia protocol and to ensure re-testing and re-assessment of resident's who are hypoglycemic. C) 12/06/23 and 12/07/23, Nursing Staff were in-serviced on the Facility's Diabetic Management Policy and Hypoglycemia Protocol by the Staff Development Coordinator (SDC) and the Director of Nurses (DON). D) 12/07/23, Nursing Staff were in-serviced on the Facility's Falls Management Policy by the Staff Development Coordinator (SDC). E) 12/13/23 - 12/15/23, A Facility wide audit of all diabetic resident's blood glucose results was completed by the Regional Director of Clinical Services. F) 12/15/23, Unit Manager #1 and Nurse #1 were in-serviced on the proper policy and procedure of their positions and compliance with standards of practice by the SDC. G) DON and Unit Managers will conduct daily audits of all diabetic resident's blood glucose results to ensure the Hypoglycemic Protocol and Diabetic Management Policy were followed. H) Audits will be conducted daily for three weeks, then weekly for three months or until substantial compliance is achieved. I) Results of the audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months for patterns, trends and continued recommendations for process monitoring and improvement. J) The DON and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had undergone a right total hip arthroplasty, had a history of arthritis of the hip and required pain management, the Facility failed to ensure nursing adequately assessed and effectively helped manage his/her complaints of increased pain. On 12/10/23, at approximately 8:30 A.M., Resident #2 complained of increased right hip pain after being repositioned in bed, and had requested pain medication, however Nurse #2 did not administer pain medication to Resident #2 until two and half hours after his/her initial complaints of increased right hip pain. An x-ray was obtained of Resident #2's right hip and he/she was found to have mild soft tissue swelling and an acute periprosthetic fracture of his/her right hip. Finding include: The Facility's Policy, titled Pain Management, dated as revised 6/16/2022, indicated the following: - the Facility ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals, quality of life, functionality and preferences; - resident's will be assessed for the presence of pain, and individualized pain management interventions will be implemented through their care plan and the effectiveness will be evaluated on an ongoing basis; - maintain the highest possible level of comfort for all residents by providing a system to identify, assess, treat, and evaluate pain; - design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with resident directed goals; - every shift, resident's will be screened for the presence of pain by making an inquiry of the resident or by observing for signs of pain; - the screen will be documented on the Electronic Medical Record (eMAR); - all staff will report any observation or communication of pain to the nurse responsible for that resident; - the nurse will assess the resident's pain based on resident interview and/or observations of signs and symptoms; - residents receiving treatment for pain will be monitored and re-assessed for the treatment's effectiveness in providing pain relief; - the date and time of each dose of pain medication administered, both routine (scheduled) and as needed (PRN), will be documented in the eMAR; - the effectiveness of PRN medication interventions will be documented in the eMAR; - the treatment plan will be evaluated for effectiveness, and changed as indicated, until satisfactory balance of side effects and pain relief is achieved; Resident #2 was admitted to the Facility in December 2023, diagnoses included: presence of right artificial hip joint, orthopedic aftercare, fracture of unspecified part of neck of right femur - subsequent encounter for closed fracture with routine healing, osteoarthritis of the hip, vertigo, post-traumatic stress disorder and major depressive disorder. Review of Resident #2's Care Plan related to Pain, dated 12/03/23, indicated goals included he/she will experience a decrease in pain after pain reducing measures are implemented and will verbalize an acceptable level of pain following individualized pain management. Interventions included to identify, assess and document presence of pain, medicate per physician's orders, observe effectiveness of pain medication and adjust as indicated, and to encourage resident to report occurrences of pain at onset and monitor for changes in signs and symptoms of pain. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], indicated that Resident #2, was cognitively intact, required moderate assistance of staff with transfers, ambulation, dressing, hygiene, bathing and toileting. The MDS indicated Resident #2's frequency of pain was almost constantly, with a pain severity rating of 5 (numerical rating scale 0 indicating no pain, to 10 indicating severe pain). Review of the Facility's Internal Investigation, dated 12/10/23, indicated that at approximately 8:30 A.M. Resident #2 reported to the nurse (later identified as Nurse #4) that a Certified Nurse Aide (CNA) came into his/her room to answer the call light and was rough and caused him/her pain during repositioning. The Investigation indicated that Resident #2 reported that the CNA grabbed him/her and put him/her into bed, and he/she complained of increased pain. The Investigation indicated that that Resident #2 had been receiving PRN medication of Tylenol (analgesic, pain reliever) and Tramadol (an opioid analgesic used for moderate to moderately severe pain) and his/her pain levels varied from 0 (none) to 10 (severe). The Investigation indicated that the Physician was notified, ordered an x-ray of Resident #2's right hip which revealed an acute periprosthetic fracture and he/she was transferred to the Hospital for further evaluation and treatment. Review of Resident #2's right hip and pelvis x-ray Report, dated 12/10/23, indicated there was an acute periprosthetic fracture of the right hip and mild tissue swelling. Review of Nurse #4's (the nurse who Resident #2 complained to) Written Witness Statement, dated 12/10/23, indicated that Resident #2 reported to her that at 8:30 A.M. (on 12/10/23), he/she put his/her call light on, a CNA came in and repositioned him/her, that he/her told the CNA that he/she was in pain and the CNA just left him/her that way. The Statement indicated that Resident #2 stated that the CNA was rough with him/her and hurt his/her legs during the repositioning. During an interview on 12/27/23 at 3:20 P.M., Nurse #4 said she was working as a CNA on 12/10/23 during the 7:00 A.M. to 3:00 P.M. shift. Nurse #4 said that at approximately 8:30 A.M., she delivered Resident #2's breakfast tray and he/she was lying in bed and his/her facial expression looked uncomfortable. Nurse #4 said Resident #2 told her that a CNA came into his/her room, repositioned him/her, hurt him/her during the repositioning, that he/she was uncomfortable, and that the CNA just left him/her that way and never came back. Nurse #4 said she reported this to the DON and Nurse #2 (who was the nurse assigned to care for and treat Resident #2 during that shift). Review of Nurse #2's Written Witness Statement, dated 12/10/23, indicated that she went into Resident #2's room and he/she told her that he/she was thrown into bed like a bag of potatoes by a CNA. The Statement indicated that Resident #2 said that the CNA grabbed him/her, put him/her in the bed and that Resident #2 complained of increased right hip pain. The Statement indicated that she notified the DON and the Physician, and the Physician ordered an x-ray of his/her right hip to rule out any injury. During a telephone interview on 1/03/24 at 4:30 P.M., Nurse #2 said Resident #2 had received his/her scheduled medications between 7:00 A.M. and 7:30 A.M. on 12/10/23 and that included Gabapentin (anticonvulsant also used for nerve pain). Nurse #2 said that Resident #2 told her that his/her usual right hip pain was not like the increased pain he/she experienced when the CNA threw him/her in bed like a sack of potatoes and repositioned him/her in bed that morning around 8:30 A.M. Nurse #2 said Resident #2 said that he/she had worked with therapy the day before and said his/her hip did not hurt as bad as it did when the CNA repositioned him/her in bed that morning. Nurse #2 said she could not recall if she medicated Resident #2 after he/she complained of increased pain after the CNA repositioned him/her in bed. Nurse #2 said she should have re-assessed Resident #2's pain and medicated him/her with the PRN Tramadol (opioid pain medication used for moderate to severe pain). Nurse #2 said that she should have written a nurse's note in Resident #2's medical record and said she believed she had re-assessed Resident #2's pain, medicated him/her with the PRN medication and wrote a nurses note. Review of Resident #2's Physician's Orders, dated 12/02/23, indicated he/she had an order for Tylenol 650 milligrams (mg) (Analgesic, treats mild to moderate pain) as needed, not to exceed 3 grams in 24 hours. Review of Resident #2's Physician's Orders, dated 12/04/23, indicated he/she had an order for Tramadol 50 mg every six hours as needed for pain, (Moderate 4-7) to (Severe 8-10). Review of Resident #2's Narcotic Administration Record, dated 12/10/23, indicated that at 11:00 A.M., he/she was administered Tramadol 50 mg, however that was two and a half hours after he/she complained to Nurse #2 about having increased hip pain. However, review of Resident #2's Medication Administration Record (MAR), for the month of December 2023, indicated that on 12/10/23, there was no documentation to support that Resident #2 received any PRN medication for complaints of increased pain. Review of Resident #2's Nurse Progress Notes, dated 12/10/23, indicated there was no documentation to support that Nurse #2 documented his/her change in condition, that she effectively monitored changes in his/her pain intensity, or effectiveness of the pain medication she administered to him/her as required per facility policies. During a telephone interview on 1/08/24 at 11:43 A.M., the Director of Nursing (DON) said she expected that Nurse #2 should have re-assessed Resident #2's increased pain, medicated him/her with PRN pain medication, re-assessed the effectiveness of the PRN pain medication and documented Resident #2's assessment and change of condition in the progress notes. The DON said Nurse #2 did not follow the Facility's Pain Management Policy. Review of Resident #2's Hospital Emergency Department After Visit Summary, dated 12/11/23, indicated Resident #2 was seen for complaints of right hip pain. The Summary indicated that Resident #2 received hydromorphone (opioid used for severe pain) 1 mg for pain and an x-ray of his/her right hip and pelvis was obtained and revealed a subtrochanteric (a break in the proximal femur bone within five centimeters of the lesser trochanter) fracture of the right hip with edema in the soft tissues which may be due to recent trauma or recent postoperative state versus a combination of these. The Summary indicated to follow up with an orthopedic surgeon. Review of Resident #2's Orthopedic Surgeon Consult, dated 12/14/23, indicated that he/she had a fracture which was non-operative, to continue with physical therapy and weight bearing as tolerated.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure he/she was free from verbal and mental abuse from a staff member when on 10/28/23, Certified Nurse Aide (CNA) #1 responded to Resident #1's call light and request for assistance with care, and per Resident #1, CNA #1 was rude, angry, abrupt, and intimidated him/her. Resident #1 became distressed, was tearful when recounting the incident with other staff members, and reported that he/she was afraid of CNA #1. Although CNA #2 said she witnessed CNA #1 verbally abuse Resident #1, she also said she did not intervene or attempt to stop the abuse, but instead stood in the doorway and watched to protect the resident. Findings include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation, and Reporting, dated as revised 10/1722, indicated the following: - Verbal abuse includes, but is not limited to, threats of harm and/or making statements to frighten resident, - Mental abuse includes humiliation, harassment, threats of punishment or deprivation, and - It is the policy of the Facility and the responsibility of all covered individuals to ensure an environment free of abuse, neglect, mistreatments, misappropriation of resident property, and exploitation. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 10/31/23, indicated that on 10/31/23 at approximately 3:30 P.M. Resident #1 reported to Social Worker (SW) #1 that on 10/28/23, a CNA #1 yelled at him/her. Review of a Police Report, dated 10/31/23, indicated that Resident #1 said CNA #1 yelled at him/her which frightened him/her enough to report it. The Report indicated that Resident #1 said that he/she had urinated in his/her bed and CNA #1 yelled at him/her saying, get out of bed, you've been here long enough. The Report indicated that Resident #1 said he/she frantically tried to get out of bed and slipped. The Report indicated that Resident #1 said CNA #1 had not physically abused him/her, but had been verbally abusive to him/her. Resident #1 was admitted to the Facility in August 2023, diagnoses included lumbar radiculopathy (pinched nerve), anxiety, urinary tract infection, post laminectomy (surgery to remove part of a vertebrae or vertebra in order relieve pressure on nerves) syndrome, and post traumatic stress disorder. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 10/16/23, indicated he/she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), and required supervision to minimal assistance from staff to meet his/her care needs. During a telephone interview on 11/29/23 at 11:40 A.M., Resident #1 said that on 10/28/23 he/she asked CNA #1 to change him/her before he/she stood up from the bed because he/she had already urinated in his/her brief. Resident #1 said he/she had a urinary tract infection at the time (back in October 2023), which caused him/her to urinate frequently. Resident #1 said CNA #1 responded back to him/her in a demanding tone of voice and said get into the wheelchair now! Resident #1 said CNA #1 was angry and yelled at him/her. Resident #1 said CNA #1 made him/her very nervous, so he/she just did whatever CNA #1 told him/her to do. Resident #1 said that when he/she attempted to stand up to get into the wheelchair, he/she slid to the floor onto his/her hands and knees because the floor was wet with urine. Resident #1 said he/she may need rehabilitation again in the future, but was afraid to return to the Facility if CNA #1 was still employed there. Review of the Facility's Investigation Summary Report, dated 10/31/23, indicated that SW #1 received a message that Resident #1 wanted to speak with her, and that SW #1 met with him/her. The Report indicated that Resident #1 was very upset about an incident that occurred on 10/28/23. The Report indicated that Resident #1 used his/her call light because he/she was incontinent, and CNA #1 responded and entered his/her room. The Report indicated Resident #1 that told SW #1 that CNA #1 told him/her that he/she needed to use the bathroom and that was why he/she (Resident #1) was still at the Facility. The Report indicated that Resident #1 said CNA #1 was very rude and almost yelling at him/her and insisted he/she get into the wheelchair to use the bathroom. The Report indicated that Resident #1 said he/she went to put his/her feet on the floor and fell forward onto his/her hands and knees because the floor was wet from him/her being incontinent. The Report indicated that Resident #1 was crying and very upset, and said he/she was fearful of CNA #1 and that he/she did not deserve that type of treatment. The Report indicated that Resident #1 was very tearful when he/she discussed the alleged incident with SW #1. During an in-person interview on 11/29/23 at 10:40 A.M., a telephone interview on 12/06/23 at 10:33 A.M., and review of CNA #2's Written Witness Statement, dated 11/01/23, CNA #2 said on 10/28/23, she told CNA #1 that Resident #1 needed help washing and changing, and that CNA #1 responded back to her and said Resident #1 could do it him/herself. CNA #2 said she followed CNA #1 to Resident #1's room and then stayed close by (stood in the doorway to Resident #1's room) to watch because she knew CNA #1 was frustrated and she (CNA #2) wanted to be there for Resident #1. CNA #2 said that CNA #1 walked into Resident #1's room and told Resident #1 that he/she could do it him/herself. CNA #2 said she heard Resident #1 say he/she wanted to stay in bed to get washed and changed, but CNA #1 insisted Resident #1 get up out of bed and to go into the bathroom. CNA #2 said she watched as Resident #1 tried to stand up but he/she ended up going down and both knees hit the floor, but was able to get up by him/herself. CNA #2 said CNA #1 did not seem concerned that Resident #1 had fallen, and said CNA #1 did not say anything to Resident #1 when he/she fell. CNA #2 said after Resident #1 fell to the floor, he/she got up and CNA #1 walked with him/her to the bathroom. CNA #2 said that CNA #1 was very rude to Resident #1 and had rushed him/her to get to the bathroom. CNA #2 said she stayed in the doorway to Resident #1's room and had not intervened to protect Resident #1. CNA #2 said that later in the day Resident #1 was in the bathroom crying and needed to be consoled because of how he/she had been treated by CNA #1. Although CNA #2 said she felt that CNA #1 was frustrated that day, and took it upon herself to go and stand in Resident #1's doorway to support him/her while CNA #1 provided care, despite witnessing what she (CNA #2) believed was rude, angry, and intimidating treatment of Resident #1, and witnessing CNA #1 stand back and offer no assistance to Resident #1 after he/she fell, CNA #1 did not intervene, did not go get help from nursing, and did not report the incident as required, all of which placed Resident #1 at potential risk for continued abuse. During a telephone interview on 11/29/23 at 11:37 A.M., Non-sampled Resident A (Resident #1's roommate at the time the allegation was made), said on 10/28/23 he/she did not hear any yelling or the conversation between CNA #1 and Resident #1 because he/she was watching a movie and had his/her ear buds in, which blocked out external sound. NS Resident A said he/she did, however, see CNA #1 in their room and saw Resident #1 on the floor crying. NS Resident A said that after CNA #1 left their room, Resident #1 was still crying and said that he/she was so scared because he/she had never been spoken to like that before. During telephone interviews on 11/29/23 at 2:28 P.M., and 12/06/23 at 1:29 P.M., Social Worker #1 (SW) said she received a general voicemail on 10/30/23 from Unit Secretary #1 that Resident #1 wanted to speak with her. SW #1 said she spoke with Resident #1 on 10/31/23 and he/she told her that CNA #1 yelled at him/her about going to the bathroom. SW #1 said Resident #1 told her that he/she fell because there was urine on the floor. SW #1 said Resident #1 was tearful when he/she talked to her. SW #1 said Resident #1 said he/she was concerned that CNA #1 would return. SW #1 said she reported the allegation to the Director of Nurses (DON) immediately. SW #1 said that once she told Resident #1 that the Police had been called, that the allegation would be investigated by the Facility, and that CNA #1 had been removed from the Facility, Resident #1 said he/she felt safe. During an interview on 11/29/23 at 1:17 P.M., the Director of Nurses (DON) said Social Worker (SW) #1 notified her on 10/31/23 in the afternoon that Resident #1 alleged that on 10/28/23, CNA #1 was rude and almost yelling at him/her about using the bathroom, and that she immediately began an investigation in to the allegation. The DON said both CNA #1 and CNA #2 were facility employees and had received abuse training. The DON said the Facility did not substantiate the allegation of abuse but did terminate CNA #1's employment.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact and required supervision to minimal assistance to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 10/28/23, after an alleged incident of verbal abuse and mental abuse of Resident #1 by Certified Nurse Aide (CNA ) #1 that occurred during the provision of care, was witnessed by one staff member (CNA #2), and Resident #1 who was emotionally distressed by how he/she had been treated by CNA #1 also reported the incident of alleged abuse to three other staff members (CNA #3, CNA #4 and Unit Secretary #1), however none of them immediately reported the abuse to their supervisor as required, and as a result CNA #1 continued to work in the Facility for several days placing Resident #1 and other residents at risk for abuse. Findings include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation, and Reporting, dated as revised 10/1722, indicated the following: - When a covered individual believes that he or she has reasonable cause to believe that a resident has been abused, neglected, mistreated, exploited, or has had property misappropriated, the covered individual has the responsibility to report to his/her supervisor, and - The preliminary investigator shall promptly remove the accused in order to prevent further potential harm to the resident. Review of the Facility's Investigation Summary Report, dated 10/31/23, indicated that Social Worker #1 received a message that Resident #1 wanted to speak with her, and that SW #1 met with him/her on 10/31/23. The Report indicated that Resident #1 was very upset about an incident that occurred on 10/28/23. The Report indicated that Resident #1 used his/her call light because he/she was incontinent, and CNA #1 responded and entered his/her room. The Report indicated that Resident #1 said CNA #1 told him/her that he/she needed to use the bathroom and that was why he/she (Resident #1) was still at the Facility. The Report indicated that Resident #1 said CNA #1 was very rude and almost yelling at him/her and insisted he/she get into the wheelchair to use the bathroom. The Report indicated that Resident #1 said he/she went to put his/her feet on the floor and fell forward onto his/her hands and knees, because the floor was wet from him/her being incontinent. The Report indicated that Resident #1 was crying and very upset and said he/she was fearful of CNA #1 and that he/she did not deserve that type of treatment. The Report indicated that Resident #1 was very tearful when he/she discussed this with SW #1. Resident #1 was admitted to the Facility in August 2023, diagnoses included lumbar radiculopathy (pinched nerve), anxiety, urinary tract infection, post laminectomy (surgery to remove part of a vertebrae or vertebra in order relieve pressure on nerves) syndrome, and post-traumatic stress disorder. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 10/16/23, indicated he/she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), and required supervision to minimal assistance from staff to meet his/her care needs. During a telephone interview on 11/29/23 at 11:40 A.M., Resident #1 said in October 2023, he/she had a urinary tract infection which caused him/her to urinate frequently. Resident #1 said he/she asked CNA #1 to change him/her before he/she stood up from the bed because he/she had already urinated in his/her brief. Resident #1 said CNA #1 responded to him/her in a demanding voice and said, get into the wheelchair now! Resident #1 said CNA #1 was angry at him/her and yelled at him/her. Resident #1 said CNA #1 made him/her very nervous, so he/she did whatever CNA #1 told him/her to do. Resident #1 said that when he/she attempted to stand to get into the wheelchair, he/she slid to the floor onto his/her hands and knees because the floor was wet with urine. Resident #1 said Nurse #1 and CNA # #3 came into his/her room right after it happened to console him/her because he/she was so afraid. Resident #1 said he/she may need rehabilitation again in the future but said he/she was afraid to return to the Facility if CNA #1 was still employed there. During an in-person interview on 11/29/23 at 10:40 A.M., a telephone interview on 12/06/23 at 10:33 A.M., and review of CNA #2's Written Witness Statement, dated 11/01/23, CNA #2 said on 10/28/23 at approximately 2:00 P.M., she told CNA #1 that Resident #1 needed help washing and changing, and said CNA #1's response to her was that Resident #1 could do it him/herself. CNA #2 said she followed CNA #1 to Resident #1's room and then stayed close (stood on the doorway to Resident #1's room) to watch because she knew CNA #1 was frustrated and she wanted to be there for Resident #1. CNA #2 said that CNA #1 walked into Resident #1's room and she heard CNA #1 tell Resident #1 that he/she could do it him/herself. CNA #2 said she heard Resident #1 say he/she wanted to stay in bed to get washed and changed, but that CNA #1 insisted Resident #1 to go into the bathroom. CNA #2 said Resident #1 tried to stand and he/she ended up going down and both knees hit the floor, but he/she was able to get up by him/herself. CNA #2 said CNA #1 did not seem concerned that Resident #1 had fallen and said CNA #1 did not say anything to Resident #1 when he/she fell. CNA #2 said after Resident #1 fell to the floor, he/she got up by him/herself and CNA #1 walked with him/her to the bathroom. CNA #2 said that CNA #1 was very rude to Resident #1 and had rushed him/her. CNA #2 said she stayed in the doorway to Resident #1's room but had not intervened verbally or physically to protect Resident #1. CNA #2 said that at approximately 2:50 P.M., Resident #1 was in the bathroom crying and needed to be consoled because of how he/she had been treated by CNA #1. CNA #2 said she did not report this, but that she just tried to console Resident #1. Although CNA #2 said she felt that CNA #1 was frustrated that day, and took it upon herself to go and stand in Resident #1's doorway to support him/her while CNA #1 provided care, despite witnessing what she (CNA #2) believed was rude, angry, and intimidating treatment of Resident #1, and witnessing CNA #1 stand back and offer no assistance to Resident #1 after he/she fell, CNA #1 did not intervene, did not go get help from nursing, and did not report the incident as required, all of which placed Resident #1 at risk for continued abuse. Review of CNA #3's Written Witness Statement, dated 11/01/23, indicated that on 10/28/23 sometime in the afternoon, he had been checking on residents when he noticed Resident #1 was upset. The Statement indicated that he asked Resident #1 if he/she was okay, and Resident #1 told him that CNA #1 is rude, rushes him/her, and has an attitude toward him/her. The Statement indicated that Resident #1 told him (CNA #3) that CNA #1 has it out for him/her. The Statement indicated that CNA #3 tried to comfort Resident #1, but he/she continued to cry because of how he/she was treated by CNA #1. The Statement indicated that Resident #1 told him (CNA #3) that he/she did not want CNA #1 to be his/her aide or to assist him/her in anything. The Statement indicated that CNA #3 told Resident #1 not to worry and that it would not happen again. The Statement indicated that CNA #3 had not reported the allegation as required, because he had to leave the Facility emergently that day and did not have time. The Surveyor was unable to interview CNA #3 as he did not respond to the Department of Public Health's telephone call or letter request for an interview. During an interview on 12/15/23 at 12:00 P.M., and review of CNA #4's Written Witness Statement, undated, CNA #4 said that Resident #1 told her that on 10/28/23, that CNA #1 yelled at him/her for being wet and that he/she should go into the bathroom. CNA #4 said that Resident #1 told her that when he/she stood up, he/she slipped and fell because the floor was wet. CNA #4 said she was not entirely sure, but said she thought she notified the evening nursing supervisor (later identified as Nursing Supervisor #1) about what Resident #1 had told her, CNA #4 and said the nursing supervisor told her that she already knew about an incident involving Resident #1 and CNA #1 that had happened on the weekend. During an interview on 12/15/23 at 1:09 P.M., Nursing Supervisor #1 said she works 12:00 P.M. to 4:00 P.M. on weekdays. Nursing Supervisor #1 said CNA #4 had reported to her on 10/30/23, sometime in the evening, that Resident #1 wanted to speak with her, so she went into Resident #1's room and he/she talked about how he/she was going to stay at the Facility longer because he/she needed more Physical Therapy. Nursing Supervisor #1 said Resident #1 never mentioned anything about a CNA yelling at him/her. Nursing Supervisor #1 said CNA #4 had not reported to her any allegations of abuse involving Resident #1. Nursing Supervisor #1 said she first heard of Resident #1's allegation of abuse on 10/31/23 after facility administration had already been made aware. During an interview on 11/29/23 at 11:06 A.M., and review of Unit Secretary #1's Written Witness Statement, dated 10/31/23, Unit Secretary #1 said she is also a CNA and had worked as a CNA on 10/29/23 during the 3:00 P.M. to 11:00 P.M. shift. Unit Secretary #1 said she answered Resident #1's call light at approximately 9:30 P.M., and said Resident #1 asked her if she heard about what had happened to him/her the day before. Unit Secretary #1 said Resident #1 told her that CNA #1 had yelled at him/her and scared her. Unit Secretary #1 said Resident #1 told her that he/she fell to his/her knees because the floor was wet. Unit Secretary #1 said Resident #1 was crying when he/she told her about the alleged incident and kept saying how scared he/she was. Unit Secretary said she left a voice message for Social Worker #1 that indicated Resident #1 wanted to speak with her. During telephone interviews on 11/29/23 at 2:28 P.M., and 12/06/23 at 1:29 P.M., Social Worker #1 (SW) said she received a general voice message on 10/30/23 from Unit Secretary #1 that Resident #1 wanted to speak with her. Social Worker (SW) #1 said Resident #1 told her that on 10/28/23 CNA #1 yelled at him/her about going to the bathroom. SW #1 said Resident #1 told her that he/she fell because there was urine on the floor. SW #1 said Resident #1 was tearful when he/she talked to her. SW #1 said Resident #1 said he/she was concerned that CNA #1 would return. Review of CNA #1's time card indicated, that after the alleged incident of verbal abuse involving Resident #1, she worked at the facility on the following shifts: -10/29/23 6:37 A.M. to 3:13 P.M. -10/31/23 6:40 A.M. to 3:09 P.M. During an interview on 12/15/23 at 12:55 P.M. the Staff Development Coordinator (SDC) said if a CNA is notified of an allegation of abuse or suspects abuse, they are required to report it their direct supervisor, and that for CNA's, that would be he nurse on the unit. The SDC said if the nurse is not on the unit for any reason, then the CNA should report the abuse to the supervisor if there is one on duty or to the Director of Nurses (DON). The SDC said CNA #1, CNA #2, CNA #3, CNA #4 and the Unit Secretary were all employees of the facility, and had received training on the facility abuse policy. During an interview on 11/29/23 at 1:17 P.M., the Director of Nurses (DON) said Social Worker #1 notified her on 10/31/23 in the afternoon that Resident #1 alleged that on 10/28/23, CNA #1 was rude and almost yelling at him/her about using the bathroom. The DON said several staff members had been made aware of the allegation on 10/28/23 involving CNA #1, but had not reported it to her or the Administrator. The DON said Nurse #1 told her during the investigation that Resident #1 felt uncomfortable with CNA #1 on 10/28/23 to the point where Nurse #1 took over his/her care. The DON said staff are required to report to any allegation of abuse to administration immediately, but had not, and therefore CNA #1 was not suspended until after she was made aware of the allegation on 10/31/23. The DON said CNA #1 worked two shifts after staff were aware of the allegation of verbal abuse and had not reported it.

2. For Resident #97, the staff failed to complete a falls risk assessment and a pain assessment and implement meaningful and timely interventions per facility policy to prevent additional falls. Findings include: Review of the facility's policy titled Falls Management: Post Fall 5 Whys Pilot, revised 11/28/18, indicated the following: 4. Remove any causes of fall and implement preventive measures to prevent reoccurrence. 5. Update care plan to reflect new interventions. 6. List resident on the 24-hour report 9. Conduct interdisciplinary falls team meeting at the subsequent clinical morning meeting 9.1. Review the 5 Whys analysis 9.2. Determine need for additional actions/interventions based on team evaluation and root cause 9.3. Communicate information to staff and care planning team Resident #97 was admitted to the facility with a diagnosis of dementia with behavioral disturbances. Review of the Resident's record indicated that Resident #97 has had a recent pathological hip fracture and a recent fall out of bed. Review of the Minimum Data Set (MDS) assessment, dated 3/13/21, indicated that Resident #97 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating the Resident had severe cognitive impairment. Review of Occupational Therapy Treatment Encounter notes indicated: 5/08/21-No fall interventions referenced in the note 5/10/21-No fall interventions referenced in the note. Patient complained of increased left hip pain with standing and weight bearing; nursing supervisor made aware. Review of Physical Therapy Treatment Encounter note, dated 5/11/21, indicated: -No interventions recommended status post fall 5/8 or 5/10. Review of Resident #97's current care plan did not have any interventions to minimize Resident #97's risk from falling out of the wheelchair. During an interview on 05/11/21 at 04:15 P.M., Unit Manager (UM) #1 said Resident #97 had two recent falls, one on 5/8/21 and the second on 5/10/21. UM #1 said the investigations are not complete and the only intervention put into place was for Rehab Services to evaluate the Resident. UM #1 said no other interventions had been put in place because the falls investigation had not been completed. Review of the facility incident checklist for Resident #97's fall on 5/8/21 indicated: -Incident report, dated 5/8/21, indicated Resident #97 observed sitting on buttocks in day room near wheelchair. Plan rehab screen for positioning. -Skin Tear, Laceration, Bruise investigation of unknown origin completed- No skin issues - One witness statement, dated 5/8/21, indicated Resident #97 found sitting on buttocks on the day room floor. No rotation of hips/legs. Resident denies pain; no open areas or bump on head. -Rehabilitation referral for positioning and cushion. -No Fall Risk or Pain Assessment performed. Review of the facility incident checklist for Resident #97's fall on 5/10/21 indicated: -Incident report, dated 5/10/21, indicated the nurse was on the phone and all three aides were attending to other residents. The nurse heard a loud bang and walked around the nurse's station and saw Resident #97 on the floor. -Post fall investigation: Resident #97 was resting, found on floor (unwitnessed), loss of balance, loss of strength/weakness, getting up from wheelchair, confused, no alarms, no injuries -Communication In-service: blank -Witness statement: blank -Fall Risk Assessment completed- Resident scored 6 out of 10- High risk for falls -Pain assessment completed- Resident denies pain During an interview on 05/11/21 at 05:00 P.M., UM #1 said the weekend staff did not complete the pain assessment or fall assessment for the fall that occurred on 5/8/21. UM #1 said agency staff is part of the problem, because they don't always know what forms they have to complete. UM #1 said there have been no interventions put into place or updates to the care plans because the investigations have not been completed. During an interview on 05/12/21 at 04:06 P.M., Rehab Staff #1 said she was aware Resident #97 had fallen over the weekend and said Resident #97 requires supervision at all times and should be at the nursing station when in his/her wheelchair. During an interview on 05/12/21 at 04:13 P.M., the Director of Rehabilitation (Rehab) said she was aware Resident #97 fell this weekend, but was not aware he/she had a second fall on 5/10/21 and the Rehab Department had not received a rehab referral to evaluate Resident #97 for either fall out of his/her wheelchair. The Rehab Director said the staff typically has a falls meeting each morning and that's when rehab receives the referrals for post falls evaluations, but there had not been a meeting since last week. Based on record review, observation, policy review and interview, the facility failed to ensure that for two Residents (#212 and #97), out of a total sample of 26 residents, accidents were minimized, interventions were implemented to prevent falls/injury, and supervision was provided to prevent accident and injury to the residents. Findings include: 1. For Resident #212, the staff failed to implement interventions to prevent falls/ injury to the Resident. Resident #212 was admitted to the facility in February 2021 after being hospitalized following a fall at home, secondary to the progression of his/her Multiple Sclerosis (disease that affects the central nervous system) as well as a urinary tract infection. Review of Resident #212's Plan of Care for falls, dated 8/8/20 (from a prior admission), indicated that the Resident was at risk for falls due to a change in mobility/gait, fell in the past year, and had unstable balance and vision problems. The goal was, Resident will be free from injury related to falls. Interventions to prevent falls/injury included: -Fall Risk Assessment upon admission, re-admission, significant change in condition -Include resident/family in assessment process to determine strategies for fall prevention -Educate resident/family on fall prevention strategies -Provide well lit, uncluttered environment -Place items resident uses frequently in reach to prevent bending or reaching -Gait belt for all transfers -Encourage participation in diversional activities -Individualize care plan to meet resident's assessed needs -Keep call bell within reach -Rehab services as needed -3/7/21: Educate patient to use call bell to call for assistance with transfers. Review of the social services' note, late entry dated 2/22/21, indicated Resident #212 presented as alert and oriented with some forgetfulness at baseline; the Resident would complete short term rehab with a plan to discharge home with services. Review of the Minimum Data Set (MDS) assessment, dated 2/22/21, indicated Resident #212 was assessed to have a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Further review of the MDS, under Section G, Functional Status, indicated Resident #212 was coded as requiring extensive assistance with bed mobility, transfers, walking in the room and corridor, locomotion, both on and off the unit, dressing, and toilet use. The MDS indicated that the Resident had a chronic urinary catheter and was occasionally incontinent of bowel. The MDS also indicated that the Resident had experienced a fall in the last month prior to admission, had fallen in the last 2-6 months prior to admission, and had not had a fracture related to a fall in the six months prior to admission/entry or reentry. Review of Resident #212's medical record indicated that on 3/6/21, the Resident had an unwitnessed fall at 12:00 P.M., while self-toileting. The Resident was found in the bathroom face down and denied hitting his/her head. The nurse's note indicated the walker was in the bathroom beside the Resident. The Resident was reportedly yelling, Help, I broke my ankle! The note indicated that there were no visible injuries, EMS was contacted, and the Resident was transported to the Emergency Department (ED) for evaluation for a suspected broken ankle. Review of the medical record indicated Resident #212 returned from the hospital on 3/6/21 at 9:00 P.M., with a diagnosis of closed left ankle fracture. The ankle was placed in a splint; the Resident was to be non-weight bearing, and to follow up with orthopedics. Review of the facility Incident/Accident Report completed for this fall indicated that the Resident was using the rest room without assistance, lost his/her balance, and was found on the floor by the nurse. Review of the Fall Risk Assessment completed following Resident #212's fall on 3/6/21 indicated that the Resident scored 6 out of 10, indicating that the Resident was at High Risk for falls. Review of Resident #212's care plan for falls indicated immediate actions taken to prevent further falls (Care Plan Adjustments) included: Call for assistance for help using restroom and or other tasks. No other interventions were identified, or implemented in the plan of care, to prevent further falls and injury. Review of the medical record indicated that on 4/15/21 at 3:00 P.M., Resident #212 experienced a second unwitnessed fall. Review of the Incident/Accident Report completed at the time of the fall, indicated Resident #212 attempted to get out of the wheelchair unassisted and fell. The Resident was described as being confused with impaired memory. The nurse who completed the post fall investigation indicated that, Resident is confused and did not say where he/she was going. The Resident's roommate told the nurse completing the post fall investigation that, He/She just tried to get up by himself/herself. Review of the nurse's note written by the nurse caring for Resident #212 at the time of the fall indicated that, Around 1500 (3:00 P.M.) this shift this nurse hears someone call for help. Went into [Resident #212's room] noted resident laying face first on the floor. Resident had attempted to get out of chair unassisted. Immediately noted that resident was lying in blood. Called for help. Moved surrounding object away. Attempted to reposition resident to determine where the blood was coming from but maintained C-spine. Resident laid on his/her back. Noted that resident was profusely bleeding from his/her forehead. Directed nursing to apply pressure to resident's left forehead. Area also noted to left hand from fall. Nursing was able to slow bleeding. EMS arrived quickly and resident was sent to [hospital] for eval [evaluation]. Review of Resident #212's care plan indicated immediate actions to prevent further falls (Care Plan Adjustments) indicated on 4/16/21 a medication review. On 5/6/21 at 11:40 A.M., the surveyor observed Resident #212 in his/her room. The Resident was alert, pleasant, and talkative. Resident #212 said that things were going well and acknowledged his/her past falls and the cast on his/her left foot from the 3/6/21 fall. The Resident had a bandage covering a wound on the left forehead, sustained during the fall on 4/15/21. The Resident was seated in a wheelchair adjacent to the left side of the bed with a hard cast on the left foot elevated on the footrest of the wheelchair. The Resident's call light was observed out of the Resident's reach. The call light was observed on the opposite side of the bed from where the Resident was sitting, tucked underneath a pillow. During an interview on 5/6/21 at 11:47 A.M., Unit Manager (UM) #2 said that the Resident would use his/her call light to alert staff if he/she needed anything. The surveyor asked UM#2 to come to the Resident's room to observe the placement of the Resident's call light. UM#2 said that the call light was not accessible to the Resident at that time due to it being under the pillow on the opposite side of the bed from where the Resident was sitting. Review of the Fall Risk Assessment completed following Resident #212's 4/15/21 fall indicated a score of 5 out of a possible 10 that inaccurately determined that the Resident was at Low Risk for falls. The assessment also indicated that the Resident had experienced a fracture related to a fall in the past six months (fractured ankle on 3/6/21), and that the Resident was confused or forgetful. Further record review indicated that no additional interventions to prevent further falls and injury were implemented for the Resident. During an interview on 5/12/21 at 3:59 P.M., the Director of Nursing (DON) said after reviewing the Plan of Care, that there were no additional interventions implemented to ensure the Resident's safety and prevent further falls for Resident #212 who continued to demonstrate unsafe behaviors by attempting to get up unassisted from the wheelchair without warning.