How many inspection deficiencies does ODD FELLOWS HOME OF MASSACHUSETTS have?

ODD FELLOWS HOME OF MASSACHUSETTS has 36 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at ODD FELLOWS HOME OF MASSACHUSETTS?

ODD FELLOWS HOME OF MASSACHUSETTS has a four-star staffing rating from CMS with 0.56 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is ODD FELLOWS HOME OF MASSACHUSETTS located?

ODD FELLOWS HOME OF MASSACHUSETTS is located in WORCESTER, MA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ODD FELLOWS HOME OF MASSACHUSETTS have?

ODD FELLOWS HOME OF MASSACHUSETTS has 100 certified beds.

Who owns ODD FELLOWS HOME OF MASSACHUSETTS?

ODD FELLOWS HOME OF MASSACHUSETTS is a non profit - corporation facility and operates independently (not part of a chain).

How does ODD FELLOWS HOME OF MASSACHUSETTS compare to other nursing homes?

ODD FELLOWS HOME OF MASSACHUSETTS has a 2-star overall rating, which is below average compared to other nursing homes in MA. Families should carefully review inspection findings and consider alternatives.

ODD FELLOWS HOME OF MASSACHUSETTS

Name: ODD FELLOWS HOME OF MASSACHUSETTS
Address: 104 RANDOLPH ROAD, WORCESTER, MA, 01606, US
Telephone: (508) 853-6687
Rating: 2.0

104 RANDOLPH ROAD, WORCESTER, MA 01606 · (508) 853-6687

Non profit - Corporation 100 Beds Independent Data: November 2025

Trust Grade

20/100

#233 of 338 in MA

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Last Inspection: December 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Odd Fellows Home of Massachusetts has received a Trust Grade of F, indicating significant concerns about the care provided at this facility. Ranking #233 out of 338 nursing homes in Massachusetts places it in the bottom half of facilities in the state, and #37 out of 50 in Worcester County suggests that there are only a few local options that are better. While the facility is showing improvement in its overall issues, reducing from 14 in 2023 to 11 in 2024, it still has serious problems, including incidents of physical and verbal abuse involving staff and inadequate monitoring of residents' health conditions leading to hospitalization. Staffing is a relative strength with a 4/5 star rating and a 44% turnover rate, which is average, but the facility has also faced $106,301 in fines, higher than 87% of Massachusetts facilities, indicating potential compliance issues. Although RN coverage is average, there are concerning findings around care that could lead to serious health issues, which families should weigh carefully when considering this home for their loved ones.

Trust Score: F
In Massachusetts: #233/338
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 44% turnover. Near Massachusetts's 48% average. Typical for the industry.
Penalties: $106,301 in fines. Higher than 50% of Massachusetts facilities. Some compliance issues.
Skilled Nurses: Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Massachusetts. RNs are the most trained staff who monitor for health changes.
Violations: 36 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2023: 14 issues

2024: 11 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (44%)
4 points below Massachusetts average of 48%

Facility shows strength in staffing levels, fire safety.

The Bad

2-Star Overall Rating

Below Massachusetts average (2.9)

Below average - review inspection findings carefully

Staff Turnover: 44%

Near Massachusetts avg (46%)

Typical for the industry

Federal Fines: $106,301

Well above median ($33,413)

Significant penalties indicating serious issues

The Ugly 36 deficiencies on record

3 actual harm

Dec 2024 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to provide a clean and homelike environment for one Resident (#35) out of a total sample of 18 residents. Specifically, the facility failed to provide Resident #35 with a wheelchair that was maintained in a clean manner and address promptly any cleaning needs as required. Findings include: Resident #35 was admitted to the facility in October 2023 with diagnoses including Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was mildly cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 total possible points. On 12/4/24 at 8:30 A.M., Resident #35 was observed seated in a wheelchair next to the bed in his/her room eating his/her breakfast meal. The surveyor observed the wheelchair was dusty with crumbs and debris on the frame of the chair and cushion. During an interview at the time, Resident #35 said that he/she uses the wheelchair at times because he/she was worried about falling. Resident #35 said that the wheelchair had not been cleaned since he/she had been using it. The Resident further said that his/her family member visited regularly and were involved in his/her care. During an interview on 12/4/24 at 12:04 P.M., Family Member #1 said he/she had asked staff several times to have Resident #35's wheelchair cleaned but the wheelchair had not be cleaned as requested. During an observation and interview on 12/5/24 at 8:59 A.M., Resident #35 said his/her wheelchair was still filthy and had been that way since he/she was admitted to the facility. The surveyor observed that the wheelchair remained dusty with debris. During an interview and observation on 12/5/24 at 12:38 P.M., the Housekeeping Manager (HM) said that there is a schedule to clean the wheelchairs wing by wing. The HM further said she did not have a log to track the cleaning process but she would let the Unit Managers (UM) know to make the wheelchairs available so they can be cleaned. The HM said that she did not have evidence of when the wheelchair used by Resident #35 had last been cleaned. The surveyor and HM observed that the wheelchair in Resident #35's room remained dusty with debris. The HM said that the wheelchair was unacceptable and would be cleaned right away. During an interview on 12/6/24 at 1:13 P.M., the Administrator said the facility did not have a policy relative to wheelchair cleaning, but that a policy and procedure would be developed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to accurately complete a Level I PASRR for one Resident (#83) out of a total sample of 18 residents, which resulted in the Resident not receiving a Level II PASRR Evaluation to determine whether the Resident met criteria for serious mental illness (SMI) and whether specialized services were required to treat the Resident's SMI. Specifically, the facility failed to: -Identify Resident #83's diagnosis of Schizophrenia on the Resident's Level I PASRR when the Resident had a diagnosis of Schizophrenia. -Indicate legal involvement within two years prior to admission to the facility when the Resident had a legal guardian appointed through the court system within two years prior to admission to the facility. Findings include: Resident #83 was admitted to the facility in August 2023 with a diagnosis of Schizophrenia. Review of Resident #83's Hospital Patient Health Summary, dated 1/20/23, indicated the following: -The Resident had been admitted to the hospital for steadily worsening Dementia and developing hallucinations and violent behavior. -The reason for the hospital visit was Schizophrenia. Review of Resident #83's Decree and Order of Appointment of Guardian for an Incapacitated Person, dated 5/5/23, indicated the powers and duties of the Guardian included the following: -Authorization to admit the Incapacitated Person to a nursing facility. The Court found that such admission was in the Incapacitated Person's best interest. Further review of the Resident's Decree and Order of Appointment of Guardian for an Incapacitated Person indicated: -The Court authorized treatment of the Incapacitated Person with antipsychotic medication Review of Resident #83's Level I PASRR, dated 8/3/23, indicated the following: -The Resident had a court appointed Legal Guardian. -The Resident did not have a documented diagnosis of a mental illness or disorder (MI/D) . that may lead to chronic disability. -Question Number Six was completed with an answer of No indicating that the Resident did not require legal intervention that was, or may have been, due to MI/D within the previous two years. -If the answer to Question Number Six was Yes, check Positive SMI screen. Otherwise, check Negative SMI screen. Further review of the Resident's Level I PASRR indicated: -Negative SMI screen was checked. -A Level II PASRR Evaluation was not indicated due to no diagnosis or suspicion of SMI. Review of Resident #83's Physician order dated 8/4/23, with no stop date, indicated the following: -Olanzapine (antipsychotic medication) tablet, one 2.5 milligram (mg) tablet once a day for Psychosis . During an interview on 12/5/24 at 9:33 A.M., the Social Worker (SW) said that Resident #83 had a court appointed Guardian. The SW said that the Resident having a court appointed Guardian within two years of admission to the facility would indicate legal involvement, and that legal involvement within two years prior to the Resident being admitted to the facility would result in a positive SMI screen and referral to the PASRR Office for a Level II PASRR evaluation to be completed for the Resident. During a follow-up interview on 12/5/24 at 12:27 A.M., the SW said Resident #83's Level I PASRR was not completed accurately. The SW said that the Resident had a diagnosis of Schizophrenia prior to being admitted to the facility, was being treated with antipsychotic medication, and had a legal Guardian appointed through the court less than two years prior to admission to the facility. The SW said that the Level I PASRR should have been completed to indicate the Resident had a diagnosis of Schizophrenia and legal involvement through the court. The SW further said that the Level I PASRR should have been completed to indicate the Resident had a positive SMI screen and that the Resident should have been referred to the PASRR Office for a Level II PASRR evaluation to determine whether the Resident met criteria for SMI and to determine whether the Resident required specialized services for SMI.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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2. Resident #37 was admitted to the facility in October 2018 with diagnoses including Unspecified Neuromuscular Dysfunction of Bladder (condition caused by damage to the brain, spinal cord or nerves that control bladder function). Review of Resident #37's November 2024 Physician's orders indicated: -Foley (a type of indwelling urinary catheter) 16 Fr (Fr-French, a form of measurement for indwelling urinary catheters [16 French - 5.3 millimeters (mm) circumference])/ 10 (10 milliliter (ml) balloon [a saline inflated balloon used to anchor the indwelling urinary catheter in the bladder]) to bedside drainage at all times. -Foley catheter care every shift. -Change Foley catheter 16 Fr/10 ml monthly on the 1st of the month. -Irrigate (flush) Foley catheter with 50 ml of normal saline for blockage/drainage every shift day, evening, and night. During an interview on 12/4/24 at 3:56 P.M., Nurse #3 said she had irrigated Resident #37's Foley catheter during the day shift (7:00 A.M. to 3:00 P.M.) on 12/4/24 but had not noticed if the correct catheter size was in place. Nurse #3 said she had not changed the Foley catheter during her shift. During an interview and observation on 12/4/24 at 4:00 P.M., Nurse #2 said that she had not changed the Foley catheter for Resident #37. The surveyor and Nurse #2 observed that Resident #37 had an 18 French/ 30 ml balloon Foley catheter in place. Nurse #2 said that Resident #37 had a Physician order for a 16 French/ 10 ml balloon. Nurse #2 said that Resident #37 did not have the correct size Foley catheter in place. Nurse #2 said that Physician's orders should be followed so that the Resident had the correct Foley catheter in place. Nurse #2 further said that all Nurses in the facility had access to the central supply room (room in the facility where supplies are stored before use) and could obtain any size Foley catheter ordered by the Physician. During an interview and observation on 12/4/24 at 4:30 P.M., the facility Staff Educator said all residents with Foley catheters should have Physician orders followed for the correct size. The Staff Educator said size was important because if the catheter and balloon size were too small, the Foley catheter could leak urine and/or fall out of the bladder. The Staff Educator said if the Foley catheter and balloon size were too big, the Foley catheter could cause pain and discomfort to the resident. The surveyor and the Staff Educator observed the stock in the central supply room, and the Staff Educator located 16 French/ 10 ml balloon Foley catheters readily available for use. The Staff Educator said Nurses had access to the central supply office and should have had the correct catheter size in place for Resident #37. During an interview on 12/5/24 at 8:50 A.M., the Director of Nursing (DON) said that Nurses should insert Foley catheters as ordered by the Physician. The DON said the 18 French/ 30 ml balloon was too big for Resident #37 and could cause trauma. The DON said that the facility did not have a policy and procedure relative to the insertion of indwelling Foley catheters but inserting the correct size as ordered by the Physician was a professional standard of practice. Based on observation, record review, and interview, the facility failed to provide services that met professional standards of quality for two Residents (#83 and #37) out of a total sample of 18 residents. Specifically, the facility failed to: 1. assess Resident #83's swallowing ability in a timely manner, as ordered by the Nurse Practitioner (NP) when the Resident had experienced a decline in swallowing function and weight loss, and required a diet texture downgrade, resulting in a delayed treatment for the Resident. 2. ensure Resident #37 had the correct Physician ordered size indwelling urinary catheter (a soft flexible tube that drains urine from the bladder) in place, placing the Resident at risk for complications related to the urinary catheter. Findings include: 1. Resident #83 was admitted to the facility in August 2023 with diagnoses including Dementia and Muscle Weakness. Review of Resident #83's Nutrition Care Plan, initiated 8/14/23 and last revised 10/11/24, indicated: -The Resident presented at potential nutrition risk related to medical conditions requiring long term care placement. -The Resident was independent with set up at meals. -Registered Dietician (RD)/Speech Language Pathologist (SLP) screen and treat PRN (as necessary). Review of Resident #83's Nursing Progress Note, dated 10/15/24, indicated: -The Resident was in the supervised dining area for his/her meal. -Nursing staff observed that the Resident had some difficulty with the meal. -A rehabilitation screen was submitted for Speech [sic]. Review of Resident #83's Minimum Data Set (MDS) Assessment, dated 10/21/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident required supervision or touching assistance for eating. -The Resident had no signs or symptoms of a possible swallowing disorder. -The Resident had experienced no significant weight loss in the prior six months. Review of Resident #83's Dietary Progress Note, dated 10/24/24, indicated the following: -The Resident was seen by the Registered Dietician (RD) for a significant change in status assessment related to changes in activities of daily living (ADLs). -The Resident's diet was a Regular Texture House Diet. -The Resident received a four- ounce House Supplement twice daily. -The Resident received diuretic (used to remove excess fluid from the body) medication daily. -The Resident fed him/herself independently after set- up. -The Resident's weight was stable over 30 days and the Resident had experienced an 8.3% weight gain over the previous six months. -No changes were recommended. Review of Resident #83's Nurse Practitioner (NP) Progress Note, dated 10/25/24, indicated: -The Resident was seen for intermittent cough with meals. -The Resident was on a regular texture diet with thin liquids. -Nursing staff reported that the Resident was coughing with meals, and that the Resident was attempting to clear his/her throat after eating. Further review of the NP Progress Note indicated the following assessment and plan: -Cough: New order for chest x-ray, downgraded diet to ground soft diet with a referral to be evaluated by Speech Therapy. Review of Resident #83's NP orders, dated 10/25/24, indicated the following: -Chest x-ray -Downgrade diet to ground soft diet. -Refer Resident to Speech Therapy for cough with eating. Review of Resident #83's clinical record indicated: -A chest x-ray had been completed as ordered. -The Resident's diet had been downgraded to a ground soft diet, as ordered. -There was no evidence the Resident had been referred to Speech Therapy for cough while eating, as ordered by the NP. Review of Resident #83's interdisciplinary Facility Weight - Initial Focus Note, dated 11/14/24, indicated: -The Resident was on a minced/moist texture diet. -The Resident received house supplements twice daily. -The Resident received diuretic medication. -Use of diuretic medication may have contributed to the Resident's weight loss. -A recommendation was made for consultation/evaluation by the SLP. Review of Resident #83's NP Progress Note, dated 11/16/24, indicated: - . referral to be evaluated by Speech Therapy . Review of Resident #83's interdisciplinary Facility Weight - Initial Focus Note, dated 11/21/24, indicated: -The Resident was on a minced/moist texture diet. -The Resident received house supplements twice daily. -The plan included adding fortified food and drink, continuing use of the house supplement twice daily, and discontinuing use of the diuretic medication. Further review of the plan indicated whether a consult with Hospice was appropriate for the Resident. Review of Resident #83's clinical record indicated that a referral for consultation by the SLP was not completed until 11/21/24. Review of Resident #83's Rehab Request/Screen Form, dated 11/21/24, indicated the following: -The Resident had weight changes (166.4 pounds (lbs) 30 days prior; current weight 141.4 lbs) -The Resident's diet had been downgraded on 10/25/24. Review of Resident #83's SLP Evaluation and Plan of Treatment, dated 11/27/24, indicated: -The Resident was referred for evaluation of swallowing due to recent weight loss of 23 pounds since the Resident's diet was downgraded on 10/25/24. -The Resident's diet was downgraded due to concerns with coughing. -The Resident had not previously received Speech Therapy services. -The Resident weighed 151.5 lbs on 10/31/24 and 139.6 lbs on 11/26/24 (significant weight loss). -The Resident's mandibular (lower jaw bone) range of motion, strength, and coordination were impaired. -The Resident's lingual (various components of tongue movement) function was impaired. -The Resident presented with moderate oropharyngeal (middle part of the throat and back of the mouth) dysphagia (difficulty swallowing). -Strategies for safe swallowing were recommended. -Treatment of swallowing dysfunction and/or oral function for feeding was recommended at a frequency of eight times over four weeks. -The long term goal was for the Resident to have safe and adequate intake on the least restrictive diet without signs/symptoms of aspiration (when something that is meant to be swallowed enters one's airway or lungs) and use of strategies. On 12/4/24 at 9:42 A.M., the surveyor observed Resident #83 sitting upright in bed. When the surveyor spoke to the Resident, the Resident responded verbally, and the surveyor observed scrambled eggs in the Resident's mouth, in between the Resident's front teeth and lips and over the top of the Resident's tongue. During an interview on 12/5/24 at 9:49 A.M., SLP #1 said she evaluated Resident #83's swallowing function on 11/27/24, when the facility's Director of Rehabilitation (DOR) had informed her that a referral for Speech Therapy had been made by nursing staff due to the Resident having experienced weight loss. SLP #1 said that she did not know when the referral was submitted because she had just started working at the facility the week prior to completing the Resident's evaluation. During an interview on 12/5/24 at 10:27 A.M., the DOR said that there were two SLPs with time available to work at the facility. The DOR said that the SLPs did not work full time, and that the SLPs were available on an as necessary (Per Diem) basis. The DOR said that SLP #1 recently began working at the facility and that the other SLP was available to work during the time that the NP ordered a Speech Therapy evaluation on 10/25/24. The DOR said that he was not made aware of the NP's order for a speech therapy evaluation for Resident #83 because a referral had not been submitted to him from facility staff. The DOR further said that if he had known the Resident required an evaluation to be completed by an SLP, he would have scheduled the evaluation with the SLP that was available, and the evaluation would have been completed timely. The DOR said that the evaluation with an SLP should have been completed when the evaluation was ordered by the NP on 10/25/24 and that the Resident should not have had to wait until 11/27/24 to be evaluated by the SLP. The DOR said he was not sure why a referral had not been submitted for a speech therapy evaluation when the NP ordered the evaluation to be completed. During an interview on 12/5/24 at 2:36 P.M., the Director of Nursing (DON) said that she recently began working at the facility and had initiated weekly interdisciplinary team (IDT) Risk Meetings where the IDT discussed residents at risk for changes in condition, including weight loss. The DON said the first time Resident #83 was discussed at the Risk Meeting was on 11/14/24. The DON said that the referral for the SLP to evaluate Resident #83 was not completed and submitted to the DOR until 11/21/24. The DON also said that the NP was unavailable for interview and that the RD would be available to speak with the surveyor. During an interview on 12/5/24 at 3:46 P.M., the RD said she participated in weekly interdisciplinary team (IDT) Risk Meetings to identify residents at risk for changes in condition. The RD said that she participated in the Risk Meeting on 11/21/24 and that during this same meeting, the IDT identified that Resident #83 had not been evaluated by the SLP, as ordered by the NP on 10/25/24. The RD said that a referral for the SLP to see the Resident was not completed and submitted to the Therapy Department until 11/21/24. Please refer to F689 and F842.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure that one Resident (#46) out of a total sample of 18 residents with contractures received services and treatment to increase range of motion and/or prevent further decrease in range of motion. Specifically, the facility failed to timely assess, monitor and/or treat Resident #46's right third and fourth finger mild contractures. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion (ROM) Policy (undated) indicated but was not limited to the following: >Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. >As part of the residents' comprehensive assessment, the nurse will identify the residents': -Current ROM of his or her joints >As part of the comprehensive assessment, the nurse will also identify conditions that place the residents at risk for complications related to ROM and mobility, including: -Contractures . >The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. >The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. Resident #46 was admitted to the facility in January 2020, with diagnoses including Dementia and generalized muscle weakness. On 12/4/24 at 10:31 A.M., the surveyor observed Resident #46 lying in bed and his/her right hand was contracted with the third and fourth digits (fingers) in flexion (bending at the joint). There was no positioning device/splint seen in the Resident's area or room. During an interview at the time, Resident #46 said he/she had no pain and has never had a positioning device. Resident #46 said staff do not provide any ROM exercises and he/she does not know if the contractures have gotten worse. The Resident was unable to open his/her hand when the surveyor asked if he/she was able to do so. On 12/9/24 at 2:23 P.M., the surveyor and Unit Manager (UM) #1 observed Resident #46's right upper extremity with the Resident's third and fourth digits in a flexed state. UM #1 asked the Resident if he/she could flex or extend those two fingers and he/she said no. UM #1 said she was unaware of any issues. UM #1 also said she was unsure if Resident #46 was seen by therapy at any point during his/her admission to the facility. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/31/24, indicated that Resident #46 had no impairment in functional limitation in range of motion (ROM) to upper extremities (shoulder, elbow, wrist, hand). Review of the medical record indicated a Visit Note from Physician Assistant (PA) #1 dated 9/5/24. Further review of the PA Visit Note indicated the following in the Additional Notes section: -Musculoskeletal: Right third and fourth finger mild contractures. Further review of the medical record failed to indicate any follow-up to the PA Visit Note or reference to the contractures or limited ROM to the right third and fourth fingers for Resident #46. During an interview on 12/10/24 at 10:06 A.M., the Director of Rehabilitation (DOR) #1 said he has not treated Resident #46. The DOR reviewed the Rehab notes and evaluations and said there was nothing about service for the Resident. The DOR said he received a Rehab request for screen this morning for the third and fourth digit trigger finger (a condition that makes the fingers or thumb difficult to move, and can freeze the fingers in a flexed position) for the Resident and he would screen Resident #46 today. Review of the medical record indicated a Physician Interim/Telephone order dated 12/10/24, for the following new order: -add dx (diagnosis) trigger finger. -PT (Physical Therapy) screen. During a telephone interview on 12/10/24 at 10:33 P.M., PA #1 said she noticed the mild contractures to Resident #46's third and fourth fingers during her evaluation on 9/5/24. PA #1 said the Resident had no functional limitations, pain or skin integrity issues and she had never noticed the contractures before. PA #1 said she discussed with nursing and had no new orders. PA #1 said the treatment (for contractures) is surgical and Resident #46 refuses most interventions. PA #1 said she did not feel rehab would be needed at that time, but expected nursing to monitor for pain, skin integrity issues, decrease in function/ROM and to notify her if anything has changed. Review of the medical record failed to indicate any assessment and/or intervention to monitor the Resident's right third and fourth finger or hand for a decrease in function or ROM. During an interview on 12/10/24 at 10:48 A.M., DOR #1 said he screened Resident #46's right hand and the Resident agreed to the evaluation and treatment. DOR #1 said the Resident's active ROM (the range of motion of a joint that occurs when a person uses their muscles to move without assistance) was impaired. DOR #1 said the Resident would benefit from therapy treatment for the contractures and evaluation for a splint to prevent the contractures from worsening and possibly help improve ROM and use. DOR #1 further said the contractures are noticeable when you see him/her and if it had not been evaluated today, it could have gotten worse. Review of the Physical Therapy (PT) Evaluation and Plan of Treatment dated 12/10/24, indicated: -diagnosis of trigger finger. -Plan of treatment including therapeutic exercises, manual therapy techniques, PT evaluation: moderate complexity and therapeutic activities. >Frequency: Three times/week >Duration: Eight Weeks >Intensity: Daily -Short Term Goal: Patient will tolerate hand splint or roll for 2 hours without signs or symptoms of skin issues to reduce the risk of contracture development. During an interview on 12/10/24 at 11:15 A.M., UM #1 said that after PA #1 found Resident #46's contractures, nursing should have started monitoring the Resident's fingers to ensure there were no complications and that it did not get worse. UM #1 said she would expect Nurses to evaluate the area, complete a pain assessment, assess skin integrity and mobility. UM #1 said Resident #46's contractures were profound but she had not noticed it until it was pointed out to her by the surveyor. UM #1 said she has provided care for Resident #46 multiple times, asking him/her to roll and grab the side rail and she just never saw the contractures. During an interview on 12/10/24, at 11:34 A.M., the Director of Nursing (DON) said that she would have expected a rehab screen to be performed in September when the PA identified that Resident #46 had contractures. The DON said she would have expected nursing to monitor, assess, establish baseline, and try to prevent the contractures from worsening.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain complete and accurate medical records for three Residents (#46, #69, and #83), out of a total sample of 18 residents. Specifically, the facility failed to: 1. accurately document measurements of urinary output as ordered when Resident #46 was identified as having a urinary catheter drainage system that provided numerical output measurements. 2. accurately document 24-hour fluid intake and urinary output (I & O) for Resident #69 when the Physician ordered 24-hour I & O monitoring to be completed and documented by staff. 3. maintain a complete clinical record for Resident #83 to include the Resident's Speech Therapy Evaluations, Speech Therapy Treatment Notes, and Speech Therapy Discharge Summary when the Resident had been evaluated, treated, and discharged from speech therapy services and recommendations for safe swallowing strategies were included in the Resident's Speech Therapy Discharge Summary. Findings include: Review of the Facility Policy titled Intake, Measuring and Recording Policy, undated, indicated the following: -The purpose of procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. -Record all fluid intake on the intake and output record in cubic centimeters (cc or milliliters [mls]). -Post an intake and output record form in the resident's room. Review of the Facility Policy titled, Nutrition/Hydration Status Maintenance revised 10/6/23, indicated the following: -Based on a resident's comprehensive assessment, the facility will ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health 1. Resident #46 was admitted to the facility in January 2020, with diagnoses including Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, and Chronic Kidney Disease (CKD), Stage 3. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #46: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a total score of 15. -had an indwelling foley catheter (a thin, flexible tube that is inserted into the bladder to drain urine into a collection bag). Review of the Comprehensive Person-Centered Care Plan dated 11/25/24, indicated: -Indwelling Catheter, active 11/25/24 -Assess the drainage system every shift and PRN (as needed). Record the amount, type, color, odor. Observe for leakage, active 12/4/24 -Document urinary output every shift. Record the amount, type, color, odor. Observe for leakage, active 11/25/24 Review of Resident #46's December 2024 Physician orders indicated: -24-hour total intake and output to be calculated daily on the 11:00 P.M. to 7:00 A.M. (11-7) shift. Please indicate totals here, initiated 11/25/24. -Encourage fluids every shift, initiated 11/26/24. Review of Resident #46's November 2024 and December 2024 Nursing Documentation of Urine Output indicated no exact measurements of urine output were documented on the following dates: -urine output was documented as 'medium' on: 11/19/24, 12/2/24, 12/4/24 and 12/5/24 -urine output was documented as 'large' on: 11/30/24 and 12/1/24 -urine output was documented as 'none' on: 11/27/24 and 11/28/24 During an interview on 12/6/24 at 10:30 A.M., Nurse #1 said that residents who are on antibiotics and have Foley catheters are placed on intake and output (I&O) monitoring. Nurse #1 also said that the 11:00 P.M. to 7:00 A.M. (11-7) shift tallies the totals for the 24-hour period by adding the total fluid amounts from the 7:00 A.M. to 3:00 P.M. (7-3) and the 3:00 P.M. to 11:00 P.M. (3-11) shifts from the prior day and then add their 11-7 shift which includes supplements, meal fluids, medications fluids. During an interview on 12/6/24 at 10:45 A.M., the Director of Nursing (DON) said that the process for monitoring intake and output totals was as Nurse #1 described, and that this process was something that she had wanted to change since she has been at the facility. The DON said she did not believe that residents who were stable with an indwelling catheter needed to be on intake and output monitoring. The DON further said that staff would monitor output but not necessarily the intake if the resident were eating and drinking well and the Foley catheter were chronic (long term use). The DON said that the intake and output totals should indicate an accurate amount of intake and output for monitoring purposes. The DON said that Resident #46's Physician's order for intake and output monitoring was confusing and she had never seen an intake and output order like that. The DON said she knows that the intake and output process needed to be revised. 2. Resident #69 was admitted to the facility in October 2021, with diagnoses including Obstructive (blockage) and Reflux (backward flow) Uropathy (in the urinary tract) and Retention of Urine. Review of Resident #69's clinical record indicated the Resident had an indwelling urinary catheter. Review of Resident #69's Indwelling Catheter Care Plan, initiated 4/10/24 and last reviewed/revised on 10/3/24, indicated: -The Resident required an indwelling urinary catheter related to Obstructive Uropathy. -Assess the drainage system every shift and PRN (as necessary). -Record the amount . Review of Resident #69's Minimum Data Set (MDS) assessment dated [DATE], indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of 15 total possible points. -The Resident was dependent on staff for toileting. -The Resident had an indwelling urinary catheter. Review of Resident #69's November 2024 Physician Orders indicated the following order, dated 11/2/23 with no stop date: -24-hour total intake and output to be calculated daily on 11:00 P.M. to 7:00 A.M. (11-7) shift. -Please indicate totals . Review of Resident #69's November 2024 Treatment Administration record (TAR) indicated: -The Resident's 24-hour intake total on 11/1/24 was recorded as 640 milliliters (ml) +. -There was no 24-hour total intake and output recorded on 11/3/24. -The Resident's 24-hour output total was recorded as 850 +, medium on 11/13/24. -The Resident's 24-hour intake total was recorded as 620 + and 24 hour output total was recorded as 800 + on 11/25/24. -There was no 24-hour total intake and output recorded on 11/27/24. On 12/4/24 at 9:54 A.M., the surveyor observed Resident #69 lying in bed with a catheter tube extending out from under the sheets, leading to a covered bedside drainage bag visible on the right side of the Resident's bed. During an interview at the time, Resident #69 said he/she did not have an indwelling urinary catheter. During an interview on 12/6/24 at 10:30 A.M., Nurse #1 said that all Residents with indwelling urinary catheters were placed on I & O monitoring. Nurse #1 said that Nurses who worked on the 11-7 shift were responsible to tally the 24-hour intake and output totals for Residents on I & O monitoring and to record the totals on the TAR. Nurse #1 said that the totals recorded for intake and output were supposed to be exact measurements. During an interview on 12/6/24 at 10:45 A.M., the Director of Nursing (DON) said that Nurses who worked on the 11-7 shift were responsible to tally and record the 24-hour intake and output totals for Residents with indwelling urinary catheters. The DON said that the totals recorded were to accurately reflect the total amount of fluid taken in and put out during the 24 hour period. The surveyor and the DON reviewed Resident #69's November 2024 TAR and the DON said that she did not know what the use of the + sign following recorded mls meant. The DON further said that she did not know how the measurements for I & O using the + sign should be interpreted relative to how much liquid the Resident took in and how much urine was put out. The DON said that none of the 24-hour totals for I & O should have been left blank. The DON said I & O monitoring was not recorded accurately in Resident #69's clinical record. 3. Resident #83 was admitted to the facility in August 2023 with diagnoses including Dementia and muscle weakness. Review of Resident #83's Rehabilitation Request/Screen Form, dated 11/21/24, indicated: -The Resident had experienced weight loss. -The Resident's diet had been downgraded on 10/25/24. -Intervention recommended was for the Speech Language Pathologist (SLP) to assess the Resident. Review of Resident #83's clinical record on 12/4/24, did not include any evidence the Resident had been assessed by the SLP. On 12/4/24 at 9:42 A.M., the surveyor observed Resident #83 room sitting upright in bed and that there were no staff or meal tray present in the Resident's room at this time. The surveyor spoke to the Resident who responded verbally and softly so the surveyor had to ask the Resident to repeat what he/she said. Resident #83 smiled and began to speak, and the surveyor observed scrambled eggs in his/her mouth, in between the Resident's front teeth and lips and over the top of the Resident's tongue. When the surveyor asked the Resident about having scrambled eggs in his/her mouth, the Resident said, No. When the surveyor asked the Resident again about the eggs in his/her mouth, the Resident swallowed the eggs. During an interview on 12/5/24 at 9:00 A.M., CNA #2 said that she assisted Resident #83 frequently with eating. CNA #2 said she had noticed that the Resident was having difficulty swallowing. CNA #2 said that she thought the SLP was supposed to see the Resident for swallowing and that she was not sure if the SLP had seen the Resident yet. When the surveyor asked how CNA #2 would know whether any recommendations had been made by the SLP relative to swallowing for Resident #83, CNA #2 said that the SLP would normally provide verbal education and a written education sign-in sheet for staff. CNA #2 said she had not yet received any education relative to safe swallowing strategies for Resident #83. During an interview on 12/5/24 at 9:07 A.M., Nurse #1 said that Resident #83 had difficulty swallowing and would cough when drinking. Nurse #1 said that the SLPs had evaluated and treated the Resident and that the treatment was being discontinued due to the Resident being admitted to Hospice services. Nurse #1 said she was not sure if the Resident's speech therapy services had been discontinued yet. Nurse #1 also said that alternating solids and liquids when assisting Resident #83 to eat was important for safety with swallowing and that she was not aware of any other recommendations made for safe swallow strategies for the Resident. During an interview on 12/5/24 at 9:20 A.M., Unit Manager (UM) #1 said Resident #83 had been evaluated by the SLP and that speech therapy services were discontinued on 12/3/24 when the Resident was admitted to Hospice services. The surveyor asked about any recommendations relative to safe swallow strategies that were made by the SLP upon discontinuing speech therapy services and UM #1 said that she did not recall any recommendations made by the SLP relative to safe swallow strategies for Resident #83. UM #1 reviewed Resident #83's electronic health record (EHR) and paper record on the Unit and said that there was no documentation in the Resident's record relative to speech therapy services. UM #1 further said that she did not know how to access the SLP's documentation for Resident #83. During an interview on 12/5/24 at 9:49 A.M., SLP #1 said she completed an evaluation for Resident #83 on 11/27/24. SLP #1 said that the evaluation was completed in an electronic format and she did not know if the evaluation automatically became part of the Resident's electronic health record (EHR) or if the evaluation needed to be scanned into the Resident's EHR. SLP #1 said she printed a copy of the evaluation on 11/27/24 and left the copy for the Director of Rehabilitation (DOR), but she was not sure if the DOR filed the printed copy of the evaluation in the Resident's paper record located on the Unit. SLP #1 said she treated Resident #83 for two visits and discharged the Resident from speech therapy services on 12/3/24. Review of Resident #83's clinical record on 12/5/24 did not include the evaluation completed by SLP #1, nor did the clinical record include any speech therapy treatments notes and speech therapy discharge summary. During an interview on 12/5/24 at 10:27 A.M., the DOR provided copies of the speech therapy evaluation, progress notes, and discharge summary completed for Resident #83 from 11/27/24 through 12/3/24. The DOR said evaluations, progress notes, and discharge summaries completed by Rehabilitation Therapists were completed electronically in a separate system from the Residents' EHRs that facility staff had access to. The DOR said that once each of the evaluations, progress notes and discharge summaries were completed, the electronic submissions were supposed to automatically transfer into the Residents' EHRs. The DOR said that he did not know Resident #83's speech therapy evaluation, progress notes, and discharge summary did not transfer into the Resident's EHR and that since the surveyor inquired about the notes, he identified other residents whose notes also did not transfer into their EHRs. The DOR said that SLP #1 did leave a printed copy of Resident #83's speech therapy evaluation on 11/27/24 and that the DOR had not yet placed the copy into the Resident's clinical record because the evaluation had not been signed by the Physician yet. The DOR also said he did not place copies of therapy evaluations into residents' clinical records until the evaluations were signed by the Physician. The DOR further said that facility staff did not have access to the electronic system used by the Therapists. Following the interview with the DOR that occurred on 12/5/24 at 10:27 A.M., the surveyor reviewed the Speech Therapy Evaluation, Speech Therapy Progress Notes, and Speech Therapy Discharge Summary provided by the DOR which indicated: -The Resident was evaluated by SLP #1 on 11/27/24. -The Resident has difficulty swallowing. -The Resident received two speech therapy sessions following the evaluation. -The Resident was discharged from speech therapy services on 12/3/24 with recommendations for safe swallowing strategies. -Safe swallowing strategies recommended for the Resident included upright positioning during all intake and greater than 30 minutes following intake, bolus size reductions, rate modifications, alternate solids with liquids at a two to one ratio to assist with oral and pharyngeal clearing of bolus, . During a follow-up interview on 12/5/24 at 4:30 P.M., the DOR said that Resident #83's Speech Therapy Evaluation, Speech Therapy Progress Notes, and Speech Therapy Discharge Summary should have been available in Resident #83's record, but they were not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#69) out of a total sample of 18 residents. Specifically, for Resident #69, the facility failed to: -appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other Residents within the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (EBP), indicated the following: -The facility will implement EBP during high contact resident care activities for those residents who are colonized with an MDRO (multi-drug-resistant organisms) unless otherwise ordered by healthcare provider. >Examples of high-contact resident care activities: -Dressing -Bathing/Showering -Transferring -Changing Linens -Changing Briefs or Assisting with Toileting -Device Care or Use: - central line, urinary catheter, feeding tube, tracheostomy/ventilator -Wound care-any skin opening requiring a dressing >The facility may choose to implement EBP to include any resident with an indwelling medical device or wound, regardless of MDRO colonization or infection. >The Infection Preventionist (IP)/Designee will provide staff, residents and/or resident representatives with education regarding the purpose of enhanced barrier precautions. >Staff will perform hand hygiene and don personal protective equipment (PPE) before entering resident's room. >Staff will remove PPE and perform hand hygiene before exiting resident's room. Resident #69 was admitted to the facility in October 2021, with diagnoses including Obstructive and Reflux Uropathy, Urinary Tract Infection (UTI) and Urethral Fistula (an opening between the urethra and perineum that causes incontinence and recurrent urinary tract infections(UTIs). Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #69: -was severely cognitively impaired as evidenced by a score of 5 out of a total score of 15 on the Brief Interview for Mental Status (BIMS) exam. -had an indwelling urinary catheter (also referred to as a Foley catheter). Review of Resident #69's Comprehensive Person-Centered Care Plan dated 4/10/24, indicated: -indwelling urinary catheter. Review of Resident #69's Nursing Progress Note, dated 11/20/24, indicated: -EBP for indwelling medical device. On 12/5/24 at 9:10 A.M., the surveyor observed EBP signage posted outside of Resident #69's room which indicated for Everyone: -to cleanse hands before entering and when leaving the room. -wear gloves and a gown for high contact resident care activities including transferring and changing linens. On 12/5/24 at 9:12 A.M., the surveyor observed two staff members transferring Resident #69 from the bed into a wheelchair with no protective gowns being worn by either staff. Certified Nurses Aide (CNA) #2 was observed to pick up Resident #69's Foley catheter and hang the Foley catheter containing urine in the bag on the Resident's wheelchair. CNA #2 then proceeded to handle the Resident's bed linen by making the bed with no protective gown on. The surveyor observed CNA #2 exit the Resident's room and re-entered a few minutes later and continued to assist the Resident without donning or doffing the appropriate PPE. During an interview immediately following the observation on 12/5/24 at 9:19 A.M., CNA #2 said that she was getting the Resident up from bed to go to the dayroom. CNA #2 further said that the Resident was already dressed and that she did not need to utilize a gown. CNA #2 said she believed she had to sanitize her hands and utilize gloves when handling the Resident's Foley catheter. CNA #2 also said that the Resident was on the EBP because he/she had a Foley catheter but she did not need to use a gown when getting the Resident out of bed because the Resident was already dressed for the day. During an interview on 12/5/24 at 10:19 A.M., the Staff Development Coordinator/Infection Preventionist (SDC/IP) said that EBP signage and PPE were used for any Resident that had an indwelling medical device. The SDC/IP also said the use of EBP's were for any high contact care for a Resident who had an indwelling medical device and required care from staff such as transferring, and when handling Resident bed linens. The SDC/IP said that the expectation for staff following EBP signs depended on what staff were doing for the Resident. The SDC/IP also said that staff should know what to do, and the expectation was that staff utilize PPE supplies provided when caring for a Resident on EBP if transferring, handling a Foley catheter, and/or making the bed of a Resident's that has a Foley catheter. During a follow-up interview on 12/5/24 at 1:50 P.M., the SDC/IP said that Residents were placed on EBP either upon admission or when something else comes up after the Resident had been admitted , such as a Foley catheter insertion and/or a Gastrostomy Tube (G-tube: a tube inserted through the abdomen that provides nutrition directly to the stomach). The SDC/IP said the Physician would enter an order in the Resident's records and a care plan would be developed for Residents who have been placed on EBP's so that staff were able to know what the expectations were. The SDC/IP further said that she was responsible for educating staff on EBP for Resident's and that she just did an education for staff and the expectation on PPE requirements.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to complete an inspection of the bed rails, to identify areas of possible entrapment, for one Resident (#49) out of a total sample of 18 residents. Specifically, the facility failed to assess the side rails and mattress in active use for entrapment when Resident #49 had limited mobility and utilized bilateral side rails, placing the Resident at risk for possible entrapment. Findings include: Review of the facility policy titled Side Rail Policy, undated, indicated: -An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails . -The resident will be checked periodically for safety relative to side rail use. -When said rail usage is appropriate, the facility will assess the space between the mattress and the side rails to reduce the risk for entrapment . Review of the facility policy titled Falls Accident/Accident Policy and Procedure, dated 2/24/24, indicated: -All mattresses and side rails do require specific measurements to be obtained to rule out the risk of entrapment and does utilize a specific weighted apparatus. -The side rail and mattress measurements are performed and maintained by Maintenance personnel. -Measurements are to be obtained on an annual basis or with any new bedframe, new mattress application, weight changes in a resident, changes noted with resident physical abilities and/or whenever a resident is newly admitted . Resident #49 was admitted to the facility in July 2020 with diagnoses including Vascular Dementia, Polyneuropathy, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #49: -was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 14 out of a total possible 15. -had range of motion impairment to the lower extremities on both sides -required maximum assistance by staff for upper body bathing and dressing -was dependent on staff for lower body bathing and dressing -was dependent with staff to roll left and right in bed -was unable to go from lying to sitting -did not ambulate. On 12/4/24 at 9:17 A.M., the surveyor observed Resident #49 lying in bed, with the head of the bed elevated and bed in a low position with bilateral side rails in place. During an interview at the time, Resident #49 said that he/she was bed bound and was unable to ambulate or transfer out of bed. On 12/6/24 at 12:04 P.M., the surveyor observed the Resident lying in bed sleeping, with the bed in low position and the head of the bed elevated with bilateral side rails in place. Review of the Care Plan for Risk of Pressure Ulcer/Injury, initiated 7/27/20, indicated Resident #49: -used 2 quarter side rails to enable him/her to participate in bed mobility. During an interview on 12/6/24 at 1:47 P.M., the Maintenance Director (MD) said that he utilizes an entrapment assessment machine, and demonstrated to the surveyor how it is used to evaluate side rails and mattresses for entrapment risk. The surveyor requested evidence of any side rail assessments for Resident #49's current bed and mattress. The MD said that he did not have an assessment on file and was unable to provide evidence of past assessments for entrapment risk for Resident #49.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled Falls Accident/Accident Policy and Procedure, dated 2/24/24, indicated: -The Fall Risk Assessment Tool .will be completed on all residents immediately upon admission, quarterly, annually, and whenever there is a significant change in resident status. The Tool will be completed by the Unit Nurse or designee. -New admissions: Any new admissions who have had a fall previously, and/or who are a known risk for falls will have an appropriate intervention initiated on admission. -Nursing will document in the nursing notes for 72 hours after admission if the intervention implemented on admission is effective and if any new intervention has been implemented. Resident #35 was admitted to the facility in October 2023 with diagnoses including difficulty in walking, Atrial Fibrillation (irregular and rapid heart rhythm), and Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #35: -was mildly cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of 12 out of a possible total of 15. -was able to ambulate short distances independently. -needed supervision to ambulate greater than 50 feet. -was prescribed an anticoagulant medication. Review of the current Physician's orders for Resident #35 included: -Eliquis (anticoagulant medication) 5 mg (milligrams), twice a day at 8:00 A.M. and 8:00 P.M. for diagnosis of atrial fibrillation, initiated 3/15/24 Review of the Nursing Progress notes indicated the following: -4/29/24: Resident #35 complained of chest pain and orders were obtained from the Nurse Practitioner (NP) to send to the emergency room (ER) for further evaluation. -5/2/24: Resident #35 returned to the facility from hospitalization where he/she was admitted for increased confusion and UTI (urinary tract infection). -5/7/24: Resident #35 sustained a fall around 2:40 P.M. at the nurses station .tripped on his/her roller walker and fell on his/her right side .stated he/she hit his/her head. The Resident complained of hip pain, sustained three skin tears .vomited undigested food twice .orders were obtained from the NP to send to ER for further evaluation. -5/13/24: Resident #35 returned from hospital where he/she had been a admitted for closed displaced comminuted (sic) fracture of shaft of right femur (broken thigh bone) and he/she underwent fixation surgery. Review of Resident #35's Care Plan for Risk of Falls, initiated 10/12/23, indicated: -Resident is at risk for fall related injury due to history of fall with fracture (right leg), history of dizzy spells leading to falls (per Resident), generalized weakness, limited range of motion to right arm and leg, and altered mobility. -Intervention of Fall Risk Assessment quarterly and PRN (as needed), initiated 10/12/23 Review of Resident #35's care plan for risk for Abnormal Bleeding, initiated 10/12/23, indicated: -Resident is at risk for abnormal bleeding due to use of [anticoagulant] for Atrial Fibrillation -Goal that Resident will not have excessive bleeding related to anticoagulant therapy -Intervention to handle Resident carefully when turning, positioning, or transferring to avoid injury, initiated 10/12/23. Further review of Resident #35's medical record did not indicate evidence of a fall risk assessment relative to 5/2/24 and 5/13/24 when the Resident returned from hospitalization. During an interview on 12/6/24 at 8:20 A.M., UM #1 said that a falls assessment would evaluate neurological status, vital signs, medication review, ambulation status, changes in skin, and include any care plan interventions implemented to prevent falls. The surveyor and UM #1 reviewed Resident #35's medical record and UM #1 said that Resident #35 should have been assessed for falls risk on re-admission after each hospitalizations but had not been. During an interview on 12/6/24 at 9:50 A.M., Nurse #4 said that when a resident is re-admitted to the facility, Nursing will conduct evaluations for pain, elopement, falls, and a Norton Scale and those evaluations are documented in the resident records under observations. Nurse #4 further said that she closely monitors residents on anticoagulant medications due to the higher risk of internal bleeding should a fall or injury occur. Nurse #4 said if a fall occurs, she would contact the Doctor or NP immediately and obtain an order for emergency room evaluation if indicated by the medical practitioner. No additional evidence of post-hospitalization fall risk assessments for Resident #35 were provided to the survey team at the time of survey exit. 3. Resident #53 was admitted to the facility in April 2024 with diagnoses including Dementia with other behavioral disturbance, Vestibular Neuritis (inner ear disorder that causes symptoms such as sudden, severe vertigo [a sudden internal or external spinning sensation, often triggered by moving your head too quickly], dizziness, balance problems, nausea and vomiting), and Atrial Fibrillation. Review of the MDS assessment dated [DATE], indicated Resident #53 was moderately cognitively impaired as evidenced by a BIMS score of 9 out of a total possible 15. Review of the current Physician's orders for Resident #53 included: -Eliquis 2.5 mg (milligrams), twice a day at 8:00 A.M. and 8:00 P.M. for diagnosis of atrial fibrillation, initiated 11/21/24. -LSO (Lumbar Sacral Orthosis, specialty device) Brace to lumbar spine every shift while out of bed, remove during care and inspect skin integrity every shift, once a day, initiated 12/2/24. Review of the Nursing Progress notes indicated: -11/30/24: Resident was out on loa (leave of absence) since 11/28 and was due to return tonight. [Spouse] called the facility at 6:00 P.M., and stated that the Resident fell at home this morning and has been in the ER since then .writer called the hospital for an update .testing revealed an L3 burst compression fracture (severe break in the spine when the vertebrae are crushed in all directions) .Patient is to be evaluated by physical therapy and they will acquire an LSO brace. -12/1/24, Resident returned from hospital where he/she was admitted following a fall while away with family. Hospital discharge notes indicated L3 Fracture with recommendation of LSO brace and ambulation with therapy. Review of Resident #53's Care Plan for Risk for Falls, initiated 4/19/24, indicated: -Resident was at risk for fall related injury due to altered mobility, use of psychotropic medications, Meniere's disease (inner ear problem that can cause dizzy spells, also called vertigo, and hearing loss), and Dementia with behavioral disturbances. -Intervention for fall risk assessment quarterly and PRN (as needed), initiated 4/19/24 During an interview on 12/5/24 at 9:07 A.M., Nurse #5 said that Resident #53 had a recent fall which occurred outside of the facility, and he/she is now wearing an LSO brace to promote healing of the fracture. Nurse #5 said that the Resident is to wear the brace while out of bed and the Resident is receiving physical therapy treatments as well. Nurse #5 further said Resident #53 is at risk of bruising or bleeding due to his/her use of anticoagulant medication. Nurse #5 said that if a fall were to occur, she would immediately complete a falls assessment, monitor the Resident's vitals closely, complete an incident report and skin check, and contact the Doctor or NP immediately as the Resident may need transfer to hospital for emergency evaluation due to risk of internal bleeding with the anticoagulant use. Further review of Resident #53's medical record did not indicate evidence of a falls risk assessment relative to 12/1/24 when the Resident returned to the facility from hospitalization. During an interview on 12/5/24 at 12:04 P.M., UM #1 said that Resident #53 was not re-assessed for fall risk when he/she was re-admitted to the facility, and should have been. Based on observation, record review, and interview, the facility failed to provide and environment as free of accident hazards as possible for three Residents (#83, #35, and #53) out of a total sample of 18 residents. Specifically, facility failed to: 1. implement safe swallow strategies for Resident #83 when the Resident had a history of swallowing difficulty, oropharyngeal (middle part of the throat and back of the mouth) dysphagia (difficulty swallowing), Dementia, and had an overall decline in function requiring dependence on staff for eating, which increased the Resident's risk for choking and/or aspiration (when food or liquids enters one's airway or lungs). 2. complete fall risk assessments for Resident #35 when the Resident was re-admitted to the facility following hospitalizations, including one hospitalization resulting from a fall with fracture that required surgical intervention, putting the Resident at risk for further falls, injury and abnormal bleeding resulting from anticoagulation (medication used to prevent blood clots) medication use. 3. For Resident #53, complete a fall risk assessment when the Resident was re-admitted to the facility following a hospitalization for a fall with fracture and surgery, putting the Resident at risk for further falls and injury and increased risk for abnormal bleeding from anticoagulant use. Findings include: 1. Resident #83 was admitted to the facility in August 2023 with diagnoses of Dementia and Muscle Weakness. Review of Resident #83's Nutrition Care Plan, initiated 8/14/23 and last revised 10/11/24, indicated the following: -The Resident presented as potential nutrition risk related to medical conditions requiring long term care placement. -The Resident was independent with set up at meals. -Registered Dietician (RD)/Speech Language Pathologist (SLP) screen and treat PRN (as necessary). Review of Resident #83's Minimum Data Set (MDS) Assessment, dated 10/21/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 total possible points. -The Resident required supervision or touching assistance for eating. -The Resident had no signs or symptoms of a possible swallowing disorder. -The Resident had experienced no significant weight loss in the prior six months. Review of Resident #83's Nurse Practitioner (NP) Progress Note, dated 10/25/24, indicated: -The Resident was seen for intermittent cough with meals. -The Resident was on a regular texture diet with thin liquids. -Nursing staff reported that the Resident was coughing with meals and that the Resident was attempting to clear his/her throat after eating. Further review of the NP Progress Note indicated the following assessment and plan: -Cough - . downgraded diet to ground soft diet . Review of Resident #83's NP Order, dated 10/25/24, indicated: -Downgrade diet to ground soft diet. Review of Resident #83's interdisciplinary Facility Weight - Initial Focus Note, dated 11/14/24, indicated: -The Resident was on a minced/moist texture diet. -A recommendation was made for consultation/evaluation by the SLP. Review of Resident #83's Rehab (Rehabilitation) Request/Screen Form, dated 11/21/24, indicated: -The Resident's diet had been downgraded on 10/25/24. -Intervention recommended was for the SLP to assess the Resident. Review of Resident #83's SLP Evaluation and Plan of Treatment, dated 11/27/24, indicated the following: -The Resident's diet was downgraded on 10/25/24 due to concerns with coughing. -The Resident had not previously received speech therapy services. -The Resident's mandibular (lower jaw bone) range of motion, strength, and coordination were impaired. -The Resident's lingual (various components of tongue movement) function was impaired. -The Resident presented with moderate oropharyngeal (middle part of the throat and back of the mouth) dysphagia (difficulty swallowing). -The Resident presented with decreased ability for breaking down and clearing bolus' (rounded mass of a substance, especially of chewed food at the moment of swallowing) from his/her mouth and decreased attention to task during meals. -The Resident presented with moderate lingual residue and residuals in the anterior portion of his/her oral cavity that accumulated over time. -Food residuals were eventually cleared by liquid wash. -The Resident presented with limited attention to bolus in the oral cavity. -Treatment of swallowing dysfunction and/or oral function for feeding was recommended at a frequency of eight times over four weeks. -The long term goal was for the Resident to have safe and adequate intake on the least restrictive diet without signs/symptoms of aspiration (when something that is meant to be swallowed enters one's airway or lungs) and use of strategies. Further review of Resident #83's SLP Evaluation and Plan of Treatment indicated the following relative to swallowing strategies recommended: -Upright positioning during all meals and 30 minutes following meals. -Alternate solids and liquids t assist with oral and pharyngeal clearing of bolus. -Rate modification. -Bolus size reductions. -General safe swallow techniques. Review of Resident #83's SLP Discharge summary, dated [DATE], indicated the following: -The Resident had experienced an overall decline in function. -The Resident had become dependent on staff for meal intake and use of safe swallow strategies. -The Resident's meal intake had reduced due to the Resident becoming increasingly confused and having decreased attention to task during meals. -Skilled interventions provided during speech therapy sessions included education provided to facility staff. -Speech therapy services were being discontinued for the Resident as the Resident was being admitted to Hospice services on 12/3/24. -Discharge Strategies recommended for the Resident included: > upright positioning for all meals and greater than 30 minutes following intake >bolus size reductions >rate modifications >alternating solids and liquids with a two to one ratio to assist with oral and pharyngeal clearing of bolus >general safe swallow precautions On 12/4/24 at 9:42 A.M., the surveyor observed the following: -the surveyor entered Resident #83's room and observed the privacy curtain was pulled between the beds in the room and the Resident was sitting upright in bed. -The surveyor observed that there were no staff in the Resident's room at this time. -The surveyor spoke to the Resident and the Resident responded verbally and softly so that the surveyor had to ask the Resident to repeat what he/she said. -The Resident then smiled and began to speak, and the surveyor observed scrambled eggs in the Resident's mouth, in between the Resident's front teeth and lips and over the top of the Resident's tongue. -The surveyor asked the Resident about having scrambled eggs in his/her mouth, and the Resident said, No. -The surveyor asked the Resident again about the eggs in his/her mouth and the Resident swallowed the eggs. -The surveyor observed that there was no meal tray in the Resident's room. During an interview on 12/5/24 at 9:00 A.M., CNA #2 said that she worked at the facility three days per week and that frequently assisted Resident #83 with eating. CNA #2 said that she had noticed a few days prior that the Resident was having difficulty swallowing and was unable to swallow any lumpy food. CNA #2 said she had assisted Resident #83 with eating over the previous three days and the Resident required his/her food to be ground up so that it was really smooth. CNA #2 said that she thought the SLP was supposed to see the Resident for swallowing and she was not sure if the SLP had seen the Resident yet. CNA #2 also said that she had not received any education or instructions from the Nurse or the SLP relative to swallowing strategies for the Resident. When the surveyor inquired about the scrambled eggs observed in Resident #83's mouth on 12/4/24 at 9:42 A.M., CNA #2 said, I'm glad you were here to see that. During an interview on 12/5/24 at 9:07 A.M., Nurse #1 said that Resident #83 had trouble when drinking and would cough when drinking. Nurse #1 said that the SLPs had been treating the Resident, and the treatment was being discontinued due to the Resident being admitted to Hospice services. Nurse #1 said that Hospice personnel had been in the facility on 12/3/24 to admit the Resident to Hospice services, and she had not seen Hospice personnel with the Resident since 12/3/24. Nurse #1 said that Hospice personnel would be responsible to further assess Resident #83's swallowing function. During an interview on 12/5/24 at 9:20 A.M., Unit Manager (UM) #1 said Resident #83 had been evaluated by the SLP and that speech therapy services were discontinued on 12/3/24 when the Resident was admitted to Hospice services. When the surveyor discussed the observation of Resident #83 from 12/4/24 at 9:42 A.M., UM #1 said she was not aware the Resident had been pocketing food in his/her mouth and that she would need to notify Hospice personnel so that the Resident could be assessed. The surveyor and UM #1 reviewed the results of the Resident's SLP Evaluation and Plan of Treatment from 11/27/24, which indicated the Resident had decreased awareness of food in his/her mouth and that the Resident held food in his/her mouth during the evaluation. UM #1 said she did not know the Resident had been holding food in his/her mouth and she could not recall any recommendations made by the SLP for Resident #83 relative to safe swallowing strategies. UM #1 further said Resident #83 was very confused and would not be aware of food left in his/her mouth. UM #1 further said if Resident #83 held food in his/her mouth, he/she would need to be cued by staff to swallow the food. UM #1 said that staff who assisted residents to eat knew to check residents' mouths for residual food before leaving them alone, and that staff who assisted Resident #83 on 12/4/24 should have made sure the Resident was not left with food in his/her mouth. During an interview on 12/5/24 at 9:49 A.M., SLP #1 said she evaluated Resident #83's swallowing function on 11/27/24, when the facility's Director of Rehabilitation (DOR) had informed her that a referral for speech therapy had been made by nursing staff due to the Resident having experienced weight loss. SLP #1 said when she evaluated the Resident, the Resident was very confused. SLP #1 said that the Resident was unable to pay attention to his/her meal, unable to feed him/herself, and was unaware of the presence of food in his/her mouth. SLP #1 said Resident #83 held food in his/her mouth and could eventually clear the food with alternating solids and liquids and with cues provided by SLP #1. SLP #1 said that after she completed Resident #83's evaluation, she spoke with one CNA and instructed the CNA to alternate solids and liquids for Resident #83. SLP #1 said she could not recall who the CNA was and that she did not discuss safe swallow strategies for the Resident with any other staff at that time. SLP #1 said she saw the Resident again on 12/3/24 and the Resident required full assistance from staff to eat at that time. SLP #1 said that she was informed on 12/3/24 that Resident #83 was being admitted to Hospice services and that she was to discontinue speech therapy services. SLP #1 said that she would normally complete a written staff education sheet with recommendations for safe swallowing strategies to be implemented for residents when they were discharged from speech therapy services, but that she did not complete a written staff education sheet for Resident #83 because she had to discontinue services due to Hospice admission. SLP #1 further said that she was not made aware Resident #83 was being admitted to Hospice until after she treated the Resident that same day, so education to staff for safe swallow strategies had not been completed prior to discontinuing speech therapy services. SLP #1 said that she could not speak to how CNAs were educated regarding swallowing safety for residents, but she thought they would know not to leave a Resident with confusion and swallowing impairments, who required assistance and cues to eat, alone with food in their mouth. During an interview on 12/5/24 at 10:15 A.M., the Staff Development Coordinator (SDC), who was also the Infection Preventionist (IP) said that Certified Nurse Aides' training included assisting residents to eat and feeding residents. The SDC said that she provided education to CNAs during orientation, regarding feeding residents and that a portion of the training was to remind staff to check residents' mouths, to ensure no food was left, for the residents' safety. Immediately following the interview with the SDC/IP, the SDC/IP provided CNA #2's Orientation Checklist to the surveyor which indicated the following: -The Orientation Checklist had been completed for CNA #2 on 4/4/24. -The CNA had been provided education and deemed competent relative to assisting residents with feeding. During an interview on 12/5/24 at 10:27 A.M., the Director of Rehabilitation (DOR) said that Resident #83 was evaluated by the SLP on 11/27/24, following a nursing staff referral for difficulty swallowing and weight loss. The DOR said that the SLP had to discontinue services for Resident #83 on 12/3/24, because the Resident was being admitted to Hospice services. The DOR said that he did not think the SLP would have been required to educate staff on safe swallowing strategies for Resident #83 upon discontinuing speech therapy services because the Resident transitioned to Hospice services. The DOR said it would now be the Hospice personnel's responsibility to assess the Resident and make recommendations relative to safe swallowing. When the surveyor asked who was responsible to ensure interventions were put in place for the Resident to ensure the Resident's safety with swallowing until Hospice personnel assessed the Resident's swallowing abilities, the DOR said, That is a good question. The DOR further said that education had not been completed with nursing staff relative to recommendations for safe swallowing strategies for Resident #83. Please refer to F842.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide routine dental services for one Resident (#46), out of a total sample of 18 residents. Specifically, the facility failed to schedule dental appointments when consent was given, to ensure that Resident #46 received routine dental services as requested, resulting in complications related to dental deterioration for the Resident. Findings include: Review of the facility policy titled Dental Services dated 11/28/17, indicated but was not limited to the following: - residents are assisted in obtaining regular and emergency dental care through the dentist or dental services indicated at the time of the admission Resident #46 was admitted to the facility in January 2020, with diagnoses including Dementia and Dysphagia. On 12/4/24 at 10:29 A.M., the surveyor observed Resident #46 lying in bed. The Resident was observed to have several missing and broken teeth in his/her mouth. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #46: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. -required substantial /maximal assistance with oral hygiene. Review of the medical record indicated a Physician order dated 3/25/21, that indicated: -Dentist Consult as needed. Review of Resident #46's Dental Care Plan indicated but not limited to: -Problem Start Date: 8/11/21, revised 11/5/24 -Resident #46 is assessed with cavity or broken teeth. -Approach Start Date: 8/11/21 - refer to dental as indicated. Review of the medical record indicated a completed Dental Consent Form (a check off form indicating a resident's interest in receiving dental services) for Resident #46. The Dental Consent Form directed the Resident check the statement for which he/she wished to apply. The statement - I would like Dentist to provide dental care was checked off. The form was signed by Resident #46 and was dated 1/20/20. Resident #46 was the responsible party at that time. Further review of the medical record failed to indicate that Resident #46 received any dental services from the Dentist as requested. During an interview on 12/6/24 at 2:20 P.M., Unit Manager (UM) #1 said that she looked through the medical record and cannot find anything about Resident #46 being seen by dental services. UM #1 said that Resident #46 refuses care a lot. UM #1 said she will reach out to the dental provider to see whether the Resident has ever been seen for routine dental services. During an interview on 12/9/24 at 1:10 P.M., UM #1 said she talked with the dental provider's office and Resident #46 had never been seen by that Dentist since signing the consent and was not on the list to be seen. UM #1 said that Resident #46 was seen after the surveyor asked about dental services last week. UM #1 said the Resident allowed the Dentist to take some x-rays and consented to cleaning during the next visit. UM #1 said there were no other visits attempted prior to this visit. On 12/9/24 at 2:57 P.M., UM #1 provided the surveyor with the recent dental visit information. The form indicated but was not limited to the following: -the Resident was given a Comprehensive Oral Evaluation and x-ray by the Dentist. -the text note indicated the Resident was sitting up in bed and consented to be seen. -Findings: very poor dentition with fractured teeth/multiple roots/poor oral hygiene/limited occlusal stop (the point where opposing teeth touch). Obvious decay/ moderate to severe gingivitis/Patient (Pt) refuses any extractions then dentures. -the Resident Ok'd (agreed to) a cleaning which I will put him/her on the list. Review of the dental x-rays dated 12/7/24, indicated: -13 teeth were fractured to the root (Tooth #1, 3, 4, 8, 9, 10, 11, 12, 14, 15, 22, 23, 26) -8 teeth were decayed (Tooth #6, 7, 18, 21, 24, 25, 27, 28) During an interview on 12/9/24 at 3:27 P.M., UM #1 said that once a consent is signed by a Resident, he/she should be added to the list to see the Dentist. UM #1 said she is surprised that this consent was signed so long ago and Resident #46 was never seen by the Dentist. UM #1 said Resident #46 should have been seen right after the consent was signed. During an interview on 12/9/24 at 3:52 P.M., the Director of Nursing (DON) said her expectation is that when a Resident requests dental services and signs a consent, he/she should receive services as soon as possible.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0582 (Tag F0582)

Minor procedural issue · This affected multiple residents

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Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN- notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for three Residents (#17, #35 and #38), out of three applicable residents, so that the Residents could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. Specifically, the facility failed to issue a SNF ABN: 1. For Resident #17, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility. 2. For Resident #35, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain a Resident in the facility. 3. For Resident #38, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) website for SNF ABN last modified 9/10/24, https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-snf-abn indicated: -Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides: >an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or >custodial care (non-medical assistance with daily tasks and basic living needs for those who are not sick or disabled). 1. Resident #17 was admitted to the facility in February 2024, with diagnoses including Hypertension, Depression, and Hyperlipidemia. Review of Resident #17's medical record indicated that the Resident's Medicare Part A benefit ended on 5/31/24. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 5/31/24, for review. 2. Resident #35 was admitted to the facility in October 2023, with a diagnosis of Diabetes Mellitus. Review of Resident #35's medical record indicated that the Resident's Medicare Part A benefit ended on 7/5/24. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 7/5/24, for review. 3. Resident #38 was admitted to the facility in January 2020, with diagnoses including Anemia, Coronary Artery Disease, and Heart Failure. Review of Resident #38's medical record indicated that the Resident's Medicare Part A benefit ended on 7/5/24. The facility was unable to provide any SNF ABN notice corresponding with the Resident ending his/her Medicare benefit on 7/5/24, for review. During an interview on 12/5/24 at 3:14 P.M., the Social Worker (SW) said that the previous Physical Therapy (PT) Director assisted with Medicare Part A beneficiary notices, and the SW began doing them when the PT Director left. The surveyor and the SW reviewed Resident's #17, #35, and #38, SNF ABN forms and the SW said that SNF ABN forms were not issued for the three Residents.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0868 (Tag F0868)

Minor procedural issue · This affected multiple residents

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Based on record review and interview, the facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the facility failed to provide evidence that the Medical Director attended two out of the four quarterly QAPI meetings as required. Findings include: Review of the facility document titled Facility QAPI Plan dated 1/16/2019, indicated the following: -Medical Director must attend at least quarterly, preferred monthly. -All attendees present sign in. If a member is unable to attend in person, due to an occasional schedule conflict, or vacation, indicate the reason they are not in attendance at the meeting. Review of the facility QAPI meeting schedule indicated the QAPI Team met quarterly on 1/18/24, 4/18/24, 7/18/24 and 10/18/24. During an interview on 12/10/24 at 3:15 P.M., the Administrator said the Medical Director is required to attend the quarterly QAPI meetings and that all attendees of the QAPI meeting were required to sign the attendance sheet. The surveyor and the Administrator reviewed the attendance sheets for the quarterly QAPI meetings held at the facility, and the Administrator said that the Medical Director had signed the attendance sheet for the QAPI meetings in April 2024 and October 2024, but did not sign the attendance sheets for the QAPI meetings that took place in January 2024 and July 2024. The Administrator further said that the Medical Director had not attended the quarterly QAPI meetings in January 2024 and July 2024, but should have attended the meetings as required.

Dec 2023 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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Based on records reviewed, review of surveillance camera video footage and interviews, for one of three sampled residents (Resident #1) who had moderate cognitive impairment, history of behaviors and was dependent on staff for care, the Facility failed to ensure he/she was free from physical and verbal abuse when on 12/06/23/23, during the day shift, Certified Nurse Aide (CNA) #1 was seen on video footage pulling Resident #1 backward out of the elevator, then he hit/slapped him/her on the left side of the back of his/her head/neck/face area, and can then be seen standing over him/her engaging verbally and physically as he moves his arms/hands in front of Resident #1's face. The altercation between Resident #1 and CNA #1 was witnessed by another resident and other staff members, who said CNA #1 was antagonizing and threatening Resident #1 and that he/she was visibly upset by the incident. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised February 2023, indicated the following: -The Facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect and misappropriation of their personal property, -physical abuse is includes hitting, slapping, kicking, and control of behaviors through corporal punishment, and -mental abuse includes humiliation, harassment, threats of punishment or deprivation. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/06/23, indicated that on 12/06/23 staff witnessed an altercation between a staff member (later identified as CNA #1) and a resident (later identified as Resident #1). The Report indicated Resident #1 was being redirected out of the elevator when he/she became agitated and CNA #1 pulled his/her wheelchair back and put his hand on the side of Resident #1's head. Review of the Facility's Investigation Report, undated, indicated that on 12/06/23, residents were accompanied by staff and were in the basement level of the Facility when Resident #1 attempted to get on the elevator in his/her wheelchair without staff. The Report indicated that another resident's (later identified as Resident #2) Written Witness Statement indicated that CNA #1 pulled Resident #1 out of the elevator and as he (CNA #1) was turning him/her (Resident #1) around, he (CNA #1) hit Resident #1 on the side of the head. The Report indicated that Resident #1 was angry and yelled at CNA #1 which immediately drew the attention of other staff members who were in the basement level. The Report indicated CNA #1 was suspended immediately and then terminated on 12/07/23 for this incident. Resident #1 was admitted to the Facility in March 2020, diagnoses included dementia with behavioral disturbances and right sided hemiparesis (weakness) and hemiplegia (paralysis). Review of Resident #1's Quarterly Minimum Set Data (MDS) Assessment, dated as completed on 12/08/23, indicated Resident #1 had moderate cognitive impairment. Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her December 2023 MDS, indicated that staff should not confront, argue, or deny his/her belief system. Review of Resident #1's Fall Care Plan, reviewed and renewed with his/her December 2023 MDS, indicated he/she required assist of two staff members for transfers. The Surveyor reviewed Facility surveillance camera video footage from the basement camera in the area of the elevator, with the Administrator and the Director of Nurses (DON) who identified Resident #1 and staff seen in the video. The video footage dated and time stamped 12/06/23 from 14:21:44 to 14:23:01 (2:21 P.M. to 2:23 P.M.) illustrated the following: (14:21:47) CNA #1 walks over to the basement elevator and looks in. (14:21:49) CNA #1 enters the elevator. (14:21:52) CNA #1 is seen pulling the wheelchair Resident #1 is seated in backward out of the elevator. (14:21:55) CNA #1 turns the wheelchair so Resident #1 is facing the camera as he backs him/her up. Then, with his right hand, CNA #1 hits Resident #1 on the left side of his/her face/head/neck area. As CNA #1's hand makes contact with Resident #1's face/head/neck, his/her head jerks backward and to the right. Resident #2 enters into the cameras view, he/she walks toward the elevator assisting (pushing) another resident in a wheelchair. Resident #2 turns his/her head and looks in the direction of Resident #1 and CNA #1, as CNA #1 hits Resident #1. (14:21:57) CNA #1 (who is tall and large in stature), stands over Resident #1 and points his finger in Resident #1's face. Resident #1 raises his/her left arm/hand to cover his/her face. (14:21:59) CNA #1 continues to stand over Resident #1 and swings his arms at Resident #1 in an aggressive manner. Resident #1's moves his/her head and neck backwards and to the right, moving away from CNA #1's reach. Resident #1 raises his/her arms up as if he/she is attempting to protect him/herself. (14:22:05) CNA #2 enters the camera's view and she walks toward CNA #1 and Resident #1, who are still by the basement elevator. (14:22:12) CNA #2 approaches CNA #1 and Resident #1 as CNA #1 continues to stand over him/her. Resident #1 continues to extend (position) his/her upper body back in his/her wheelchair as if he/she is trying to move or keep away from CNA #1. (14:22:19) CNA #1 can be seen pointing down the hall and Resident #1's upper body is still pulled or extended back in his/her wheelchair, away from CNA #1. CNA #2 is standing close to CNA #1 and Resident #1. (14:22:24) Resident #1 moves his/her wheelchair backward, away from CNA #1, and now CNA #1 is no longer standing over him/her in a threatening manner. Resident #1 straightens his/her posture so he/she is seated more upright in his/her wheelchair. (14:22:27) CNA #1 backs away from Resident #1. (14:22:42) The Director of Admissions enters the cameras view and looks toward the direction of CNA #1, CNA #2 and Resident #1 who are near the elevator. (14:22:54) CNA #1 walks away from Resident #1, gets another resident in a wheelchair and pushes him/her onto the elevator. Review of a Disciplinary Action Form, dated 12/08/23, indicated that on 12/06/23 at approximately 2:23 P.M., CNA #1 struck Resident #1 on the neck after taking him/her off the elevator. The Form indicated that the incident was on captured on video surveillance and witnessed by Resident #2. The Form indicated that the incident constitutes physical abuse and assault and battery. The Form indicated that CNA #1 was terminated on 12/07/23. During an interview on 12/20/23 at 3:32 P.M., Resident #1 said he/she could not recall an altercation with CNA #1. Although Resident #1's understanding and/or ability to recall of the incident was limited due to his/her impaired cognitive status, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner. The Facility was unable to provide a Written Witness Statement and/or Interview from Resident #1, so there was no documentation of Resident #1's account of incident. During an interview on 12/20/23 at 2:54 P.M. and review of Resident #2's Written Witness Statement, dated 12/06/23, Resident #2 said he/she was downstairs with other residents after they went out to smoke and that they were waiting by the basement elevators to go back upstairs. Resident #2 said he/she saw CNA #1 pull Resident #1 out of the elevator and then smack/slap him/her on the left side of his/her face. Resident #2 said Resident #1 was very upset and was screaming but he/she could not remember what Resident #1 said. Resident #2 said he/she was also very upset, and said, If CNA #1 did that to Resident #1, what is he (CNA #1) doing to other residents that cannot say anything? During an interview on 12/20/23 at 10:48 A.M., and review of her Written Witness Statement, dated 12/06/23, the Director of Admissions said on 12/06/23 at approximately 2:20 P.M., she was in her office (which is in the basement of the Facility) when she heard screaming. The Director of Admissions said she heard Resident #1 yell, fuck you, I will fuck you up for hitting me in the face! The Director of Admissions said she walked around the corner and said when Resident #1 saw her, he/she said, he really did it! The Director of Admissions said CNA #1 was antagonizing Resident #1 and that Resident #1 looked very anxious. The Director of Admissions said Resident #1 was swinging his/her fists at CNA #1 and he (CNA #1) kept pushing Resident #1's hands down. The Director of Admissions said in response to Resident #1 saying, he really did it!, CNA #1 kept saying, no I didn't, let's go up (in the elevator). The Director of Admissions said Resident #1 was very upset. During an interview on 12/20/23 at 11:52 P.M., and review of her Written Witness Statement, dated 12/06 (year not documented), CNA #2 said that after she and CNA #1 had taken residents out to smoke, she heard Resident #1 yelling and that he/she said you slapped me to CNA #1. CNA #2 said she told CNA #1 to stop fighting with Resident #1. CNA #2 said that CNA #3 and CNA #4 came out of the break room and also tried to stop CNA #1 from fighting with Resident #1. CNA #2 said Resident #1 was very angry and he/she kept saying that CNA #1 slapped him/her in the face. During an interview on 12/20/23 at 2:13 P.M., CNA #3 said she was in the break room downstairs which is near the basement elevator when she heard very loud yelling in the hallway. CNA #3 said she went out into the hallway and told CNA #1 to stop yelling at Resident #1. CNA #3 said Resident #1 told her three times that CNA #1 had slapped him/her. CNA #3 said CNA #1 was yelling and arguing with Resident #1. CNA #3 said she and CNA #4 helped Resident #1 calm down. During an interview on 12/20/23 at 2:26 P.M., CNA #4 said she was in the break room with CNA #3 when she heard Resident #1 screaming. CNA #4 said she left the break room and saw Resident #1 sitting in his/her wheelchair near the elevator. CNA #4 said Resident #1 was yelling that CNA #1 had slapped him/her. CNA #4 said she and CNA #3 were tried to calm Resident #1 down. CNA #4 said she told CNA #1 to stop arguing with Resident #1. CNA #4 said that Resident #1 was very upset and angry. During an interview on 12/20/23 at 3:59 P.M., Unit Manager #1 said she heard Resident #1 screaming in the elevator and that he/she was surrounded by staff trying to calm him/her down when he/she returned to the unit. Unit Manager #1 said Resident #2 came to her and said, it really happened, he (CNA #1) slapped Resident #1. During a telephone interview on 12/20/23 at 3:10 P.M., CNA #1 said he knew Resident #1 well and that he/she sometimes plays with the elevators. CNA #1 said he dragged Resident #1 out of the elevator in his/her wheelchair and put his hand on the front of his/her (Resident #1's) face to stop him/her from yelling. CNA #1 said he had been trained to back away from residents if they exhibit behaviors, but said, This time it was too much, and I put my hand on the front of his/her face. During an interview on 12/20/23 at 4:12 P.M., the Administrator said that on 12/06/23 the Director of Admissions called him and said there was a disruption in the basement. The Administrator said he looked at surveillance camera video footage and saw CNA #1 pull Resident #1 out of the elevator. The Administrator said he saw CNA #1 put his fist up to Resident #1's temple. The Administrator said Resident #1 looked angry, and that CNA #1 kept putting his hands up. The Administrator said CNA #1 should have deescalated the situation or walked away, but he had not. The Administrator said he substantiated the allegation of physical abuse and CNA #1 was terminated.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1) who was physically abused by a staff member, the Facility failed to ensure they reported a reasonable suspicion of a crime, when although the Administrator was aware on 12/06/23, that Certified Nurse Aide (CNA) #1 hit Resident #1 in the head/neck/face area, and substantiated the incident as physical abuse, the Facility did not notify local law enforcement until 12/20/23, the day of survey. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised February 2023, indicated the following: - Physical abuse is defined as hitting, slapping, pinching, kicking, and control of behavior through corporal punishment, -The Facility will ensure reporting of a reasonable suspicion of crimes against a resident or individuals receiving care from the Facility within prescribed timeframes to the appropriate entities within two hours after forming suspicion if serious bodily arm or if the allegation involves abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriations of resident property, and - When a facility has identified abuse, the facility must immediately take all appropriate steps to remediate the noncompliance and protect the resident from additional abuse. This includes reporting the alleged violation and investigation within the required timeframes. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/06/23, indicated that on 12/06/23 staff witnessed an altercation between a staff member (later identified as CNA #1) and resident (later identified as Resident #1). The Report indicated Resident #1 was being redirected out of the elevator when he/she became agitated, CNA #1 pulled his/her wheelchair back and put his hand on the side of Resident #1's head. Review of the Facility's Investigation Report, undated, indicated that on 12/06/23 residents were accompanied by staff in the basement level of the Facility when Resident #1 attempted to get on the elevator in his/her wheelchair without staff. The Report indicated that another resident's (later identified as Resident #2) Written Witness Statement indicated that CNA #1 pulled Resident #1 out of the elevator and as he was turning him/her (Resident #1) around, he (CNA #1) hit Resident #1 on the side of the head. The Report indicated that Resident #1 was angry and yelled at CNA #1 which immediately drew the attention of other staff members who were in the basement level. The Report indicated CNA #1 was suspended immediately and then terminated on 12/07/23 for this incident. Resident #1 was admitted to the Facility in March 2020, diagnoses included dementia with behavioral disturbances and right sided hemiparesis (weakness) and hemiplegia (paralysis). Review of Resident #1's Quarterly Minimum Set Data (MDS) Assessment, dated 12/08/23, indicated Resident #1 had moderate cognitive impairment. The Surveyor reviewed Facility surveillance camera video footage with the Administrator and the Director of Nurses (DON) who identified Resident #1 and staff seen in the video. Review of the basement elevator area video footage dated and time stamped 12/06/23 from 14:21:44 to 14:23:01 (2:21 P.M. to 2:23 P.M.) illustrated the following: (14:21:47) CNA #1 walks to the basement elevator and looks in. (14:21:49) CNA #1 enters the elevator. (14:21:52) CNA #1 is seen pulling the wheelchair Resident #1 is seated in backwards out of the elevator. (14:21:55) CNA #1 turns the wheelchair so Resident #1 is facing the camera as he backs him/her up. Then, with his right hand, CNA #1 hits Resident #1 on the left side of his/her face/head/neck area. As CNA #1's hand makes contact with Resident #1's face/head/neck, his/her head jerks backward and to the right. Resident #2 enters the cameras view, as he/she walks toward the elevator assisting (pushing) another resident in a wheelchair. Resident #2 turns his/her head and looks in the direction of Resident #1 and CNA #1, as CNA #1 hits Resident #1. (14:21:57) CNA #1 (who is tall and large in stature), stands over Resident #1 and points his finger in Resident #1's face. Resident #1 raises his/her left arm/hand to cover his/her face. (14:21:59) CNA #1 continues to stand over Resident #1 and swing his arms at Resident #1 in an aggressive manner. Resident #1's moves his head and neck backward and to the right, moving away from CNA #1's reach. Resident #1 raises his/her arms up as if he/she is attempting to protect him/herself. (14:22:05) CNA #2 enters the camera's view and she walks toward CNA #1 and Resident #1, who are still by the basement elevator. (14:22:12) CNA #2 approaches CNA #1 and Resident #1 as CNA #1 continues to stand over him/her. Resident #1 continues to have his/her upper body extended (positioned) towards the back of his/her wheelchair as if he/she is trying to move away from CNA #1. (14:22:19) CNA #1 is pointing down the hall and Resident #1's upper body is still extended (positioned) back in his/her wheelchair, away from CNA #1. CNA #2 is standing close to CNA #1 and Resident #1. (14:22:24) Resident #1 moves his/her wheelchair backward, away from CNA #1, and now CNA #1 is no longer standing over him/her in a threatening manner. Resident #1 straightens his/her posture so he/she is seated more upright in his/her wheelchair. (14:22:27) CNA #1 backs away from Resident #1. (14:22:42) The Director of Admissions enters the camera view and looks towards the direction of CNA #1, CNA #2, and Resident #1 who are near the elevator. (14:22:54) CNA #1 walks away from Resident #1, gets another resident in a wheelchair and pushes him/her onto the elevator. Review of a Disciplinary Action Form, dated 12/08/23, indicated that on 12/06/23 at approximately 2:23 P.M., CNA #1 struck Resident #1 on the neck after taking him/her off the elevator. The Form indicated that the incident was on video surveillance and witnessed by Resident #2. The Form indicated that the incident constitutes physical abuse. The Form indicated that CNA #1 was terminated on 12/07/23. The Form indicated that Resident #1's Guardian did not want law enforcement to be notified, and that the incident was assault and battery. During an interview on 12/20/23 at 3:32 P.M., Resident #1 said he/she could not recall an altercation with CNA #1. The Facility was unable to provide a Written Witness Statement and/or Interview from Resident #1, therefore there was no documentation of Resident #1's account of incident after it happened. During an interview on 12/20/23 at 2:54 P.M. Resident #2 said he/she was downstairs with other residents after they went out to smoke and that they were waiting by the elevators to go back upstairs. Resident #2 said she saw CNA #1 pull Resident #1 out of the elevator and then smack him/her on the left side of his/her face. Resident #2 said Resident #1 was very upset and was screaming but he/she could not remember what Resident #1 said. During an interview on 12/20/23 at 10:48 A.M., and review of her Written Witness Statement, dated 12/06/23, the Director of Admissions said on 12/06/23 at approximately 2:20 P.M., she was in her office when she heard screaming. The Director of Admissions said she heard Resident #1 yell, fuck you, I will fuck you up for hitting me in the face! The Director of Admissions said she walked around the corner and said when Resident #1 saw her, he/she said, he really did it! The Director of Admissions said CNA was antagonizing Resident #1 and that Resident #1 looked very anxious. The Director of Admissions said Resident #1 was swinging his fists at CNA #1 and he (CNA #1) kept pushing Resident #1's hands down. During an interview on 12/20/23 at 11:52 P.M., and review of her Written Witness Statement, dated 12/06 (year not included), CNA #2 said that after she and CNA #1 had taken residents out to smoke, she heard Resident #1 yelling and that he/she said you slapped me to CNA #1. CNA #2 said Resident #1 was very angry and he/she kept saying that CNA #1 slapped him/her in the face. During an interview on 12/20/23 at 2:13 P.M., CNA #3 said she was in the break room downstairs which is near the elevator when she heard very loud yelling in the hallway. CNA #3 said Resident #1 told her three times that CNA #1 had slapped him/her. CNA #3 said CNA #1 was yelling and arguing with Resident #1. During an interview on 12/20/23 at 2:26 P.M., CNA #4 said she was in the break room with CNA #3 when she heard Resident #1 screaming. CNA #4 said Resident #1 was yelling that CNA #1 had slapped him/her. During an interview on 12/20/23 at 3:59 P.M., Unit Manager #1 said she heard Resident #1 screaming in the elevator and was surrounded by staff trying to calm him/her down when he/she returned to the unit. Unit Manager #1 said Resident #2 came to her and said, it really happened, he (CNA #1) slapped him/her (Resident #1). During an interview on 12/20/23 at 3:41 P.M., the Director of Nurses (DON) said she was not in the Facility at the time the allegation was made and said the Administrator conducted the investigation. The DON said the allegation could have been a reasonable suspicion of a crime. The DON said she called Resident #1's guardian and asked if he would like the Police to be involved and he (Resident #1's guardian) declined, so she did not notify them. The DON said she called the Police at the time of the survey (12/20/23). During an interview on 12/20/23 at 4:12 P.M., the Administrator said he looked at surveillance camera video footage immediately after the Director of Admissions notified him that there was a disruption in the basement. The Administrator said upon review of the footage, he saw CNA #1 pull Resident #1 out of the basement elevator in his/her wheelchair, and then saw CNA #1 put his fist up to Resident #1's temple. The Administrator said Resident #1 looked angry, and that CNA #1 kept putting his hands up near Resident #1. The Administrator said he substantiated the incident as physical abuse and that CNA #1 had been terminated. The Administrator said he had not called the Police because Resident #1 had not been injured. The Administrator also said Resident #1's guardian declined Police involvement, so he did not notify them.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had moderate cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that after being made aware on 12/06/23 of an allegation of physical and verbal abuse, that they obtained and maintained evidence that a thorough investigation was completed. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised February 2023, indicated the following: -The Supervisory personnel are responsible to ensure that the initial investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure resident safety or protect the resident from additional harm, -The interventions include, obtaining statements from witnesses of incidents, the outcome of the supervisory investigation, and timely notification of Administrative personnel regarding the incident to ensure that a comprehensive internal facility investigation is completed in a timely fashion, and - The Administrator shall assume the overall responsibility to ensure that incident reports are completed accurately, and personnel statements are obtained timely to ensure completion of the internal facility investigation. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 12/06/23, indicated that on 12/06/23 staff witnessed an altercation between a staff member (later identified as CNA #1) and resident (later identified as Resident #1) where Resident #1 was being redirected out of the elevator when he/she became agitated and CNA #1 pulled his/her wheelchair back and put his hand on the side of Resident #1's head. Review of the Facility's Investigation Report, undated, indicated that on 12/06/23 residents were accompanied by staff in the basement level of the Facility when Resident #1 attempted to get on the elevator in his/her wheelchair without staff. The Report indicated that another resident's (later identified as Resident #2) Written Witness Statement indicated that CNA #1 pulled Resident #1 out of the elevator and as he was turning him/her (Resident #1) around, he (CNA #1) hit Resident #1 on the side of the head. The Report indicated that Resident #1 was angry and yelled at CNA #1 which immediately drew the attention of other staff members who were in the basement level. The Report indicated CNA #1 was suspended immediately and then terminated on 12/07/23 for this incident. Resident #1 was admitted to the Facility in March 2020, diagnoses included dementia with behavioral disturbances and right sided hemiparesis (weakness) and hemiplegia (paralysis). Review of Resident #1's Quarterly Minimum Set Data (MDS) Assessment, dated 12/08/23, indicated Resident #1 had moderate cognitive impairment. Review of the Facility's Investigation File indicated there was no documentation to support that Resident #1 had been interviewed immediately after the incident about what happened, and/or asked to provide a Written Witness Statement. The File indicated there was no documentation to support other residents on CNA #1's schedule that day had been interviewed. to determine if any other residents had concerns about care or treatment provided by CNA #1. Further review of the Investigation File indicated that although the Facility's Investigation included Statements/Interviews from CNA #1, CNA #2, Resident #2, and the Director of Admissions, there were no statement from another staff member (Housekeeping Staff #1) who was seen in the video footage near the elevator at the time of the incident, or from CNA #3 and CNA #4, identified by the Surveyor upon staff interviews, to have been present and witnessed the verbal altercation. Review of Resident #1's Medical Record indicated that he/she had been assessed by the Director of Social Services and Unit Manager #1 after the altercation, but there was no documenation to support Resident #1 had been interviewed by either staff member about what happened during the incident. During an in person interview on 12/20/23 at 12:46 P.M., and a telephone interview on 12/22/23 at 9:39 A.M., the Director of Social Services said he talked to Resident #1 approximately one hour after the incident occurred and that he had seen the video surveillance footage. The Director of Social Services said the purpose of his visit with Resident #1 was not to obtain a statement or an interview, but to make sure Resident #1 was okay The Director of Social Services said he had not been asked to get a statement or interview from Resident #1, and said that he did not think any other staff member had been asked either. During an interview on 12/20/23 at 3:41 P.M., the Director of Nurses (DON) said she was not in the Facility at the time the allegation involving Resident #1 was made and said the Administrator conducted the investigation. The DON said she was not sure who interviewed Resident #1, but said the Director of Social Services offered support after the allegation was made. The DON said other residents that had been on CNA #1's schedule had not been interviewed. When asked by the Surveyor if the Investigation File provided on the day of Survey (12/20/23) was the complete investigation, the DON said yes. During an in person interview on 12/20/23 at 4:12 P.M., and a telephone interview on 12/27/23 at 3:10 P.M., the Administrator said the Director of Social Services interviewed Resident #1. The Administrator said he did not interview any other residents that were on CNA #1's schedule that day and said no one else had either When asked by the Surveyor if the Investigation File provided on the day of Survey (12/20/23) was the complete investigation, the Administrator said yes.

Oct 2023 11 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the Resident's/Resident Representative's (RRs) choices for one Resident (#27), out of a total sample of 19 residents. Specifically, the facility failed to adequately assess Resident #27's acute change in condition and accurately monitor his/her food intake or fluid intake and fluid output when the Resident demonstrated frequent refusal of medications, had reduced food and fluid intake, had a history of constipation, and complained of abdominal pain, which resulted in rectal fecal impaction and hospitalization. Findings include: Review of the facility's policy titled, Change of Resident Condition, revised June 2020, included the following: -The purpose was to ensure timely communication of a resident's change in condition between nursing staff and the prescriber to better evaluate and manage residents in the facility and to thereby avoid transfer to an acute care setting. -The facility recognized that timely communication of a resident's change of condition to the prescriber (Physician [MD]/Nurse Practitioner [NP]) was essential to the initiation of therapeutic interventions. -The facility also recognized the important role filled by family, surrogate, and representatives in the care of each resident . -A change in condition was a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. -Clinically important meant a deviation, that without intervention, might result in complications . Review of the facility's policy titled, Intake and Output Policy, undated, indicated: -The Nursing personnel would keep an accurate record of a resident's fluid balance when the resident had a drainage collection device and/or per the Physician's order. -Fluid output includes all fluid that leaves a resident's body, including urine . -Whenever possible, output will be measured versus estimated. -A resident's fluid output was to be documented in the intake and output form. -The 11:00 P.M. through 7:00 A.M. (11-7) shift would total the intake of fluids for the previous 24-hour cycle and document in the 24-hour total intake space. -The Nurse was required to notify the Physician if any one of the following occurred: 1. A resident's fluid intake fell below 1000 milliliters (mls)/24 hours for a period of greater than 72 hours. 2. A resident's 24-hour fluid intake fell below 500 mls. Review of the facility's policy titled, Nutrition/Hydration Status Maintenance, undated, indicated: -The facility would provide nutrition/hydration status maintenance services in accordance to State and Federal Regulations. -Residents would be offered sufficient fluid intake to maintain proper hydration and health. -Residents would be offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet. Resident #27 was admitted to the facility in August 2023 with diagnoses including Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Oropharyngeal (the area of the throat behind the mouth and the tonsils) Phase Dysphagia (difficulty in swallowing food or liquid), and Muscle Weakness. Review of Resident #27's Nursing admission assessment dated [DATE], indicated the Resident: -had muscle weakness -was alert and confused -had fair appetite -difficulty swallowing. Further review of the Nursing admission Assessment indicated the Resident had an indwelling urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag). Review of Resident #27's Discharge Plan Care Plan initiated 8/23/23, indicated the Resident was to remain in the facility for long term care due to requiring 24-hour supervision and care. Review of Resident #27's Behavioral Symptom Care Plan initiated 8/23/23, indicated the Resident could be resistive to care and staff were to reiterate the purpose and advantages of treatment for the Resident. Review of Resident #27's Nutritional Status Care Plan initiated 8/24/23, indicated: -The Resident had a potential nutrition risk related to medical condition requiring a mechanically altered diet. -Staff were to monitor intakes and weights. -Registered Dietician (RD)/Speech Language Pathologist (SLP) screen (brief meeting with an individual to determine strengths and weakness through informal measures) and treat PRN (as the situation demands). Review of an RD Note dated 8/24/23, included the following: -House (a healthy meal plan that includes a variety of healthy foods from all the food groups), soft and bite-sized diet. Allow soft bread products and soft salad sandwiches. -Appetite was 75-100% -No supplements were in place. -The Resident and Health Care Proxy (HCP: someone designated to make choices about one's care if they are unable to make those decisions for themselves) were happy with the diet texture. -No interventions were required at that time. -Will monitor intakes, weights . Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #27 was severely cognitively impaired as evidenced by a score of five out of 15 possible points on the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment indicated the Resident had inattention and disorganized thinking, and required supervision and set-up for eating. Further review of Resident #27's active Comprehensive Care Plan dated 9/1/23, included: -The Resident had tooth decay and staff were to encourage enough fluid consumption to keep his/her mouth moist and provide diet as ordered. -The Resident had communication difficulties and staff were to allow him/her time to process information. -The Resident was unable to perform activities of daily living (ADLs) independently and required continuous supervision at a ratio of one staff to eight residents for eating. *ADLs could vary in the course of the day due to disease process of Parkinson's Disease with delusions (fixed, false conviction in something that is not real or shared by other people) and hallucinations (experience in which one sees, hears, feels, or smells something that does not exist). *Assess Resident and carry out ADLs as needed. *Evaluate Resident ability to perform ADLs. *Notify MD/NP, Rehab of any decline if noted. *Provide assistance as needed . -The Resident had an indwelling urinary catheter and preferred a leg drainage bag at all times. -The Resident's urinary catheter drainage system was to be assessed every shift and as needed. The amount, color, and odor of urinary output was to be recorded. Review of Resident #27's Speech Therapy Discharge summary dated [DATE], indicated the Resident was able to swallow thin consistency liquids from an open cup using compensatory strategies (techniques used to help an individual perform tasks in a manner to be more independent) from trained staff. Review of a Physician's order, dated 9/26/23, indicated: Downgrade (reduce) thin liquids to nectar liquid consistency until further evaluation is done. Review of Resident #27's clinical record included no evidence of a referral to the RD or SLP for further evaluation after the liquid downgrade was ordered. On 9/29/23 from 8:58 A.M. through 9:11 A.M., the surveyor observed the following: -Resident #27 was lying in bed with the head of the bed slightly elevated. -The Resident's breakfast tray was placed on a rolling overbed table, to the left of the Resident's bed, beside the window. -All food and drink items on the tray were covered. Resident #27 pointed toward the breakfast tray and said he/she was hungry, continued to point at the breakfast tray and said, It's over there. -The surveyor observed the items on the tray included one full cup of juice, one full cup of coffee, one full cup of milk, one full covered bowl of cereal, and one covered plate of scrambled eggs and toast. -the surveyor did not observe any staff members enter the Resident's room to offer or assist with breakfast for the Resident. Review of Resident #27's fluid intake and output on the September 2023 Treatment Administration Record was as follows: -Intake was 600 mls and urine output was 700 mls on 9/29/23. Intake and output was not recorded for the 11:00 P.M. through 7:00 A.M. shift. -Intake was 840 mls and urine output was 400 mls on 9/30/23. Urine output was recorded as Medium on the 7:00 A.M. through 3:00 P.M. shift and the 11:00 P.M. through 7:00 A.M. shift. Review of a Nursing Progress Note, dated 10/1/23, indicated Resident #27's HCP expressed a noted decline in the Resident's eating and drinking to the Director of Nursing (DON) and that the HCP wanted to give the Resident thin liquids. Further review of the Nursing Progress Note indicated the DON explained the Resident's risk for aspiration/choking and Pneumonia to the HCP and that the NP would follow-up on this [sic]. On 10/3/23 between 8:40 A.M. and 8:53 A.M., the surveyor observed the following: -Resident #27 was lying in bed sleeping. -The Resident's breakfast tray was resting on a rolling overbed table to the Resident's left side, within reach of the Resident, and contained scrambled eggs, one piece of toast that was cut in half, one bowl of oatmeal, and one bowl of rice cereal. -There were four individual unopened coffee creamers on the tray and one plastic cup which was positioned upside down. There was no remnants of liquid in the cup. There was one covered metal mug on the tray that was full of thin consistency ice water. There were no other drinks on the tray and no staff were in the room assisting the Resident. During an interview on 10/3/23 at 8:46 A.M., outside the Resident's room with Nurse #2, she said that Resident #27's liquid consistency had recently been downgraded to nectar thick from thin due to difficulty swallowing. Nurse #2 said the Resident's HCP had been attempting to provide thin consistency water to the Resident over the previous week or so due to the HCP having concerns that the Resident was not drinking enough liquids since the downgrade to nectar thick, but she did not think the HCP had been in as yet that day. The surveyor, Nurse #2 and CNA #11 entered the Resident's room together and Nurse #2 said the Resident could not have thin liquids. Nurse #2 instructed CNA #11 to dump it and the CNA removed the metal mug from the tray, entered the bathroom and emptied the metal cup of ice water. -the surveyor did not observe any food or liquids being offered to the Resident during this time and CNA #11 removed Resident #27's tray from his/her room. During an interview on 10/3/23 at 11:30 A.M., Resident #27's HCP said he/she noticed the Resident had a recent decline in eating and drinking over the previous week, since the Resident's liquid consistency had been changed from thin to nectar thick. The HCP said he/she had concerns the Resident was not eating or drinking enough and that he/she would lose weight and become dehydrated. Resident #27's HCP also said the Resident had been refusing medications frequently, including medications used to treat symptoms of Parkinson's Disease and medications to regulate the Resident's bowels. On 10/4/23 between 12:10 P.M. and 12:26 P.M., the surveyor observed the following: -Resident #27 was lying in bed. His/her lunch tray was resting on a rolling overbed table that was positioned against the wall by the window, to the left of the Resident. -The meal tray contained one covered cup of thickened milk, one covered mug of water with a packet of unopened thickened coffee, one covered bowl with applesauce, and one covered plate that contained a stuffed pepper. -The Resident pointed toward the meal tray but did not vocalize out loud to the surveyor. When the surveyor asked the Resident if anyone had offered him/her lunch, the Resident shook his/her head, indicating no. When the surveyor asked if the Resident wanted lunch, he/she nodded his/her head, indicating yes. -At 12:26 P.M., CNA #7 entered Resident #27's room. CNA #7 spoke to the Resident's roommate, then approached Resident #27 and asked if he/she wanted to get up out of bed. Resident #27 said no, and CNA #7 left the room. -No staff were observed offering Resident #27 assistance with his/her meal during this time and the Resident's tray remained on the rolling overbed table against the wall by the window. Review of Resident #27's Meal Intake Monitoring Record for 10/4/23 indicated the Resident ate 76-100% of his/her lunch meal that day, despite the surveyor's observation that the meal tray was untouched. On 10/4/23 at 2:45 P.M., the surveyor observed Resident #27's HCP standing at the nurses station. The Resident's HCP said he/she was looking for a Nurse to assess the Resident and that the Resident was requesting to go to the hospital with complaints of feeling impacted (inability to evacuate large hard stool, most commonly found in the rectum). At this time, Nurse #7 came out of the office located behind the nurses station and introduced himself to the surveyor as the 3:00 P.M. to 11:00 P.M. shift Supervisor. Nurse #7 further said that he had a rapport with the HCP and walked down the hallway with him/her. Review of a Nursing Note dated 10/4/23, indicated Resident #27's indwelling urinary catheter was changed due to blockage. The Nursing Note did not include any information relative to the Resident having had abdominal pain, feeling impacted, or requesting to go to the hospital. During a telephone interview on 10/5/23 at 10:30 A.M., the NP said she was unavailable to come to the facility during the previous week, but she was available to the facility by phone. The NP said she returned to work onsite on 10/2/23 and was aware the Resident had been having trouble with his/her urinary catheter becoming blocked and had been refusing indwelling urinary catheter care and medications. The NP also said she was aware Resident #27's HCP requested to be able to provide the Resident with thin liquids, but was not aware that the Resident had reduced food and thickened fluid intake. The NP further said she was not aware that the Resident had expressed feeling impacted on 10/4/23 or that he/she had requested to go to the hospital. The NP said she had not assessed Resident #27's status that week as this was new information. She said she would want to obtain a urinalysis for the Resident to rule out a urinary tract infection (UTI) and that she needed to review the Resident's record and see the Resident in order to develop a clinical plan. Review of Resident #27's Meal Intake Monitoring Record for 10/5/23 indicated the Resident ate no lunch that day and the surveyor observed that the documentation was completed at 10:53 A.M., which was prior to the lunch meal being served. On 10/5/23 at 11:45 A.M., the surveyor observed Resident #27 seated in a wheelchair beside his/her bed and the Resident's HCP was present. The Resident did not respond to his/her HCP's verbal cues or physical touch. The Resident's head was positioned downward, his/her eyes were closed, and his/her mouth was open. The surveyor observed that the Resident's lips were dry, there was a light grey tint to the skin surrounding the Resident's lips, darkened grey circles around the Resident's eyes, and the Resident's face had a greyish hue. Resident #27's HCP talked to the Resident and touched the Resident on his/her arms and hands, but the Resident did not respond. During an interview at the time, Resident #27's HCP said the Resident had a scheduled outside appointment that afternoon and that transportation services were booked to pick the Resident up at 12:00 P.M. The Resident's HCP also said the Resident had not yet received a lunch even though the Resident was not going to be at the facility for lunch that day. The HCP said he/she did not know if the facility planned to send a lunch with Resident #27, so he/she brought some food from home for the Resident. The HCP then opened a container of yogurt and attempted to provide a spoonful to Resident #27, which fell from the Resident's mouth. The HCP then attempted to provide a drink of water from an open cup which also fell from the Resident's mouth. When the HCP made a second attempt, the Resident accepted and swallowed one spoon of yogurt and one sip of water provided by the HCP while the Resident was cued for the yogurt, water, and to swallow. The Resident's HCP told the Resident he/she needed to wake up so that he/she could talk with the Provider at the scheduled appointment that day, but the Resident did not respond. The HCP said he/she had helped the Resident get dressed that morning and that the Resident's clothes no longer fit as they were too big. The HCP also said she thought the Resident had lost weight and was afraid he/she may have been dehydrated. Resident #27's HCP also said he/she requested the Nurse to check the Resident's rectum for impaction the prior day (10/4/23) as the Resident expressed feeling impacted and requested hospital transfer, but the rectum assessment did not occur because when the Nurse assessed the Resident, the Resident's indwelling urinary catheter was blocked and the drainage bag was empty, so the urinary catheter was changed. The HCP said when the catheter was changed, a large amount of urine flow occurred and the Resident's abdominal pain decreased. The HCP said the Resident's rectum was not assessed for impaction. The HCP then told the surveyor the Resident's community Physician was located in the same building where the Resident was scheduled for an appointment that afternoon, and he/she was hoping that the Physician could assess the Resident. On 10/5/23 at 11:55 A.M., the surveyor observed CNA #7 remove Resident #27's lunch meal tray from the meal cart. When the surveyor asked whether the Resident had been provided lunch as yet that day, CNA #7 said no, pointed to the tray on top of the cart, and said that the tray was Resident #27's lunch meal. CNA #7 said he was going to bring the meal to the Resident at that time. When the surveyor asked why the Resident's Meal Intake Monitoring Record was already completed for the lunch meal, CNA #7 said it should not have been. CNA #7 also said Resident #27 did not eat lunch the previous day, on 10/4/23, so it should not have been recorded as 76-100% consumed on the Meal Intake Monitoring Record. During an interview on 10/5/23 at 12:45 P.M., Nurse #9 said she worked through a staffing agency and that this was the first time she worked on the Unit and was assigned to Resident #27. Nurse #9 said she could not provide an accurate assessment of Resident #27's baseline status because it was the first time she had seen the Resident and had nothing to compare it to, but that the Resident was very sleepy when she went in to provide his/her medications. Nurse #9 also said she did not know the facility's policy for monitoring fluid intake and output (I & O) for Residents on I & O monitoring. Review of the clinical record included a photograph of Resident #27 taken on admission to the facility. The Resident's eyes were slightly sunken and his/her mouth was open in the photograph, but the surveyor did not observe any grey tint to the skin surrounding the Resident's lips, no darkened grey circles around the Resident's eyes, and the Resident had no grey hue to his/her face. During an interview on 10/5/23 at 12:50 P.M., with Nurse #5 (who was covering for the Unit Manager), she said that when a resident had an outside appointment during meal time, the facility was supposed to provide an early meal for the resident. Nurse #5 said Resident #27 left the facility for a scheduled appointment at 12:00 P.M. that day, that she checked on him/her prior to leaving and saw a lunch tray in the room. Nurse #5 said she did not know if the Resident had an opportunity to eat lunch, but she did see the Resident's HCP attempting to feed him/her some yogurt. When the surveyor asked whether five minutes was an adequate amount of time for Resident #27 to eat lunch prior to leaving for his/her appointment, Nurse #5 said she did not know why the Resident did not receive an early lunch tray. Nurse #5 also said that the Resident experienced a recent decline in ability to swallow, so she contacted the NP to obtain an order to downgrade the Resident's liquid consistency from thin to nectar thick. Nurse #5 further said Resident #27 required someone to sit and talk with him/her, and take their time when providing food and fluids. During a telephone interview on 10/5/23 at 2:52 P.M., the RD said if a resident had a change in nutrition, including eating or drinking, she would expect to be notified so she could assess the change. The RD said she was in the facility on 10/4/23, but was not asked to see Resident #27. The RD said that the fact that Resident #27 had a recent downgrade in liquid consistency and had reduced food and fluid intake would be cause for her to have assessed him/her. The RD further said if she had been made aware of Resident #27's status, she would absolutely have seen him/her. Review of Resident #27's fluid intake and output on the October 2023 Treatment Administration Record was as follows: -Intake was 790 mls and urine output was 790 mls on 10/1/23. Urine output measurement for the 7:00 A.M. through 3:00 P.M. shift was indicated as Not administered: Refused. -Intake was 280 mls and urine output was 700 mls on 10/2/23. Urine output measurement for the 7:00 A.M. through 3:00 P.M. shift was indicated as Not administered: Refused. -Intake was 720 mls and urine output was indicated as Medium on the 7:00 A.M. through 3:00 P.M. shift and Large on the 3:00 P.M. through 11:00 P.M. shift on 10/3/23. Urine output on the 11:00 P.M. through 7:00 A.M. shift was not recorded. -Intake was 940 mls and urine output was 500 mls combined from the 7:00 A.M. through 3:00 P.M. and 3:00 P.M. and 11:00 P.M. shift on 10/4/23. Urine output on the 11:00 P.M. through 7:00 A.M. shift was recorded as Medium. -No entry for fluid intake or urine output was recorded for 10/5/23. On 10/5/23 at 4:55 P.M., the surveyor observed the NP seated at the nurses station. During an interview at this time, the NP said she had planned to see Resident #27, but the Resident had not returned to the facility since he/she left for an appointment. During an interview on 10/5/23 at 5:00 P.M., the DON said Resident #27 had been transferred to the hospital Emergency Department (ED) directly from his/her appointment due to the Resident being under-responsive while at the appointment. Review of the hospital ED Note dated 10/5/23, indicated: -Resident #27 presented to the ED with abdominal pain and question of worsening mental status. -The Resident was provided with one liter of intravenous (IV- administered directly into a vein) fluids, Sinemet (medication used to treat symptoms of Parkinson's Disease) that was dissolvable under the tongue as the Resident was not swallowing well, and Zosyn (antibiotic medication used to treat infection). -A computed tomography (CT- computerized x-ray imaging procedure) scan was completed, notable for Stercoral Colitis (rare and severe condition where feces causes blockages within the colon) with possible rectal Pneumatosis (gas found within the wall of the bowel) and inflammatory changes around the bladder consistent with cystitis (inflammation of the bladder). -Per general surgery, air was more likely surrounding stool, and rectal enemas (technique used to stimulate stool evacuation, usually to relieve constipation) and by mouth bowel regimen was recommeded. -Manual disimpaction (removal of stool from the rectum using a gloved finger or retractor. Procedure performed when a person is unable to pass stools due to severe constipation or fecal impaction) was performed in the ED. -Plan was to admit the Resident to the hospital for further bowel regimen management. During an interview on 10/6/23 at 8:24 A.M., Nurse #7 said he spoke with Resident #27's HCP on 10/4/23 and that the HCP was concerned about whether the Resident had been moving his/her bowels as the Resident was complaining of impaction. Nurse #7 said he reported this to Nurse #5 who was assigned to care for Resident #27 at that time. During an interview on 10/6/23 at 8:38 A.M., Nurse #5 said prior to 10/4/23, earlier in the week, Resident #27's HCP questioned whether the Resident had been moving his/her bowels. Nurse #5 said she reviewed the Resident's bowel records which did not indicate a three-day period of no bowel movements, and she also assessed the Resident for bowel sounds, which were present, and abdominal distention, which was not present. Nurse #5 said when the Resident reported feeling impacted on 10/4/23, she assessed the Resident and found that the Resident's urinary catheter collection bag was empty and his/her catheter was blocked. Nurse #5 said she was unable to flush the catheter, so she had to change it. Nurse #5 said once the catheter was changed and urine flow occurred, the Resident's discomfort decreased. Nurse #5 said she assessed the Resident's bowel sounds, which were present, and abdominal distension, which was not present, then offered the Resident an as needed (PRN) dose of Milk of Magnesia, but the Resident refused. Nurse #5 did not say whether she checked the Resident's rectum for fecal impaction. At this time, the surveyor and Nurse #5 reviewed the facility's policy relative to I & O and also reviewed Resident #27's I & O monitoring on the September 2023 and October 2023 Treatment Administration Records (TARs). Nurse #5 said recording fluid intake and urine output on the TAR was the facility's process for accurately monitoring a Resident's fluid I & O. She said that upon review of Resident #27's I & O monitoring and the facility's policy, the NP should have been notified of the Resident's reduced fluid intake, but she could not speak to what the NP knew[sic]. During an interview on 10/6/23 at 9:30 A.M., the Administrator said the facility did not have an SLP as of 9/21/23. During a telephone interview on 10/6/23 at 9:48 A.M., Resident #27's HCP said that at the Resident's baseline, he/she fed him/herself. The HCP said at times the Resident would not want to taste his/her meal, but if a taste of the meal was provided for him/her, he/she would then eat the whole meal. Resident #27's HCP said the Resident responded best to gentle talking and entering his/her reality when talking with him/her to engage the Resident in daily activities. Resident #27's HCP said the Resident was unable to respond to the Provider during his/her appointment on 10/5/23, so the Resident's community Physician was contacted by the Provider to assess the Resident at that time. Resident #27's HCP said the community Physician assessed the Resident and sent him/her to the hospital ED via ambulance. The HCP said the Resident was assessed at the hospital ED and was provided with one liter of IV fluids, a half-dose of antibiotic, and medication to treat symptoms of Parkinson's Disease that dissolved under his/her tongue. The HCP also said when the Resident was assessed at the ED, he/she was diagnosed with fecal impaction and ED staff manually disimpacted the Resident. Resident #27's HCP said he/she left the ED around midnight, and by that time the Resident had been admitted to the hospital for further assessment and was waiting in the ED for an inpatient bed. The HCP said when he/she left the hospital, Resident #27's mental status had improved, his/her eyes were open, and he/she was asking to drink liquids. During an interview on 10/6/23 at 11:09 A.M., the DON said CNAs and Nurses documented resident fluid intake, and that if a resident was on I & O monitoring, the Nurses were responsible to total all fluid intake for their shift and document it on the resident's Treatment Administration Record. The DON said the TAR would indicate all the fluids the resident received on that shift. The surveyor and the DON reviewed Resident #27's fluid intake recorded on the TAR from 9/29/23 through 10/5/23, as listed above. The DON also reviewed the Resident's food intake for 9/29/23 through 10/5/23 with the surveyor with the following findings: -Of 20 meals provided during that timeframe (9/29/23 through 10/5/23), six meals had no record of monitoring. -The lunch meal on 10/4/23 was recorded as the Resident having consumed 76-100% when the Resident did not eat any of the meal. -Record of the lunch meal for 10/5/23 was also reviewed as it indicated the Resident ate no lunch, the documentation was completed prior to the lunch meal being provided. When asked how Resident #27's food and fluid intake and urine output could be accurately assessed based on the facility's system for monitoring, the DON said the Nurses and CNAs needed to communicate more clearly about documenting fluid intake and if a resident's fluid intake fell below the amount stated in the facility policy, the Physician/NP should be notified as required. The DON also said food intake is supposed to be monitored for each meal and documented by the CNAs. The DON said accurately completing the Meal Intake Monitoring Record and Treatment Administration Record were the facility's means for tracking nutrition and hydration. Please Refer to F692.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed, and interviews, the facility failed to provide necessary nutrition and hydration treatment, services, assessment and monitoring for one Resident (#27) out of a total sample of 19 residents. Specifically, the facility failed to: Provide necessary treatment and services to promote food and fluid consumption, and accurately monitor food and fluid intake for Resident #27 when the Resident was identified as having potential nutrition and swallowing problems. The facility also failed to assess and manage changes in the Resident's functional status pertaining to eating and drinking and an unidentified rectal fecal impaction (inability to evacuate large hard stool, most commonly found in the rectum), and provide required assistance from facility staff to eat and drink. Findings include: Review of the facility's policy titled, Intake and Output (I & O) Policy, undated, indicated: -The Nursing personnel would keep an accurate record of a resident's fluid balance when the resident had a drainage collection device and/or per the Physician's order. -Nursing personnel under the following circumstances and/or per the physician's order will keep an accurate record of a resident's fluid balance: On admission for 72 hours (3 days). -Fluid output includes all fluid that leaves a resident's body, including urine . -Whenever possible, output will be measured versus estimated. -A resident's fluid output was to be documented in the intake and output form. -The 11:00 P.M. through 7:00 A.M. (11-7) shift would total the intake of fluids for the previous 24-hour cycle and document in the 24-hour total intake space. -The Nurse was required to notify the Physician if any one of the following occurred: >1. A resident's fluid intake fell below 1000 mls (milliliters)/24 hours for a period of greater than 72 hours. >2. A resident's 24-hour fluid intake fell below 500 mls. Review of the facility's policy titled, Nutrition/Hydration Status Maintenance, undated, indicated: -The facility would provide nutrition/hydration status maintenance services in accordance to State and Federal Regulations. -Residents would be offered sufficient fluid intake to maintain proper hydration and health. -Residents would be offered a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet. 1. Resident #27 was admitted to the facility in August 2023 with diagnoses including Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Oropharyngeal (the area of the throat behind the mouth and the tonsils) Phase Dysphagia (difficulty in swallowing food or liquid), and Muscle Weakness. Review of Resident #27's Nursing admission assessment dated [DATE], indicated the Resident had muscle weakness, was alert and confused, had fair appetite and difficulty swallowing. Review of Resident #27's Discharge Plan Care Plan initiated 8/23/23 indicated the Resident was to remain in the facility for long term care due to requiring 24-hour supervision and care. Review of Resident #27's Behavioral Symptom Care Plan, initiated 8/23/23, indicated: - The Resident could be resistive to care . - Staff were to reiterate the purpose and advantages of treatment for the Resident. Review of Resident #27's Nutritional Status Care Plan, initiated 8/24/23, indicated: -The Resident had a potential nutrition risk related to medical condition requiring a mechanically altered diet. -Staff were to monitor intakes and weights. -Registered Dietician (RD)/Speech Language Pathologist (SLP) screen (brief meeting with an individual to determine strengths and weakness through informal measures) and treat PRN (as the situation demands). Review of an RD Note, dated 8/24/23, included the following: -House (a healthy meal plan that includes a variety of healthy foods from all the food groups), soft and bite-sized diet. Allow soft bread products and soft salad sandwiches. -Appetite was 75-100% -No supplements were in place. -The Resident was independent after set-up for feeding. -The Resident and Health Care Proxy (HCP-someone designated to make choices about one's care if they were unable to make those decisions) were happy with the diet texture. -No interventions were required at that time. -Will monitor intakes, weights . Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #27 was severely cognitively impaired as evidenced by a score of five out of 15 possible points on the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment indicated the Resident had inattention and disorganized thinking, and required supervision and set-up for eating. Further review of Resident #27's active Comprehensive Care Plan, dated 9/1/23, included: -The Resident had tooth decay and staff were to encourage enough fluid consumption to keep his/her mouth moist and provide diet as ordered. -The Resident had communication difficulties and staff were to allow him/her time to process information. -The Resident was unable to perform activities of daily living (ADLs) independently and required continuous supervision at a ratio of one staff to eight residents for eating. >ADLs could vary in the course of the day due to disease process of Parkinson's Disease with delusions (fixed, false conviction in something that is not real or shared by other people) and hallucinations (experience in which one sees, hears, feels, or smells something that does not exist). >Assess Resident and carry out ADLs as needed. >Evaluate Resident ability to perform ADLs. >Notify MD/NP, Rehab of any decline if noted. >Provide assistance as needed . Review of Resident #27's Speech Therapy Discharge summary dated [DATE], indicated the Resident was able to swallow thin consistency liquids from an open cup using compensatory strategies (techniques used to help and individual perform tasks in a manner to be more independent) from trained staff. Review of a Physician's order dated 9/26/23, indicated: Downgrade (reduce) thin liquids to nectar liquid consistency until further evaluation is done. Review of Resident #27's clinical record included no evidence of a referral to the RD or SLP for further evaluation after the liquid downgrade was ordered. On 9/29/23 from 8:58 A.M. through 9:11 A.M., the surveyor observed the following: -Resident #27 was lying in bed with the head of the bed slightly elevated. -The Resident's covered breakfast tray was sitting on a rolling overbed table, to the left of the Resident's bed, beside the window. -Resident #27 pointed toward the breakfast tray and said he/she was hungry, pointed at the breakfast tray and said, It's over there. -The surveyor observed the items on the tray included one full cup of juice, one full cup of coffee, one full cup of milk, one full covered bowl of cereal, and one covered plate of scrambled eggs and toast. -The surveyor did not observe any staff entering the Resident's room to offer breakfast to the Resident or assist him/her with breakfast. Review of a Nursing Progress Note, dated 10/1/23, indicated that Resident #27's HCP expressed a noted decline in the Resident's eating and drinking to the Director of Nursing (DON) and that the HCP wanted to give the Resident thin liquids. Further review of the Nursing Progress Note indicated the DON explained the Resident's risk for aspiration/choking and Pneumonia to the HCP and that the NP would follow-up on this [sic]. On 10/3/23 between 8:40 A.M. and 8:53 A.M., the surveyor observed the following: -Resident #27 was lying in bed sleeping. -The Resident's breakfast tray was resting on a rolling overbed table to the Resident's left side, within reach of the Resident, and contained scrambled eggs, one piece of toast that was cut in half, one bowl of oatmeal, and one bowl of rice cereal. There were four individual unopened coffee creamers on the tray and one plastic cup which was positioned upside down. The surveyor did not observe any remnants of liquid in the cup. There was one covered metal mug on the tray that was full of thin consistency ice water. There were no other drinks on the tray. -The surveyor did not observe any staff in the room assisting the Resident. During an interview on 10/3/23 at 8:46 A.M. outside the Resident's room, Nurse #2 said Resident #27's liquid consistency had recently been downgraded to nectar thick from thin due to difficulty swallowing. Nurse #2 said the Resident's HCP had been attempting to provide thin consistency water to the Resident over the previous week or so due to the HCP having concerns that the Resident was not drinking enough liquids since the downgrade to nectar thick. The surveyor, Nurse #2 and CNA #11 entered the Resident's room, and Nurse #2 further said the Resident could not have thin liquids and instructed CNA #11 to dump it. The CNA then removed the metal mug from the tray, entered the bathroom, and emptied the metal cup of ice water. The surveyor did not observe any food or liquids being offered to the Resident during this time, and CNA #11 removed Resident #27's tray from his/her room. During an interview on 10/3/23 at 11:30 A.M., Resident #27's HCP said he/she noticed the Resident had a recent decline in eating and drinking over the previous week, since the Resident's liquid consistency had been changed from thin to nectar thick. The HCP said he/she had concerns the Resident was not eating and drinking enough and that he/she would lose weight and become dehydrated. Resident #27's HCP also said the Resident had been refusing medications frequently, including medications used to treat symptoms of Parkinson's Disease and medications to regulate the Resident's bowels. On 10/4/23 between 12:10 P.M. and 12:26 P.M., the surveyor observed the following: -Resident #27 was lying in bed. His/her lunch tray was resting on a rolling overbed bedside table that was positioned against the wall by the window, to the left of the Resident. -The surveyor observed that the meal tray contained one covered cup of thickened milk, one covered mug of water with a packet of unopened thickened coffee, one covered bowl with applesauce, and one covered plate that contained a stuffed pepper. -The Resident pointed toward the meal tray but did not vocalize out loud to the surveyor. When the surveyor asked the Resident if anyone had offered him/her lunch, the Resident shook his/her head, indicating no. When asked if the Resident wanted lunch, he/she nodded his/her head, indicating yes. -At 12:26 P.M., CNA #7 entered Resident #27's room. CNA #7 spoke to the Resident's roommate, then approached Resident #27 and asked if he/she wanted to get out of bed. Resident #27 said no and pointed at the overhead light in the room. CNA #7 asked the Resident if he/she wanted the light on, turned the light on, and left the room. -The surveyor did not observe any staff offering Resident #27 assistance with his/her meal during this time, and the Resident's tray remained on the rolling overbed beside table against the wall by the window, to the left of the Resident. Review of Resident #27's Meal Intake Monitoring Record for 10/4/23 indicated the Resident ate 76-100% of his/her lunch meal that day, when the surveyor's observation was the lunch tray was left in the room and no staff assisted the Resident with eating. During a telephone interview on 10/5/23 at 10:30 A.M., the Nurse Practitioner (NP) said she was available to the facility by phone. The NP said she was aware Resident #27's HCP requested to be able to provide the Resident with thin liquids, but was not aware that the Resident had reduced food and thickened fluid intake. The NP said she had not assessed Resident #27's status that week as this was new information and that she would need to review the Resident's record and see the Resident in order to develop a clinical plan. Review of Resident #27's Meal Intake Monitoring Record for 10/5/23 indicated the Resident ate no lunch that day and the Meal Intake Monitoring Record was completed at 10:53 A.M., which was prior to the lunch meal being served to the Resident. On 10/5/23 at 11:45 A.M., the surveyor observed Resident #27 seated in a wheelchair beside his/her bed and the Resident's HCP was present and providing care to the Resident. Resident #27's HCP talked to the Resident and touched the Resident on his/her arms and hands, but the Resident did not respond. During an interview at the time, Resident #27's HCP told the surveyor the Resident had a scheduled outside appointment that afternoon and that transportation services were booked to pick the Resident up at 12:00 P.M. The Resident's HCP stated concern that the Resident had not yet received lunch since he/she would not be at the facility for the lunch meal. The HCP further said he/she did not know if the facility planned to send a lunch with Resident #27, so he/she brought some food from home for the Resident. The HCP then attempted to provide a spoonful of yogurt to Resident #27 which fell from the Resident's mouth. The HCP also attempted to provide a drink of water from an open cup, which also fell from the Resident's mouth. During a second attempt, the Resident accepted and swallowed one spoon of yogurt and one sip of water provided by the HCP while the HCP cued the Resident to swallow for the yogurt and water. Resident #27's HCP was observed encouraging the Resident to wake up so that he/she could talk with the Provider at the scheduled appointment later that day, but the Resident did not respond. The HCP said he/she had helped the Resident to get dressed that morning and that the Resident's clothes no longer fit and were too big on him/her. The HCP also said she thought the Resident had lost weight and was afraid he/she may have been dehydrated. Resident #27's HCP also said that he/she requested the Nurse to check the Resident's rectum for impaction on 10/4/23, as the Resident expressed feeling impacted and requested hospital transfer, but checking the rectum as requested did not occur. The HCP then told the surveyor the Resident's community Physician was located in the same building where the Resident was scheduled for an appointment that afternoon and he/she was hoping that the Physician could assess the Resident. On 10/5/23 at 11:55 A.M., the surveyor observed CNA #7 remove Resident #27's lunch meal tray from the meal cart. When asked whether the Resident had been provided lunch as yet that day, CNA #7 said no, pointed to the tray on top of the cart, and said that the tray was Resident #27's lunch meal. CNA #7 said he was going to bring the meal to the Resident at that time. When the surveyor asked why the Resident's Meal Intake Monitoring Record was already completed for the lunch meal currently being served, CNA #7 said it should not have been. CNA #7 also said Resident #27 did not eat lunch the previous day on 10/4/23, so it should not have been recorded as 76-100% consumed on the Meal Intake Monitoring Record. During an interview on 10/5/23 at 12:45 P.M., with Nurse #9 who was assigned to Resident #27, she said she worked through a staffing agency and that this was the first time she worked on the Unit. Nurse #9 said she could not provide an accurate assessment of Resident #27's baseline status because it was the first time she had seen the Resident and had nothing to compare it to, but that the Resident was very sleepy when she went in to provide his/her medications. Nurse #9 also said she did not know the facility's policy for monitoring fluid intake and output (I & O) for Resident's on I & O monitoring or where the policy could be located. During an interview on 10/5/23 at 12:50 P.M., Nurse #5 (who was covering for the Unit Manager [UM]) said that when a resident had an outside appointment during meal time, the facility was supposed to provide an early meal for the resident. Nurse #5 said Resident #27 left the facility for a scheduled appointment at 12:00 P.M. that day, that she checked on him/her prior to leaving and saw a lunch tray in the room. Nurse #5 said she did not know if the Resident had an opportunity to eat lunch, but she did see the Resident's HCP feeding him/her some yogurt. When the surveyor asked whether five minutes was an adequate amount of time for Resident #27 to eat lunch prior to leaving for his/her appointment, Nurse #5 said she did not know why the Resident did not receve an early lunch tray. Nurse #5 also said that the Resident experienced a recent decline in ability to swallow, so she had contacted the NP and obtained an order for his/her liquid consistency to be downgraded from thin to nectar thick. Nurse #5 further said Resident #27 required someone to sit and talk with him/her, and take their time when providing food and fluids. During a telephone interview on 10/5/23 at 2:52 P.M., the RD said if a resident had a change in nutrition, including eating or drinking, she would expect to be notified so she could assess the change. The RD said she was in the facility on 10/4/23, but was not asked to see Resident #27. The RD said that the fact that Resident #27 had a recent downgrade in liquid consistency and had reduced food and fluid intake would be cause for her to have assessed him/her (reason for a RD referral). The RD further said if she had been made aware of Resident #27's status, she would absolutely have seen him/her. During an interview on 10/6/23 at 9:30 A.M., the Administrator said the facility did not have an SLP as of 9/21/23. During an interview on 10/5/23 at 5:00 P.M., the DON said Resident #27 had been transferred to the hospital Emergency Department (ED) directly from his/her appointment due to the Resident being under-responsive while at the appointment. Review of the hospital ED Note, dated 10/5/23, indicated Resident #27 presented to the ED with abdominal pain and question of worsening mental status. The Resident was provided with one liter of intravenous (IV: administered directly into a vein) fluid, Sinemet (medication used to treat symptoms of Parkinson's Disease) that was dissolvable as the Resident was not swallowing well, and Zosyn (antibiotic medication used to treat infection). A computed tomography (CT - computerized x-ray imaging procedure) scan was completed, notable for Stercoral Colitis (rare and severe condition where feces causes blockages within the colon) with possible rectal Pneumatosis (gas found within the wall of the bowel). Manual disimpaction (removal of stool from the rectum using a gloved finger that is used when a person is unable to pass stools due to severe constipation or fecal impaction) was performed in the ED and the plan was to admit the Resident to the hospital for further bowel regimen management. During an interview on 10/6/23 at 8:38 A.M., Nurse #5 said prior to 10/4/23, earlier in the week, Resident #27's HCP questioned whether the Resident had been moving his/her bowels. Nurse #5 said she reviewed the Resident's bowel records which did not indicate a three-day period of no bowel movements, and she also assessed the Resident for bowel sounds, which were present, and abdominal distention, which was not present. Nurse #5 said when the Resident reported feeling impacted on 10/4/23, she again assessed the Resident for bowel sounds, which were present, and abdominal distension, which was not present. Nurse #5 said she offered an as needed (PRN) dose of Milk of Magnesia (medication that reduces stomach acid, and increases water in the intestines which may induce bowel movements), but the Resident refused. Nurse #5 did not say she checked the Resident's rectum for fecal impaction. At this time, the surveyor and Nurse #5 reviewed the facility's policy relative to I & O and also reviewed the Resident #27's I & O monitoring on the September 2023 and October 2023 Treatment Administration Record (TAR). Nurse #5 said recording fluid intake on the TAR was the facility's process for accurately monitoring a Resident's fluid I & O. She said that upon review of Resident #27's I & O monitoring and the facility's policy, the NP should have been notified of the Resident's reduced fluid intake, but she coud not speak to what the NP knew. During a telephone interview on 10/6/23 at 9:48 A.M., Resident #27's HCP said that at the Resident's baseline, he/she fed him/herself. The HCP said at times the Resident would not want to taste his/her meal, but if a taste of the meal was provided for him/her, he/she would then eat the whole meal. Resident #27's HCP said the Resident responded best to gentle talking and entering his/her reality when talking with him/her to engage the Resident in daily activities. Resident #27's HCP said the Resident was unable to respond to the Provider during his/her appointment on 10/5/23, so the Provider contacted the Resident's community Physician to assess the Resident which resulted in the Resident being sent to the hospital ED via ambulance. The HCP said the Resident was assessed at the hospital ED and was provided with one liter of IV fluid, a half-dose of antibiotic, and medication dissolved under his/her tongue to treat symptoms of Parkinson's Disease. The HCP also said the Resident was identified as having fecal impaction and ED staff manually disimpacted the Resident. Resident #27's HCP said he/she left the ED around midnight, and by that time the Resident's mental status had improved, his/her eyes were open, and he/she was asking to drink liquids. During an interview on 10/6/23 at 11:09 A.M., the DON said CNAs and Nurses documented resident fluid intake, and that if a resident was on I & O monitoring, the Nurses were responsible to total all fluid intake for their shift and document it on the resident's TAR. The DON said the TAR would indicate all the fluids the resident received on that shift. The surveyor and the DON reviewed Resident #27's fluid intake recorded on the TAR from 9/29/23 through 10/5/23 with the following findings for the total 24-hr period: -600 milliliters (mls) on 9/29/23 -840 mls on 9/30/23 -790 mls on 10/1/23 -280 mls on 10/2/23 -720 mls on 10/3/23 -940 mls on 10/4/23 -No entry for fluid intake on 10/5/23 At this time, the surveyor and the DON reviewed food intake monitoring records for Resident #27 from 9/29/23 through 10/5/23 with the following findings: -Of 20 meals provided during that timeframe, six meals had no record of monitoring. -The lunch meal on 10/4/23 was recorded as the Resident having consumed 76-100% when the Resident did not eat. -Record of the lunch meal for 10/5/23 was also reviewed as it indicated the Resident ate no lunch and was completed prior to the lunch meal being provided to the Resident. When the surveyor asked how Resident #27's food and fluid intake could be accurately assessed based on the facility's system for monitoring, the DON said the Nurses and CNAs needed to communicate more clearly about documenting fluid intake and if a resident's fluid intake fell below the amount stated in the facility policy, the Physician/NP should be notified as required. The DON also said food intake was supposed to be monitored for each meal and documented by the CNAs. The DON said accurately completing the Meal Intake Monitoring Record and Treatment Administration Record were the facility's means for tracking nutrition and hydration.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #14 was admitted to the facility in May 2011 with diagnoses including Schizoaffective Disorder (a mental health disorder that may include hallucinations or delusions and mood disorder symptoms, such as Depression or mania). Review of the Resident's clinical record showed evidence that MDS Assessments were completed on the following dates: -8/3/23 Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #14 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the clinical record indicated a Nursing Note on 9/12/23 that an IDT care plan meeting was held with a Nurse, Activities Director and Director of Social Services. The record further indicated that there was no evidence that the Resident and/or their Representative were invited to, or participated in the care plan meeting process. During an interview on 10/5/23 at 10:59 A.M., SW #1 provided evidence of care plan meetings for the last year. She said that the receptionist sends out notices to Residents and/or their Representatives but they do not keep copies of notices. She further said that they do keep copies of care plan schedules from which notices were sent. She said that the receptionist checks off each person that she sends notices to, then she sends notices out based on the care plan schedule. She said that she was unable to provide evidence on the schedule that Resident #14 had a notice sent. SW #1 said she would look for additional evidence of the notices but did not provide any by the end of the survey period. Based on records reviewed and interviews, the facility failed to develop, review, and revise comprehensive care plans with the interdisciplinary team (IDT) and include the participation of the Residents/Resident Representatives (RRs) for two Residents (#27 and #14), out of a total sample of 19 residents. Specifically, the facility failed to: 1. Develop and review Resident #27's comprehensive care plan with the Resident and/or RR's participation when the RR was available for participation. 2. Notify Resident #14 and his/her RR of a scheduled interdisciplinary care plan meeting that was held to review the Resident's comprehensive care plan, resulting in the care plan review occurring without the Resident and/or his/her Representative participation. Findings include: Review of the facility policy titled, Interdisciplinary Care Planning, undated, included the following: -The care planning schedules were developed by the case manager, social services, and nursing supervisors. -Family members were notified by phone or mail. -Meetings were held weekly depending on the resident's schedule. 1. Resident #27 was admitted to the facility in August 2023 with diagnoses including Parkinson's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a total of five points out of 15 possible points on the Brief Interview for Mental Status (BIMS), indicating the Resident was severely cognitively impaired. Review of Resident #27's clinical record included no evidence the Resident's comprehensive care plan was developed or reviewed with the IDT, to include the participation of the Resident/RR, as required. During an interview on 10/3/23 at 11:30 A.M., Resident #27's Representative said he/she visited the Resident at the facility daily, but had never been invited to develop or review the Resident's comprehensive care plan with the IDT since the Resident had been admitted to the facility. During an interview on 10/5/23 at 10:59 A.M., Social Worker (SW) #1 said there was no evidence Resident #27's comprehensive care plan was developed with the input of the Resident or RR after the Resident's comprehensive assessment was completed as required. SW #1 further said that a comprehensive care plan meeting should have been held and that the Resident and his/her Representative should have been invited to attend.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #51 was admitted to the facility in September 2021 with diagnoses including Hemiplegia (paralysis on one side of the body) and Hemiparesis (another name for hemiplegia) following unspecified Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left non-dominant side due to old cardiovascular accident (CVA- medical term for a stroke), unspecified convulsions (sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders), and generalized muscle weakness. Review of Resident #51's MDS assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a score of seven out of 15 total possible points on the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment indicated Resident #51 required extensive assist of one staff member for hygiene, which included groomimg. Review of Resident #51's ADL Care Plan, revised 9/7/23, indicated the Resident was unable to complete ADLs independently and was totally dependent on two staff for grooming. On 10/3/23 at 8:30 A.M., the surveyor observed Resident #51 seated in a wheelchair in the Day Room on Unit One. The Resident had facial hair, approximately one half to three quarters of an inch long on the sides of his/her face, across his/her chin, and over his/her top lip. On 10/4/23 at 8:15 A.M., the surveyor observed Resident #51 in his/her bed. The Resident still had facial hair approximately one half to three quarters of an inch long on the sides of his/her face, across his/her chin, and over his/her top lip. During an interview at the time, Resident #51 placed his/her right hand over the facial hair, rubbed it lightly and said he/she wanted it removed. The Resident said he/she meant to ask someone to remove it but he/she kept forgetting. Resident #51 then said, I really want it off. During an interview on 10/4/23 at 8:29 A.M., CNA #4 said residents were groomed (shaved) on their shower days, but if they needed to be shaved in between their shower days, staff were to offer to shave them. CNA #4 said she noticed Resident #51 did have a lot of facial hair, but that she had never offered to shave him/her, as required. During an interview on 10/4/23 at 8:43 A.M., CNA #6 said she began working at the facility a few weeks before and was familiar with Resident #51. CNA #6 said Resident #51 had never refused care when she has provided care for him/her and that the Resident was dependent on staff for ADL care. CNA #6 said the Resident did have a lot of facial hair, but she had never offered to remove it for the Resident, as required. Based on observations, interviews, records and policy review, the facility failed to ensure that two Residents (#51 and #54) out of a total sample of 19 residents, were provided timely activities of daily living (ADLs - Daily self-care activities like grooming, eating, dressing) assistance. Specifically, the facility staff failed to ensure: 1. For Resident #54, that timely assistance during meals and personal hygiene relative to nail care were provided. 2. For Resident #51, that timely assistance during meals and grooming assistance relative to facial hair were provided. Findings include: Review of the facility ADL/Maintain Abilities Policy, undated, indicated: -the facility will create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident, -and that the care and services provided are person-centered, and support each resident's preferences, choices, values and beliefs. The policy also included the following: -The facility will ensure a resident is given appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. -The facility would provide care and services for the following ADLs: hygiene (bathing, dressing, grooming, and oral care) . -A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 1. Resident #54 was admitted to the facility in March 2023 with diagnoses including severe Dementia with other behavioral disturbance, severe protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), Dysphagia (difficulty swallowing), Aphasia (difficulty with speech) and adult failure to thrive (state of decline that is multifactorial and include weight loss, poor nutrition and inactivity). Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #54: -had severe cognitive impairment as evidenced by staff assessment. -required extensive assistance of one staff with dressing and personal hygiene. -supervision with eating, and was on a mechanically altered diet (foods/fluids that are altered by blending, grinding, or chopping so they can be easily chewed/swallowed). Review of the ADL Care Plan initiated 3/15/23, and last reviewed/revised 9/14/23, indicated Resident #54 was unable to complete ADLs independently related to his/her Dementia, and included the following: -Provide assist of one to two staff/dependent for grooming. -Provide continual supervision/assist of one staff with eating. -ADLs can vary in the course of the day, provide additional support if Resident is noted with agitation/fatigue. Review of the Nutrition Care Plan initiated 6/15/23, and last reviewed/revised 9/22/23, indicated Resident #54 was at increased nutritional risk related to mechanically altered diet and low body weight. The plan included the following interventions: -Provide diet and supplements as ordered. -Provide fortified foods as ordered. -Monitor intake of food and fluids. -Assist with meal intake. Review of the Certified Nurse Aide (CNA) Profile Care Plan Approaches (information for the CNAs relative to specific resident needs) initiated 3/15/23, indicated that the Resident's ADLs can vary in the course of the day and for staff to provide additional support if he/she has agitation/fatigue. The Profile Care Plan Approaches also indicated the following: -Assist of one to two staff/dependent for grooming. -Continual supervision/assist of one staff with eating. Review of the September 2023 and October 2023 Physician's orders included the following, initiated on 3/15/23: -Regular Pureed Diet with Nectar thick liquids. -Fortified cereal at breakfast and fortified mashed potatoes at lunch and dinner. -House supplement with meals. On 9/29/23 at 9:54 A.M., the surveyor observed Resident #54 lying in bed, dressed in a hospital gown with a privacy curtain almost surrounding the bed. The Resident's eyes were open and he/she was looking up towards the ceiling. The surveyor observed a breakfast tray on top of the Resident's dresser, that was inaccessible to the Resident and was untouched (covered beverages/hot cereal). The Resident was thin in appearance and was non-verbal when the surveyor attempted to interview him/her. At 10:45 A.M., the surveyor observed Resident #54 in the same position, lying in bed. The breakfast tray was still positioned on the dresser in the same location, and remained covered and untouched. On 10/3/23 from 7:37 A.M. through 8:46 A.M., Resident #54 was observed lying in bed. -At 8:46 A.M., the surveyor observed the Resident's breakfast tray located on the meal cart and was untouched. During an interview at the time with CNA #2, she said Resident #54 sleeps late and breakfast items are taken off his/her tray and put into the room for when he/she wakes up. The surveyor observed a covered bowl, a covered cup of milk, and a covered cup of orange juice on the Resident's meal tray which was located on the meal cart. -At 8:51 A.M., the surveyor observed Resident #54 lying in bed with his/her eyes closed. A covered bowl, a clean spoon and an unopened container of whole milk were observed on the dresser in the Resident's room. -At 9:09 A.M., the food/beverage items remained in the same position within the Resident's room. -At 9:29 A.M., the surveyor observed CNA #4 in Resident #54's room assisting him/her with breakfast. During an interview at the time, CNA #4 said that she heated up the Resident's milk and bowl of hot cereal prior to assisting him/her with the meal. On 10/3/23 at 1:19 P.M., the surveyor observed Resident #54 ambulating near the nurses station. The Resident had dried food on his/her chin and his/her nails had dark material underneath them. On 10/4/23 from 8:17 A.M. through 8:52 A.M., the surveyor observed the following: - 8:17 A.M., the meal cart was brought to the hallway where Resident #54 resides. - 8:26 A.M., the surveyor observed tray pass begin from this meal cart. - 8:31 A.M. CNA #10 took two used cups from an overbed table in the hallway and put them on the meal cart where unpassed resident trays were located. - At 8:43 A.M., the surveyor observed Resident #54 lying in bed with his/her eyes open, and muttering unintelligibly. The surveyor did not observe a breakfast tray for the Resident in his/her room. The meal cart was observed to be located outside of the Resident's room and included Resident #54's untouched breakfast tray, which had not been passed. The tray had several covered items including a fortified cereal, 4 ounces (oz) of nectar thick orange juice, a container of magic cup ice cream and 4 oz of house supplement. The surveyor also observed several used (dirty) cups placed on the Resident's meal tray. During an observation and interview on 10/4/23 at 8:52 A.M., CNA #10 said that Resident #54 was a late sleeper and was offered breakfast when he/she wakes up. CNA #10 said that the Resident's breakfast tray should be saved in the unit kitchenette until he/she was awake. The surveyor and CNA #10 observed the meal cart which had Resident #54's untouched breakfast tray and also had several dirty cups on the tray. CNA #10 said that the dirty items should not have been placed there. CNA #10 removed the covered hot cereal, milk, and orange juice from the tray and said that she would put it in the kitchenette to be reheated for the Resident when he/she is awake. When the surveyor asked how the staff knew Resident #54 was ready to be assisted with breakfast, CNA #10 said that the Resident will have his/her eyes open when he/she was ready to be up and offered breakfast. The surveyor relayed the observation from 8:43 A.M., that Resident #54 was awake and making verbalizations. Shortly after the interview, the surveyor observed CNA #5 enter the Resident's room and close the door. On 10/4/23 at 9:28 A.M., the surveyor observed Resident #54 seated in stationary chair in the hallway, dressed, and with an overbed table placed in front of him/her. The Resident was thin appearing and had multiple cups containing liquids placed in front of him/her. The Resident's nails were observed to be jagged and still had dark material underneath. During an interview on 10/4/23 at 9:50 A.M., with CNA #5 who was caring for Resident #54, she said that she assisted the Resident with ADL care and with breakfast. She said that breakfast should be offered to the Resident when he/she was awake. CNA #5 further said the Resident is not receptive to feeding assistance at times but should be encouraged by staff to eat and drink. During a subsequent interview on 10/4/23 at 12:07 P.M., CNA #5 said that Resident #54 was dependent for all care related to dressing and grooming. She said that nail care should be provided twice daily, once in the morning and then at night. When asked about the Resident's nails, CNA #5 said that she did not provide nail care that morning. During an observation on 10/4/23 at 12:10 P.M., the surveyor observed Resident #54 ambulating near the nurses station. He/she was dressed and was observed to have the same dark colored matter under his/her nails. During an observation and interview on 10/4/23 at 12:40 P.M., Unit Manager (UM) #1 said she noticed that Resident #54's nails were very dirty and needed to be cleaned. When the surveyor asked about when nail care was provided, UM #1 said that it should be provided during morning and evening care. UM #1 said Resident #54 was dependent on staff for ADL care and was often awake by 8:00 A.M. but sometimes slept late. She said that if Resident #54 was awake when the breakfast meal was being served, he/she should be provided with care and have breakfast served to him/her. She further said if the Resident was sleeping, then the breakfast meal should be put in the unit kitchenette and reheated prior to serving when he/she awakens. UM #1 said that the Resident's food should not be left out for extended periods of time on his/her dresser or left in the room if he/she was not eating.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed, and interviews, the facility failed to provide two residents (#12 and #54) with an environment as free of accident hazards as possible. Specifically, the facility failed to: 1. Implement effective fall prevention interventions for Resident #12, to reduce the risk for fall related injuries when the Resident was identified as having a seizure disorder, abnormal gait, and a history of falling, and sustained frequent falls resulting in striking his/her head and sustaining upper extremity bruising and skin tears. 2. Ensure supervision was provided to minimize accidents/hazards related to falls, drinking fluids not ordered by the Physician, and potential resident to resident interactions for Resident #54. Findings include: Review of the facility's policy, titled Falls Accident/Accident Policy and Procedure, revised 2/24/22, included the following: -The purpose was to identify residents at high risk for falls and alteration in skin integrity and establish appropriate individualized interventions, and review all resident falls for causal factors in order to reduce the incidence and severity of resident falls. -The facility would provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents, including: identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s), and monitoring for effectiveness and modifying interventions when necessary. 1. Resident #12 was admitted to the facility in January 2019 with diagnoses including other Seizures, other abnormalities of Gait and Mobility, Dementia, Subdural Hygroma (accumulation of fluid in the area between the outermost and middle layer of the membranes that cover the brain), and frequent falls resulting in striking his/her head and sustaining upper extremity bruising and skin tears. Review of a Minimum Data Set (MDS) assessment, dated 8/1/23, indicated Resident #12 was severely cognitively impaired, as evidenced by a score of six out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment indicated the Resident required supervision of one staff member for transfers and walking. Review of Resident #12's active Fall Care Plan, last reviewed 10/1/23, indicated the following: -The Resident was at risk for falls due to the use of antidepressant medication and orthostatic hypotension (low blood pressure that happens when you stand up from sitting or lying down). -Safety signage in room to cue Resident to ask for assistance with transfers, initiated 8/26/23. Review of Resident Event Reports provided by the facility indicated Resident #12 sustained falls on the following dates: -6/24/23 without injury -7/21/23 without injury -8/9/23 where the Resident experienced a head strike Review of Resident #12's Fall Risk Assessment completed 8/7/23, indicated the Resident was at risk for falls as evidenced by a score of 15.0. Review of a Resident Event Report dated 8/26/23, indicated that Resident #12 sustained a fall at 12:00 A.M. while ambulating and the Resident was transferred to the hospital. Review of the Interdisciplinary Post Fall Evaluation, dated 8/26/23, indicated the following: -Resident #12 fell while ambulating to the bathroom independently, and the fall was unwitnessed by staff. -Safety devices at the time of the fall included call bell in place and low bed. -Conditions that may have contributed to the fall included unsteady gait, history of falls, and non-compliance. -The intervention recommendations included safety signage to ask for help. Review of the hospital Emergency Department (ED) Discharge Note dated 8/26/23, indicated: -The Resident's reason for visit was that the Resident fell from standing when he/she tried to get up to use the bathroom. -The Resident did not know if he/she hit his/her head. -The Resident sustained skin tears to his/her left forearm and an abrasion to his/her right posterior ribs with tenderness to palpation. -The Resident was found to have a subdural hygroma that was likely chronic. On 9/29/23 at 8:44 A.M., the surveyor observed Resident #12 in his/her room, seated on the edge of the bed. The Resident had a dark purple, slightly asymmetrical bruise to his/her left outer elbow and an uncovered, scabbed over asymmetrical skin impairment to the right outer forearm. There was no safety signage to ask for help observed anywhere in the Resident's room. During an interview at this time, Resident #12 said he/she was unsure how the bruise was sustained, but that he/she probably bumped it on something or fell. -Review of a Resident Event Report dated 10/2/23, indicated Resident #12 sustained a fall at 8:00 P.M. while ambulating and sustained a skin tear to his/her left upper extremity. Review of the Interdisciplinary Post Fall Evaluation dated 10/2/23, indicated the following: -The Resident sustained an unwitnessed fall during an unassisted transfer at 8:00 P.M. and was found at the bedside on his/her buttocks. -Conditions that may have contributed to the fall included unsteady gait, history of falls, and non-compliance. -The immediate intervention taken to protect the Resident/prevent re-occurrence indicated: Re-educate Resident on importance of using call bell to ask for assistance. -Further intervention recommendations were not indicated. On 10/3/23 at 9:00 A.M., the surveyor observed Resident #12 in his/her room, seated on the edge of the bed. The Resident still presented with a bruise to the left outer elbow and an uncovered, scabbed over asymmetrical skin impairment to the right outer forearm. The Resident also had a bandage on the left outer forearm, adjacent to the bruise on the left elbow, and there was a large blue colored bruise on the Resident's back upper arm, between the elbow and armpit area. No safety signage to ask for help was observed in the Resident's room. During an interview at this time, Resident #12 said he/she did not know how he/she sustained the bruise to his/her right back upper arm or the skin tear to his/her left outer forearm. During a follow-up interview on 10/3/23 at 1:23 P.M., Resident #12 said he/she had no problem being able to get up and walk to the bathroom without assistance. When asked if the Resident had ever been instructed to ask for help, the Resident said, that's a good question. The Resident then looked up at the ceiling, then back at the surveyor and said he/she couldn't remember whether anyone had instructed him/her to ask for help when getting up. During an interview on 10/3/23 at 2:43 P.M., Certified Nurse Aide (CNA) #7 said Resident #12 often attempted to ambulate on his/her own and that if he saw the Resident attempting to get up, he would enter the room and assist the Resident. CNA #7 further said that he had never seen any safety signage to call for help anywhere in Resident #12's room. During an interview on 10/3/23 at 4:24 P.M., the Director of Nursing (DON) said Resident #12 was non-compliant and very forgetful. The DON said safety signage to remind the Resident to call for help had been implemented in the Resident's room as a fall prevention intervention and should have been posted on the Resident's bureau. On 10/3/23 at 4:24 P.M., the surveyor observed Resident #12's room with the DON. No safety signage to call for help was observed anywhere in the room, as required. 2. Resident #54 was admitted to the facility in March 2023 with diagnoses including Dementia with severe behavioral disturbance, seizure disorder, generalized muscle weakness, abnormal gait and history of falls. Review of the MDS assessment dated [DATE], indicated Resident #54: -had severe cognitive impairment as determined by staff interview, -exhibited inattention and altered level of consciousness that fluctuates, -required extensive assistance of transfers and ambulation, -had a fall with fracture prior to admission, -was not steady with transfers and ambulation, -required staff for stabilization, -and was receiving physical therapy during the reference period. Review of the Activities of Daily Living (ADL) Care Plan, initiated 3/15/23, and last reviewed/revised on 9/14/23, indicated Resident #54 was unable to complete ADLs independently due to a Dementia diagnosis and included the following approaches initiated on 3/15/23: -Ambulation: continual supervision/assist of one -Locomotion: continual supervision/assist of one -Transfer: continual supervision/assist of one -Eating: continual supervision/assist of one -ADL can vary in the course of the day. Provide additional support if the Resident was noted to have agitation/fatigue Review of the Falls Care Plan initiated 3/15/23, and last reviewed/revised on 9/14/23, indicated Resident #54 was at risk for falls related to falls with injury prior to admission, diagnosis of Dementia with behavioral disturbances, frail, and emaciated appearance. The plan of care included the following interventions initiated 3/15/23: -Encourage participation in meaningful activity. -Keep personal items and frequently used items within reach. -Provide resident an environment free of clutter, and initiated 5/2/23: -Assist resident through high traffic areas such as dayrooms. Review of the Resident #54's clinical record indicated the Resident sustained five falls since admission, four of which were unwitnessed by staff. Review of the facility fall investigations that were unwitnessed indicated the following: -Fall on 5/2/23 in the dayroom at 3:30 P.M. in front of the television. The Resident had no injury and the plan of care was adjusted to include the following intervention: Assist the Resident through high traffic areas -Fall on 5/7/23 while ambulating in the hallway at 4:45 P.M. and hit the back of his/her head resulting in a hematoma. -Fall on 6/8/2023 at 1:45 P.M. while ambulating in the dayroom. The Resident hit his/her head on the molding, was sent to the hospital for evaluation and returned. The plan of care was updated to include the following intervention: Assist the Resident through crowded areas, place Resident in a seat in the dayroom and provide one to one assistance when he/she was tired. -Fall on 7/27/23 at 3:15 P.M. while ambulating in front of the nursing station. The Resident sustained a cut to his/her upper lip. Review of the Certified Nurse Aide (CNA) Profile Care Plan Approaches (information for the CNAs relative to specific resident needs) initiated 3/15/23, indicated that the Resident's ADLs can vary in the course of the day and for staff to provide additional support if he/she had agitation/fatigue. The Profile Care Plan Approaches also indicated the following: -continual supervision/assist of one with ambulation and transfers -continual supervision/assist of one with eating Review of the September and October 2023 Physician's orders included the following initiated 3/15/23: -Regular Pureed Diet with Nectar thick liquids. On 10/3/23 at 1:19 P.M., the surveyor observed Resident #54 ambulating in the hallway near the nurses station. The Resident approached Resident #63 who was seated in a stationary chair in an alcove across from the nurses station and attempted to sit on his/her lap. Resident #63 redirected Resident #54 away from him/her and then Resident #54 ambulated to the nurses station where a covered cup with a straw containing thin water was placed on top of the counter and was accessible. Resident #54 reached for the cup of water but was redirected by the surveyor who removed the cup and placed it out of reach. There were no staff present during this time and several minutes later, a Nurse was observed to enter the nurses station. The surveyor relayed the observations pertaining to Resident #54 and the Nurse thanked the surveyor and said the Resident could not have the thin beverage in the covered cup. On 10/3/23 at 4:04 P.M., the surveyor observed Resident #54 ambulating in the area across from the nurses station. He/she approached Resident #17 who was seated in a stationary chair in the area. Resident #17 was observed to state get away from me in an angry tone of voice, and Resident #54 was observed to walk away. There were no staff present during the interaction. On 10/4/23 at 11:50 A.M., the surveyor observed Resident #54 sit in a stationary chair positioned directly next to Resident #17 in the alcove across from the nurses station. Resident #54 and was leaning and touching the overbed table which was positioned in front of Resident #17. Resident #17 was heard to say in a very stern tone keep your hands off me and then grab Resident #54's hands and pushed them towards his/her body and away from the overbed table. The Unit Manager (UM) #1 had approached the nurses station at the time of the interaction and removed Resident #54 away from Resident #17. Review of the Healthcare Facility Reporting System (HCFRS) indicated Resident #54 and Resident #17 previously had a resident to resident altercation on 7/26/23 that was reported. During an interview on 10/4/23 at 12:40 P.M., UM #1 said Resident #54 needed to be supervised by staff due to his/her cognitive status and increased risk of falls. She said that he/she required supervision to redirect him/her away from other residents and unsafe situations. UM #1 said that Resident #54 does not sit for long periods of time, but mostly ambulates throughout the unit. When the surveyor relayed the safety concerns related to Resident #54 attempting to sit on another Resident's lap and numerous interactions with Resident #17 that were observed, in addition to the observation of the Resident attempting to drink unthickened liquids that did not belong to him/her, that were left on the counter of the nurses station, UM #1 said that staff need to monitor and supervise Resident #54 at all times but depending on the staffing, this could be a problem. She also said that the facility uses agency staff who do not always know the residents care needs. During an interview on 10/4/23 at 2:57 P.M., CNA #3, who said she often cares for Resident #54, said that he/she ambulates around the unit, had a history of falls and can at times be unsteady. CNA #3 said that because the Resident was not able sit for long periods of time and participate in activities, that he/she needed to always be supervised by staff because he/she wanders into other resident rooms or resident spaces. CNA #3 said that Resident #54 does not eat well but does drink well and will grab items from the nurse station if items are placed there so things should not be left there. She further said that Resident #17 does not like other residents in his/her personal space, so staff also need to monitor when others are around him/her, especially Resident #54 because he/she does not understand. During a subsequent interview on 10/4/23 at 3:18 P.M., UM #1 said she saw the interaction between Resident #54 and Resident #17 out of the corner of her eye. She said that Resident #17 likes his/her personal space and does not want other residents near him/her. When the surveyor asked UM #1 how the facility staff keep residents safe, especially Resident #54, she said that the staff are to supervise the common areas and hallways at all times. She said that one staff member should be in each of the three hallways, and one should be in the dayroom/unit dining room if a scheduled activity was not occurring. She further said that by having staff located in the hallways, they were able to monitor residents who wander and were also able to see the nurses station/alcove area across from the nurses station. When the surveyor asked when this process was instituted, UM #3 said that this supervision from staff has been in place prior to her position which started three years ago. On 10/6/23 at 11:19 A.M., the surveyor reviewed the circumstances including times/locations of Resident #54's unwitnessed falls with UM #1, as well as observations made during the survey period. UM #1 said that Resident #54 needed to be watched more closely by staff and if the CNAs were providing care and unable to be supervising, then other staff including the Nurses, Activities and other staff need to assist with providing supervision. When the surveyor asked what continual supervision meant, UM #1 said that continual supervision was when staff have eyes on a person at all times.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one Resident (#33), out of 2 applicable residents who receive dialysis (removal of toxins from the blood in people whose kidneys stop working properly), out of a total sample of 19 residents, received care and services relative to dialysis services. Specifically, the facility staff failed to ensure that Resident #33 received breakfast as required and medications as ordered by the Physician on scheduled dialysis days. Findings include: Review of the facility policy titled, Dialysis, undated, indicated the facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #33 was admitted to the facility in August 2014 with diagnoses including End Stage Renal Disease (ESRD - medical condition in which a person's kidneys cease to function normally leading to a need for regular dialysis or kidney transplant to maintain life) and Diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #33 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, had no behaviors or rejections of care and was on dialysis. On 9/29/23 at 11:45 A.M., the surveyor observed Resident #33 seated in a wheelchair in his/her room watching television. During an interview at the time, the Resident stated that he/she was hungry and wanted something to eat. When the surveyor asked if he/she ate something prior to going to dialysis or at dialysis during the treatment, Resident #33 said no. A staff member who entered the room during the interview, said that breakfast was no longer being served but told the Resident that lunch would be served shortly. The surveyor observed no fluids or food items in the Resident's room during the interview. Review of the Dehydration/Fluid Maintenance Plan of Care, initiated 11/23/2015 and reviewed/revised 9/21/23, indicated Resident #33 was started on dialysis on 1/28/2016 for Chronic Kidney Failure and included the following interventions: -Refer to the dietary plan of care. -Medications dose adjustments/time changes to accommodate dialysis schedule. Review of the September and October 2023 Physician's orders included the following: -Dialysis three times weekly on Mondays, Wednesdays and Fridays, pick up at 5:30 A.M., initiated 3/30/21. -Two bowls of cereal and 8 ounces (oz) of milk to be provided prior to dialysis treatments on Monday, Wednesday and Fridays at 5:00 A.M., initiated 3/30/21. -Obtain blood pressures daily at 8:00 A.M., initiated 10/12/21. -Lamisil AT (antifungal cream) 1% topically twice daily at 8:00 A.M. and 8:00 P.M., initiated 2/2/23. -Eliquis (anticoagulant medication) 5 milligrams (mg) every 12 hours at 8:00 A.M. and 8:00 P.M., initiated 6/8/23. Review of the September 2023 Medication Administration Record (MAR) indicated the following on Mondays, Wednesdays and Fridays (the Resident's scheduled dialysis days): -Blood pressures scheduled daily at 8:00 A.M. were documented as administered after 11:00 A.M. (three hours after the scheduled time) on eight occurrences. On two dates (9/6/23 and 9/20/23), the Nurse documented that the Resident was not available. -Lamisil AT cream scheduled daily at 8:00 A.M. was documented as administered after 11:00 A.M. (three hours after the scheduled time) on eight occurrences. -Eliquis 5 mg scheduled daily at 8:00 A.M. was documented as administered after 11:00 A.M. (three hours after the scheduled time) on eight occurrences. Review of the October 2023 MAR, from 10/1/23 through 10/6/23, indicated the following on Mondays, Wednesdays and Fridays (the Resident's scheduled dialysis days): -Blood pressures scheduled for 8:00 A.M. were documented as administered after 1:00 P.M. (five hours after the scheduled time) on two days. On one date (10/6/23), the Nurse documented that the Resident was not available. -Lamisil AT cream scheduled daily at 8:00 A.M. was documented as administered after 12:00 P.M. (four hours after the scheduled time) on two occurrences. On 10/6/23, the Nurse documented that the Resident was not available. -Eliquis 5 mg scheduled daily at 8:00 A.M. was documented as administered after 12:00 P.M. (four hours after the scheduled time) on two occurrences. On one date (10/6/23), the Nurse documented that the Resident was not available. Further review of the September and October 2023 MARs did not indicate if breakfast was provided to Resident #33 as ordered, on scheduled dialysis days prior to him/her leaving for treatment. On 10/4/23 at 3:52 P.M., the surveyor observed Resident #33 seated in a wheelchair in his/her room watching television. During an interview at the time, the Resident said that he/she had dialysis this morning and that the communication book goes with him/her from the facility to the clinic. Resident #33 said that no medications are sent with him/her to dialysis but medications are given at the dialysis clinic during the treatment. The Resident said a bagged meal/snack was not sent with him/her nor does the facility provide breakfast prior to him/her leaving for dialysis treatments. During an interview on 10/5/23 at 6:53 A.M., with Nurse #8, who is a regular 11:00 P.M. to 7:00 A.M. staff familiar with Resident #33's care, she said that the Resident gets up prior to dialysis, gets washed and dressed, is given medications and provided with Nepro (a nutritional supplement) and then picked up for dialysis around 5:15 A.M. She said the Resident's dialysis communication binder goes with him/her but that no medications or bagged lunch/snack are sent with him/her. When the surveyor asked if the Resident receives breakfast prior to dialysis, Nurse #8 said no. During an interview on 10/5/23 at 3:09 P.M., the Food Service Director (FSD) said that a bagged meal is sent only if the kitchen is notified that one is needed but there was no routine schedule for residents who go out to dialysis. He further said that he cannot recall when the staff last called to request a breakfast meal for Resident #33. During an interview on 10/6/23 at 10:58 A.M., Unit Manager (UM) #1 said that Resident #33 should receive a Nepro nutritional supplement prior to leaving for dialysis. In addition, she said that a sandwich or snacks should be sent in his/her dialysis bag in case the Resident gets hungry at dialysis. When the surveyor inquired about the Physician's order for two bowls of cereal and 8 oz of milk that was ordered prior to dialysis on Mondays, Wednesdays and Fridays, UM #1 said that if there was an order, then it should be provided. UM #1 further said that the Resident's medications should be scheduled around his/her dialysis schedule. If the medications were scheduled to be administered at 8:00 A.M. on Mondays, Wednesdays and Fridays, they could not be administered timely because the Resident was not at the facility during that time and should be ordered to be administered either before or after dialysis. She further said she would need to check into the Eliquis, Lamisil AT cream and blood pressure checks scheduled at 8:00 A.M. on dialysis days. During an interview and review of the October 2023 MAR on 10/6/23 at 11:05 A.M., with Nurse #6, she said she has worked with Resident #33 on a few occasions and said that certain medications and treatments like the Eliquis, Lamisil AT and blood pressures that were scheduled for 8:00 A.M. could not be administered because the Resident was at dialysis. She further said the mediations and treatments should be scheduled around his/her dialysis schedule, and that the Resident typically returns from dialysis between 11:00-11:30 A.M.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observations, interviews and records reviewed, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#4 and #99), out of five applicable residents, out of 32 opportunities. Specifically, the medication error rate was observed to be 6.5% when: 1. For Resident #4, relative to the administration of eye drops not given as ordered. 2. For Resident #99, relative to the total dose of Potassium Chloride medications not given as ordered by the Practitioner. Findings include: Review of the Facility's policy, titled Medication Administration, undated, indicated medications are administered in accordance with written orders of the attending Physician or Physician extender. 1.Resident #4 was admitted to the facility in October 2021 with a diagnosis of Neurocognitive Disorder with Lewy bodies (a type of dementia that leads to a decline in thinking, reasoning, and independent function). On 10/3/23 at 8:26 A.M., during a medication pass administration, the surveyor observed Nurse #3 remove oral (by mouth) medications from the medication cart, together with Artificial Tears eye drops. Nurse #3 took the Artificial Tears eye drops together with the oral medications to the Resident. Nurse #3 was observed to administer the oral medications to Resident #4 but was not observed instilling the Artificial Tears eye drops to Resident #4's eyes. Review of the Physician's order dated October 2023, indicated: Artificial Tears, one drop in each eye twice a day. Review of the Medication Administration Record (MAR), dated October 2023, indicated Artificial Tears with directions to instill one drop in each eye two times a day for Resident #4 had been signed off as administered on 10/3/23 at 8:00 A.M. During an interview on 10/3/23 at 9:04 A.M., Nurse #3 said she should have given Resident #4 his/her eye drops but she did not. 2. Resident #99 was admitted to the Facility in June 2021 with diagnoses of Schizophrenia and syndrome of inappropriate secretion of antidiuretic hormone (a condition where the body produces too much antidiuretic hormone). On 10/3/23 at 7:55 A.M. during a medication pass administration, the surveyor observed Nurse #2 take one Sodium Chloride 1 gram (gm) tablet from the medication cart. The surveyor then observed Nurse #2 administer the one Sodium Chloride 1 gm tablet to Resident #99. Review of Physician's order dated July 2023, indicated: Sodium Chloride tablet, 1 gm, give two tablets to equal 2 grams (gms) by mouth four times a day. Review of the October 2023 MAR, indicated Sodium Chloride tablet one gram, administer two tablets for a total dose of two grams orally (by mouth) had been signed off as administered on 10/3/23 at 8:00 A.M. During an interview on 10/3/23 at 9:07 A.M., Nurse #2 said she should have given Resident #99 two Sodium Chloride 1 gram tablets, but she only administered one Sodium Chloride 1 gram tablet to Resident #99. During an interview on 10/3/23 at 11:25 A.M., the Director of Nursing (DON) said Nurses are expected to give medications as ordered but Nurse #2 had not.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that four Residents (#37, #42, #9 and #57) out of total sample of 19 residents, were afforded a dignified dining experience. Specifically, the facility staff failed to be seated next to the Residents while assisting them during meals on one (Unit Two) of two units observed. Finding include: On 9/29/23 at 8:23 A.M., the surveyor observed the breakfast meal distribution in the Unit Two Dining Room where 14 residents were present. At 8:33 A.M., Certified Nurse Aide (CNA) #1 was observed standing while assisting Resident #37 with his/her meal while the Resident was seated at a dining room table. After several minutes, CNA #1 then walked over to Resident #42 who was seated in a geriatric chair and continued to stand while assisting him/her with the breakfast meal. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #37 had severe cognitive impairment as evidenced by staff interview and required supervision (cueing and encouragement) of one staff with eating. Review of the MDS assessment dated [DATE], indicated Resident #42 was rarely/never understood, had severe cognitive impairment as evidenced by staff interview, and required total assistance of one staff with eating. On 10/3/23 at 7:56 A.M., the surveyor observed the breakfast meal distribution in the Unit Two Dining Room where 16 residents were present. At 8:12 A.M., CNA #1 set up a breakfast tray for Resident #9, who was seated at a table in a geriatric chair, and then assisted the Resident with the meal while standing next to him/her. At 8:24 A.M., CNA #1 assisted Resident #37 and Resident #57, who were both seated in wheelchairs at the dining room table, with their meals while standing beside them. Review of the MDS assessment dated [DATE], indicated Resident #9 had severe cognitive impairment as evidenced by staff interview, and required extensive assistance of one staff with eating. Review of the MDS assessment dated [DATE], indicated Resident #57 had moderate cognitive impairment as evidenced by staff interview, and required limited assistance of one person with meals. On 10/4/23 at 7:55 A.M., the surveyor observed the breakfast meal distribution in the Unit Two Dining Room where ten Residents were present in the dining room. At 7:59 A.M., CNA #1 provided Resident #9 with a meal tray and stood next to him/her while assisting the Resident with the breakfast meal. On 10/4/23 at 8:09 A.M., the surveyor observed Unit Manager (UM) #1 enter the Unit Two Dining Room. The surveyor asked UM #1 what her observations were of the breakfast meal service. UM #1 said staff should be seated next to the residents while assisting them with their meals.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and policies reviewed, the facility failed to provide a sanitary and homelike environment during dining on one of two resident units. Specifically, the facility staff failed to: -ensure that residents were served meals at the same time for residents seated at the same table. -ensure meals were served off of meal trays. -ensure that staff conducted hand hygiene while providing meals and between assisting residents with meals. -ensure that staff were seated while assisting residents with meals in the Unit Two Dining Room. Findings include: Review of the facility Hand Hygiene Policy, dated 4/15/20, indicated hand hygiene (hand washing) is the single most important means of preventing the spread of infection. Application of nursing facility approved hand hygiene disinfectant is allowed in place of soap and water. The policy also included that hand washing should be done during the following: -Before and after each resident contact -Before eating or preparing food -Before and after feeding a resident -Before setting up a resident's tray On 9/29/23 from 8:20 A.M. through 9:00 A.M., the surveyor observed the following during the breakfast meal service in the Unit Two Dining Room: -Fifteen residents were present in the dining area. -Eleven residents were seated at four large dining room tables in the dining room and four residents were seated near the walls with overbed tables placed in front of them. The news was on the television which was located on a wall in the dining room. -The surveyor did not observe any tablecloths on any of the four large dining room tables. -At 8:20 A.M., the breakfast meal distribution began in the Dining Room. Residents who were seated at the four large tables were were not served their breakfast meals at the same time as their tablemates during the meal pass. All of the breakfast meals were observed to be provided on meal trays which were placed in front of the residents. -At 8:33 A.M., Certified Nurse Aide (CNA) #1 stood next to a resident while assisting him/her with the breakfast meal. Another resident who was seated at the same table still did not have a breakfast meal placed in front of him/her. -Seven of the 14 residents that were seated at the four tables did not have a meal provided to them, while others at the same tables were eating or being assisted by staff. -A tablecloth was placed on one of the four large tables at 8:41 A.M. -At 8:49 A.M., all residents in the Unit Two Dining Room had been provided their breakfast meals. -CNA #1 was observed standing and assisting two residents with their meals. -The surveyor did not observe staff performing hand hygiene in the dining room during the breakfast meal between assisting residents with meal set up and providing meal assistance. On 10/3/23 from 7:57 A.M. through 8:41 A.M., the surveyor observed the following in the Unit Two Dining Room: -Sixteen residents were present in the dining room, either seated at a large dining room table or against the wall with overbed tables placed in front of them. The news was on the television. -At 8:05 A.M., two CNAs began to pass the breakfast meal trays. The surveyor did not observe hand hygiene being performed when the staff were distributing the meal trays to residents. The breakfast meal was served on trays placed in front of the residents. -The residents who were seated at the large dining room tables were not served the breakfast meals at the same time as their tablemates. -CNA #3 was observed assisting several residents with the breakfast meal set-up, and did not perform hand hygiene. -At 8:10 A.M., the surveyor observed CNA #3 using her bare hands to pick up jellied toast from Resident #37's meal tray and assist him/her with eating it. Three other residents were also seated at this table and did not have their breakfast meals provided. -At 8:13 A.M., CNA #1 was observed standing next to and assisting a resident seated at a large dining room table with his/her breakfast meal. -Seven of the 16 Residents had their breakfast meals and several of the residents were seated at tables without a meal provided while their tablemates had their meals. -At 8:17 A.M., a Resident who was seated in a stationary chair by the wall with an overbed table was observed standing up from his/her seat and was redirected by the CNAs to sit back down because his/her meal was coming. The Resident was observed without a breakfast meal. -At 8:22 A.M., after distributing several meal trays, CNA #3 was observed to again pick up Resident #37's jellied toast and assist him/her with eating. No hand hygiene was observed by CNA #3 prior to assisting the resident and during the meal pass. -At 8:25 A.M., CNA #1 was observed standing next to two residents while assisting them with their meals. -At 8:26 A.M., a breakfast tray was placed in front of Resident #42, who was seated at a large dining room table with three other residents who were already served. Resident #42 was not assisted by CNA #3 with his/her meal until 8:38 A.M. (12 minutes later). -At 8:27 A.M., the last breakfast meal tray was served in the dining room (22 minutes later). On 10/4/23 from 7:55 A.M. through 8:10 A.M., the surveyor observed the following during the breakfast meal in the Unit Two Dining Room: -Ten residents were present in the dining room, either seated at a large table or seated against the wall with overbed tables. -Three covered meal trays were placed at a table where no residents were seated. -One resident seated at a large table with two tablemates was provided a breakfast meal tray and was eating while the tablemates did not have meals. -Resident #65, who was seated in a stationary chair with an overbed table positioned in front of him/her, was overheard to state to another resident seated near him/her that there were numerous residents seated in the dining room without their meals provided and the staff were serving breakfast trays for residents not present in the dining room. -At 7:59 A.M., CNA #1 was observed assisting in transferring a resident from a wheelchair to a stationary chair in the dining room, then assisted another resident with his/her meal without conducting hand hygiene between the two residents. -While assisting the resident with his/her meal, CNA #1 was observed standing next to him/her. -At this time, there were eight residents in the dining room without their breakfast meals while only two residents were provided their breakfast. During an interview at 8:03 A.M., Resident #65 said he/she thought it was stupid that this was how the meals were served. He/she said that residents meals are served when they are not in the dining room and there are several residents present who were sitting and waiting for their meal and it was not offered. On 10/4/23 at 8:09 A.M., the surveyor observed Unit Manager (UM) #1 enter the Unit Two Dining Room. During an interview at the time, UM #1 was asked what her observations were of the residents dining experience. UM #1 said that resident meals should not be served on meal trays, that the items should be placed on the tables in front of the residents and not served on meal trays. She also said that residents seated at tables with other residents should be served at the same time and that when staff were assisting residents, they should be seated, not standing. When the surveyor asked when hand hygiene should be occurring, UM #1 said that hand hygiene should be conducted anytime before and after assisting residents with their meal trays. Refer to F880

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to obtain a completed Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form for one Resident (#239) out of a total sample of 19 residents. Specifically, the facility staff failed to have Resident #239, and/or their Resident Representative date as required, a completed MOLST form. Findings include: Review of MOLST instructions, approved by The Department of Public Health (DPH), dated 8/10/13, indicated the following: -Sections A-C are valid orders only if sections D and E are complete. -Sections D and E are the signature and the date section of the MOLST form to be signed by the Resident or Resident Representative and the Medical Provider. Review of Resident #239's MOLST, section D, indicated the form was signed but was not dated by the Resident and/or the Resident Representative. The MOLST form was signed and dated by the Physician on 9/27/23, and indicated the following: - Do Not Resuscitate (DNR) - Do Not Intubate and Ventilate (DNI/DNV) - Do not use Non-Invasive Ventilation (NIV) - Do not Transfer to Hospital (DNH) - No Dialysis - No Artificial Nutrition - No Artificial Hydration Review of Resident #239's Baseline Care Plan titled, Advanced Directives, initiated 9/27/23, indicated the following: -Code Status DNR/DNI/DNH During an interview on 10/3/23 at 10:32 A.M., Unit Manager (UM) #1 said the MOLST form should have been dated by the Resident and/or the Resident Representative and that it was not.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Resident #48 was admitted to the facility in January 2020 with diagnoses including Stage 4 Pressure Ulcer of the sacral area (large wound in which the skin is significantly damaged), Vascular Dementia (brain damage cause by multiple strokes) with behavioral disturbance, and muscle weakness. Review of October 2023 Physician's orders included the following: -Cleanse sacral wound with normal saline and pat dry. Apply alginate (a pad placed on wound bed to prevent wound from drying out) followed by foam dressing (a protective pad to provide cushioning and absorb fluid from wound), twice daily and as needed for drainage and or removal, initiated 3/23/23. -metronidazole tablet (antibiotic sprinkled into wound to control odor), crushed 250 milligrams (mg), amount: 1 tablet, topical. Special Instructions: crush and sprinkle on/in wound bed on coccyx area (the area containing the tail bone) for increased odor twice a day, initiated 3/23/23. During an observation on 10/4/23 at 1:07 P.M., for a wound dressing change, the surveyor observed Nurse #4 had loose gauze, normal saline, crushed medication in a small medicine cup, a protective foam dressing and alginate pad on the bedside table in preparation for dressing change. -Nurse #4 went to the bathroom washed hands and put on new gloves. -Nurse #4 removed the old dressing from Resident #48's wound, and with the same gloves, poured some of the saline on a loose gauze, patted the wound bed, poured the crushed powdered medication on the alginate pad, and -placed it on the wound bed. Then, with the same gloves, Nurse #4 covered the wound with the protective foam dressing. -Nurse #4 reached into her pocked while wearing the same gloves and took out a pen and dated the wound on the outside of the foam dressing. -Nurse #4 wiped Resident #48's bedside table with the remainder of the saline and gauze, while wearing the same gloves. -The Nurse went to the bathroom, removed her gloves, and washed her hands. During an interview on 10/4/23 at 1:30 P.M., the surveyor asked Nurse #4 which part of the procedure had a breach in infection control. Nurse #4 said she should have removed her gloves after removing the old dressing, then washed her hands, applied new gloves before re-applying the new dressing but she did not. -Nurse #4 further said she should have removed her gloves, washed her hands, and then applied new gloves before disinfecting Resident #48's bedside able but she did not. During an interview with the Director of Nurses (DON) on 10/4/23 at 2:30 P.M., the DON said she expected Nurse #4 to change gloves after taking off the old wound dressing, wash her hands, and then put on new gloves before applying a new dressing, but Nurse #4 did not. The DON further said Nurse #4 should have wiped Resident #48's table with bleach wipes and washed her hands, but she did not. Based on observations, interviews, and policies reviewed, the facility failed to prevent and reduce the potential spread of infection by maintaining an effective infection surveillance program. Specifically, the facility failed to ensure that: 1. residents with active respiratory symptoms were identified and interventions put in place to reduce the spread of infection to other residents. 2. staff were conducting hand hygiene as indicated during resident care activities, including meals and a wound treatment for Resident # 48. Findings include: Review of the facility Hand Hygiene Policy, dated 4/15/20, indicated hand hygiene (hand washing) is the single most important means of preventing the spread of infection. Application of nursing facility approved hand hygiene disinfectant is allowed in place of soap and water. The policy also included that hand washing should be done during the following: -Before and after each resident contact -Before eating or preparing food -Before and after feeding a resident -Before setting up a resident's tray -After use of the bathroom -Before and after donning and removing gloves -During a medication pass in between each resident's medications given Review of the facility Infection Control Policy, dated 7/14/20, indicated it was the policy of the facility to coordinate the surveillance, prevention, and control of the infection process in order to reduce the risks of nosocomial infections (healthcare-associated infections or infections that are acquired during the process of receiving health care that were not present during the time of admission) in residents and health care workers. The policy also included the following: -surveillance, prevention and control of the infection focuses not only on direct resident care, but also resident support services such as housekeeping, maintenancce, dietary, volunteer and employee health services. -the plan will include prioritizing risks and strategies to minimize, reduce or eliminate the prioritized risks -a qualified Infection Control Nurse will be assigned the responsibility of coordinating the surveillance, prevention and control of infection activities in including collecting, analyzing and reporting data, and approving and recommending actions to prevent and control infections -the infection control surveillance nurse collaborates with and reports any significant infection control issues to the Director of Nurses (DON), Administrator and the Medical Directors -any staff member who identifies the resident with signs and symptoms of infection reports the resident to the Infection Control Nurse by filling out the Infection Report Form -the Infection Control Nurse identifies employees with infections by reports of illnesses/potential infections. Each department director is responsible for reporting employee illnesses or infections to the Infection Control Nurse. The Infection Control Nurse is responsible for follow-up of employee illnesses and also for recommending appropriate actions to department directors. -documentation of infection control data analysis which includes line listing of infections . -the Infection Control Nurse conducts investigations whenever appropriate, analyzes data, consults with appropriate resources, develops strategies to prevent and control infection based on the causative agent, characteristics of high-risk residents and souces of contamiation, and reports to the resident's physician/ -based on the identified trisk and trends, the Committee (Infection Control) will establish priorties and goals including, but not limited to: limiting unprotected exposure to pathogens, enhancing hand hygiene and minimizing the risk of transmitting infections associated with the use of procedures, medical equipment and medical devices 1. During an observation of Unit Two on 10/3/23 from 7:50 through 9:54 A.M., the surveyor observed numerous residents in the alcove area across from the nursing station with frequent cough and respiratory symptoms, including Resident #17, Resident #63 and Resident #65. During an interview at the time, Resident#17 stated he/she was not feeling well. The surveyor observed that Resident #17 was not wearing a mask, did not have tissues, was not covering his/her mouth when actively coughing and also observed that numerous other residents were present. During an interview with Unit Manager (UM) #1, immediately after the observation, she said that there appears to be a virus with respiratory symptoms going around the Unit. She said they have been testing symptomatic residents for COVID/flu as per Physician's order and have not had any positives. On 10/3/23 at 10:33 A.M., the surveyor observed the activities which were occurring in the Unit Two Dining Room where 11 residents were present. Activities Assistant #1 was observed assisting multiple residents with individualized activities. She was wearing a mask and was actively coughing throughout the observation. At 10:41 A.M., Activities Assistant #1 was observed seated next to Resident #37, was actively coughing and during the coughing fit, the surveyor observed Resident #37 ask Activities Assistant #1 if she was okay. Activities Assistant #1 said that she would be better in a week or two. At 10:47 A.M., the Hairdresser was observed to enter the Unit Two Dining Room. During a conversation between the Hairdresser and Activities Assistant #1, the surveyor heard Activities Assistant #1 tell the Hairdresser that she called out last Thursday and has had a virus for a week. Activities Assistant #1 further said that residents are being tested for COVID-19 and have been negative but that numerous residents have been on nebulizer treatments due to the respiratory virus going around. At the time, the Hairdresser was heard to say that she should probably put on a mask. On 10/5/23 at 6:40 A.M., the surveyor observed Resident #16 seated in a wheel chair in the hallway outside of the Unit Dining Room with other residents, with respiratory symptoms, holding tissues and actively blowing his/her nose. During an interview on 10/5/23 at 10:35 A.M., the surveyor discussed with the Infection Control Nurse the respiratory symptoms that have been observed on Unit Two during the survey and the facility's infection surveillance program. The Infection Control Nurse said that she had only been in the position for a few months, and was not aware of the process for tracking infections in the facility but that she did track monthly antibiotic use. When asked specifically about the facility process for monitoring of infections that do not require antibiotics, she said she would have to check. The surveyor relayed observations of residents/staff on Unit Two with cold/respiratory symptoms, and the Infection Control Nurse said that she keeps track of this information in a separate location, which the surveyor requested to review. The Infection Control Nurse returned several minutes later and provided the surveyor with a list of three residents on Unit Two who had cold/respiratory symptoms. She further said that the facility did not track on a surveillance form unless it was more then three residents or staff that have symptoms, and that she has not tracked any infections except for COVID-19 because it did not meet the criteria. The Infection Control Nurse said that if there was an increase in residents/staff with symptoms, she was supposed to be notified. She said that she is up on the Unit daily and had not had any concerns about infection control relative to hand hygiene. The list of residents with current respiratory symptoms included the following: - Resident #17 who started on 9/29/23 - Resident #37 who started on 9/29/23 - Resident #67 who started on 10/2/23 When the surveyor asked the Infection Control Nurse what was done to assist from a facility standpoint to prevent or limit transmission of respiratory symptoms, she said the facility staff should offer masks, encourage the symptomatic resident to stay in their rooms but that some of the resident's upstairs refuse to wear masks and will not stay in their rooms. The Infection Control Nurse said she was not aware of any other plans from the facility to reduce potential transmission. During an interview on 10/5/23 at 11:53 A.M., the Director of Nurses (DON) said that respiratory and gastrointestinal viruses/symptoms would be tracked on an infection surveillance tool if greater then three residents/staff were identified. She said the facility would follow up with the Provider and if it was considered an outbreak, it would be reported to the appropriate entities. The DON said that the respiratory symptoms started last week and those with symptoms were discussed in morning meetings. She said that if there were multiple residents with respiratory symptoms, they would obtain orders for additional testing/clinical follow up. The DON said that if more than three residents were identified with respiratory symptoms, a surveillance log would be initiated but felt that if it was three or less residents, then the infection is managed. The surveyor provided the DON with a list of additional residents (Resident #9, Resident #54 and Resident #63) who were observed with respiratory symptoms and were not identified from the Infection Control Nurse. When the surveyor asked what the facility did to reduce transmission of communicable infections, the DON said that frequent hand hygiene should be occurring on the affected unit and that if staff were symptomatic, they should wear masks and test for infection. She said if residents were symptomatic, they should be encouraged to wear masks, conduct hand hygiene and be redirected to their rooms if receptive. On 10/6/23 at 8:25 A.M., the surveyor was seated at the Unit Two nurses station and observed and heard numerous residents with respiratory symptoms (coughing, sneezing) from the common area across from the nurses station, in the hallway (North) and in the Unit Dining Room. At 8:32 A.M., the surveyor discussed the observations with UM #1 who said she had heard people coughing and will try to figure out who it is. She further said that some residents smoke and some have coughing episodes during meals. The surveyor relayed observations since the survey start on 9/29/23, and then the updated change on the Unit with increased numbers of residents with coughing, sneezing and cold symptoms observed on 10/3/23. UM #1 said she was aware that the DON was working on this and that the facility needed to improve their process. On 10/6/23 at 8:44 A.M., the surveyor observed Resident #16 seated in the Unit Two Dining Room with other residents during breakfast. The Resident was actively coughing and was holding a box of tissues. Resident #82, who was also seated in the Dining Room was observed to be frequently coughing. During an interview with Certified Nurse Aide (CNA) #1, who was in the Dining Room, she said that there were numerous residents with respiratory symptoms including Resident #9, Resident #83, Resident #16 and Resident #37. She further said that if she notices a resident with a medical change, like cold and respiratory symptoms, she would notify the Nurse and make sure the resident has extra fluids. During an interview on 10/6/23 at 9:07 A.M., CNA #2 said that Resident #17 has had respiratory symptoms. She said if a resident presented with respiratory symptoms, she would notify the Nurse. When the surveyor asked if there was anything that was done to reduce potential of transmission of viruses/infections, CNA #2 said that she would offer the symptomatic resident a mask, try to keep them away from other residents, offer them tissues if they are openly coughing and would provide hand wipes to clean their hands. On 10/6/23 from 8:44 A.M. through 9:41 A.M., Resident #54, who was seated in an stationary chair in the hallway, was observed with an intermittent wet sounding cough. During an interview at the time, UM #1 said that the coughing observed was typical for this Resident. During an observation and interview on 10/6/23 at 9:29 A.M., CNA #2 provided a mask for Resident #82 who was still present in the Unit Dining Room with other residents and continued to have coughing episodes. CNA #2 said that this was not typical for Resident #82. On 10/6/23 at 9:39 A.M., Resident #30 approached the surveyor, who was seated a the Unit Two nurses station, and asked for a box of tissues, stating that he/she had a cold. The surveyor observed that the Resident sounded congested. At 9:40 A.M., the surveyor relayed Resident #30's request and the observation to UM #1. During an interview on 10/6/23 at 12:29 P.M., the DON said Unit Two provided a list of residents who had respiratory symptoms, that an infection surveillance listing was initiated, and that the facility was following up. Review of the infection surveillance tool, provided by the DON indicated eight residents were identified as having respiratory symptoms on Unit Two. 2. On 9/29/23 from 8:20 A.M. through 9:00 A.M., the surveyor observed the breakfast meal pass on the Unit Two Dining Room where 14 residents were present. During that time, the surveyor observed resident meal trays and feeding assistance occur for several residents who were seated in the dining room. The surveyor did not observe hand hygiene being conducted by the CNAs prior to delivering and setting up resident meal trays and between assisting residents with their meals. On 10/3/23 from 7:57 A.M. through 8:41 A.M., the surveyor observed the breakfast meal pass on the Unit Two Dining Room where 16 residents were present. During that time, the surveyor observed two CNAs distribute and set up resident meal trays. No hand hygiene was observed between tray pass and assisting individual residents with feeding assistance, as required. The surveyor observed CNA #3 assist several residents with breakfast meal set up, but did not conduct hand hygiene and then at 8:10 A.M. and again at 8:22 A.M., CNA #3 was observed to use her bare hands to pick up jellied toast from Resident #37's meal tray and assist him/her with eating it. At 8:24 A.M., CNA #1 was observed to assist Resident #37 who was actively coughing during the breakfast meal. The surveyor heard CNA #1 tell Resident #37 to drink his/her orange juice to help with the cough. On 10/4/23 from 7:55 A.M. through 8:10 A.M., the surveyor observed the breakfast meal pass on the Unit Two Dining Room where 10 residents were present. During that time, the surveyor observed CNA #1 distribute resident meal trays and assist with set up. No hand hygiene was observed during the resident meal tray pass. At 7:59 A.M., CNA #1 was observed to assist another CNA with transferring a resident from a wheelchair to a stationary chair in the Dining Room, then CNA #1 was observed to assist another Resident with his/her meal without conducting hand hygiene. On 10/4/23 at 8:09 A.M., Unit Manager (UM) #1 entered the Unit Two Dining Room. During an interview at the time, the surveyor asked UM #1 when hand hygiene should be occurring and UM #1 said that hand hygiene should be conducted anytime before and after assisting residents with their meal trays. At 10/4/23 at 8:17 A.M., the surveyor observed the meal cart being brought to the North Wing on Unit Two, and observed breakfast tray pass by two CNAs. -At 8:31 A.M., the surveyor observed CNA #10 taking two used cups from an overbed table in the hallway and placing them in the meal cart where resident breakfast trays were located and had not yet been passed. The surveyor then observed that CNA #10 continued to distribute the resident trays. No hand hygiene was observed during the retrieval of the used (dirty) cups and the distribution of the breakfast trays in the meal cart. -At 8:37 A.M., the surveyor observed the meal cart and saw a Resident breakfast tray located at the bottom of the meal cart which had not been passed. There were several items on the breafast tray including a bowl of hot cereal, unopened milkshake and magic cup ice cream, and a covered cup with beverage, along with the Resident's meal ticket. The surveyor observed that also located on the same breakfast tray were several dirty cups. During an observation and interview on 10/4/23 at 8:52 A.M., CNA #10 said that the Resident was a late sleeper and was offered breakfast when he/she wakes up. CNA #10 said that the Resident's breakfast tray should be saved in the unit kitchenette when he/she was awake. The surveyor and CNA #10 observed the meal cart which had the Resident's untouched breakfast tray and also had several dirty cups on the tray. CNA #10 said that the dirty items should not have been placed there and she was observed removing the covered hot cereal, milk and orange juice from the tray and said that she would put it in the kitchenette to be reheated for the Resident when he/she was awake. During an interview on 10/4/23 at 10:50 A.M., with the DON, the surveyor discussed the observations pertaining to lack of hand hygiene and meal distribution on Unit Two. The DON said that dirty and used resident items should not be put on a clean cart or clean tray when the food items are going to be offered to the Resident, and that she understood about the concern for hand hygiene.

Mar 2022 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure one Resident's (#74) representative: -was provided education of risks and benefits of an antipsychotic and, - and the representative consented to administration of the antipsychotic, out of a total sample of 19 residents. Findings include: Review of the facility's Psychotropic Medication Policy, May 2018, indicated the following; Nursing needs to notify the resident's responsible party and primary care physician prior to administering a psychotropic medication. Resident #74 was discharged to another facility and later readmitted back into the current facility in August 2021, with diagnoses including dementia. Review of the clinical record indicated the resident's healthcare proxy (HCP) had been invoked on 6/4/20. Review of a physician's order, dated 12/14/21, indicated Quetiapine (antipsychotic medication), 25 milligrams (mg) twice a day. The medication was increased to 50 mg, twice a day, as ordered on 2/9/22. Review of the March 2022 Medication Administration Record (MAR) indicated Quetiapine, 50 mg, was administered twice daily as ordered 3/1/22 through 3/29/22. Review of the clinical record indicated an informed consent to administer the antipsychotic medication as ordered was not obtained from the HCP. During an interview on 3/30/22 at 3:25 P.M., Unit Manager (UM) #1 said, after reviewing Resident #74's clinical record, that there was not a consent to administer the medication as ordered. She said nursing should have had the HCP sign a consent when the medication was order in December 2021.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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Based on record review, observation and interview, the facility failed to determine if one Resident (#27) was clinically appropriate to self-administer a medication, out of a total sample of 19 residents. Findings include: Review of the facility's Medication: Self Administration policy, dated 12/1/15, indicated the following: -Residents may administer their own medications, if requested, once the facility's interdisciplinary team (IDT) determines that this practice is safe. -The resident must meet the following criteria: Be able to read the administration label on the medication, be able to demonstrate an ability to dispense the medication from the receptacle and must pass the self administration medication assessment. -The resident must request permission to self-administer medications and the assessment must be completed with results documented in the medical record. -Nursing will continue to monitor the resident's ability to self-administer medication and need for continued education on an on-going basis, including reliability in following the program and a reassessment of functional ability. Resident #27 was admitted into the facility in October 2021 with diagnoses including chronic obstructive pulmonary disease (COPD). Review of a Self-Administration of Medications Informed Consent And Assessment Form, undated and signed by Resident #27, indicated he/she wished to have the medication nurse administer his/her medications. A physician's order, dated 10/8/21, indicated; Budesonide (steroid) suspension for nebulization 0.25 milligrams (mg)/2 milliliters (ml), amount 2 ml inhalation four times a day. On 3/30/22 at 9:55 A.M., the surveyor observed the resident sitting in his/her recliner in his/her room. The surveyor observed medication on the bedside table to the right of the resident's recliner. At this same time, Resident #27 said it was his/her medication for the nebulizer and he/she administered it him/herself. He/she said the nurses leave the nebulizer medication with him/her as he/she requests it. Review of the clinical record indicated no self-administration assessment or documentation of education provided to the resident relative to the resident's ability to self-administer medications safely. During an interview on 3/30/22 at 10:51 A.M., Unit Manager #1 said, after reviewing the clinical record, that there was no documented evidence of the resident's ability to safely self-administer the medication or any education that was provided to the resident. During an interview on 3/30/22 at 3:30 P.M., the Director of Nurses said nursing should have done an assessment of the resident's ability to safely self-administer the medication and had the resident sign a new consent to self-administer his/her medication. She said all of that information should have been documented in the clinical record but was not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to accommodate the needs of one Resident (#51), out of a total sample of 19 residents, by failing to ensure that the call system was within reach. Findings include: Resident #51 was admitted to the facility in May 2011. Review of the facility policy titled Call Light, Use of Policy, revised 10/2/2019, indicated: -When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. Review of the Minimum Data Set Assessment, dated 2/9/2022, indicated the Resident was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview of Mental Status. On 3/29/22 at 9:12 A.M., the surveyor observed the Resident's call bell cord hanging upside down by the right side of the bed, wrapped around the enabler bar (an assistive device at the side of the bed to aid in bed mobility and transfers). During an interview on 3/29/22 at 9:13 A.M., the resident attempted to reach the call bell but was unable to and said that the call bell cord was caught on the enabler bar. On 3/30/22 at 9:54 A.M., the surveyor observed the resident lying in bed. The call bell cord remained hanging upside down by the right side of the bed, wrapped around the enabler bar as it was the day before. During an interview on 3/30/22 at 1:54 P.M., Nurse #2 and the surveyor observed the resident's call bell cord caught on the outside of the bed by the lower section of the enabler bar, angled upside down. When asked, the resident said that he/she could not reach the call light but thought it was off to the right side of the bed. Nurse #1 untangled the call cord from the enabler bar and handed it to the resident. The resident demonstrated how to use the call bell, and was successful. The nurse said that the call light should have been within reach of the resident, but it wasn't.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to develop baseline care plans, within 48 hours of admission, for two Residents (#194 and #74) out of 19 sampled residents. Findings include: 1. Resident #194 was admitted to the facility in March 2022 with diagnoses including status post dislocation of right shoulder. Review of the clinical record indicated a baseline care plan was not developed with 48 hours of admission as required. During an interview on 3/30/22 at 2:23 P.M., Unit Manager (UM) #2 said that a care plan was not developed within 48 hours of admission and should have been. Refer to F684. 2. Resident #74 was readmitted to the facility (after a planned discharge to another facility) in August 2021 with diagnoses including dementia requiring hospice care. Review of the clinical record indicated an incomplete baseline care plan for the resident. During an interview on 3/30/22 at 2:17 P.M., the Director of Nurses said, after reviewing the clinical record, the baseline care plan was incomplete but it should have been completed within 48 hours of admission as required.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one Resident (#194) received appropriate care and services related to non-weight bearing status (NWB), out of 19 sampled residents. Findings include: Resident #194 was admitted to the facility in March 2022 with diagnoses including unspecified dislocation of the right shoulder. Review of the hospital Discharge summary, dated [DATE], indicated the Resident sustained a fall at home that resulted in an anterior (front) dislocation of the right shoulder. The Resident had a closed reduction (manual manipulation) of the shoulder dislocation under general anesthesia on 3/21/22. Discharge instructions included to use a right upper extremity (RUE) brace and maintain NWB status to RUE until orthopedic follow up. On 3/29/22 at 8:55 A.M., the surveyor observed the Resident lying in bed with a sling over his/her right shoulder, the right arm was not in the sling and the sling hung loose next to the arm. On 3/30/22 at 8:30 A.M., the surveyor observed the Resident seated at the edge of the bed, in a hospital gown, with the sling hanging from his/her right shoulder. On 3/30/22 at 1:51 P.M., the surveyor observed the Resident lying in bed. The sling was on the bureau. During an interview on 3/30/22 at 1:53 P.M., Certified Nurse Aide (CNA) #3 said she took care of Resident #194. CNA #3 said she helped the Resident to the bathroom and she thought the Resident had a problem with his/her right shoulder that came and went. CNA #3 said the Resident could feed him/herself with that arm and there weren't any restrictions. She said the Resident used the sling sometimes, but not all of the time. The surveyor asked CNA #3 for the CNA [NAME] or care plan that would indicate how to care for the Resident, CNA #3 looked in the CNA assignment book and said there wasn't one and maybe no one had done it because the Resident was recently admitted to the facility. On 3/30/22 at 2:04 P.M., the surveyor observed the Resident seated on the side of his/her bed. The Resident waved to the surveyor with his/her right arm. Review of the March 2022 physician's orders, indicated no orders for the care and services of the status post right shoulder dislocation, including but not limited to, weight bearing restrictions and use of sling. During an interview on 3/30/22 at 2:16 P.M., Nurse #3 said the Resident had a history of repeated right shoulder dislocations. She said she thought the Resident was NWB to the right arm, but wasn't completely sure. During an interview on 3/30/22 at 2:23 P.M., the surveyor and Unit Manager (UM) #2 reviewed the Resident's current orders. UM #2 said there were no orders for NWB to the right arm or sling use, and there should have been. She said the care plan didn't include the care and services for the right arm dislocation and should have. UM #2 said whatever was on the care plan went to the CNA [NAME] electronically, but the two items listed on this Resident's care plan were not applicable to CNA care. She said the information on how to care for the Resident and the NWB status should have been on a CNA [NAME].

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice related to an indwelling Foley Catheter (a tube inserted into the bladder to drain urine into a drainage bag) for one Resident (#67) out of a total sample of 19 residents. Findings include: Review of the Lippincott Nursing Procedures: Professional Standards for Foley Catheter Care indicated the following: - provide routine hygiene for the periurethral area - make sure catheter tubing is properly secured - monitor intake and output - keep catheter tubing free of kinks to allow a free flow of urine - keep drainage bag below level of patient; keep drainage bag off of the floor - empty drainage bag regularly when it becomes one-half to two-thirds full. Resident #67 was admitted to the facility in November of 2021 with diagnoses including urinary retention (inability to expel urine from the body) and End Stage Renal Disease (ESRD) (decreased normal kidney function resulting in the inability to remove waste and excess water from the body). On 3/29/22 at 9:14 A.M., the surveyor observed the Resident in bed with a Foley Catheter drainage bag hooked to the bedside. Review of the current physician orders indicated that Foley Catheter care orders initiated on 11/26/21 were discontinued on 3/2/22. Review of the Treatment Administration Record (TAR) indicated no Foley Catheter care had been signed off as being done since 3/2/22. During an interview on 3/30/22 at 4:05 P.M., Nurse #3 said that there were no current orders for Foley Catheter care but there should be orders.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure staff administered oxygen (O2) as ordered for two Residents (#41 and #38) and failed to store nebulizer equipment in a sanitary manner for one Resident (#85), out of 19 sampled residents. Finding include: Review of the policy Oxygen and Nebulizer Administration and Setup/Tubing Infection Control Policy and Plan, dated 8/31/18, indicated the following: -A practitioner's order is required to initiate oxygen therapy. -A practitioner's order may include: O2 rate or FiO2 (fraction of inspired oxygen), and a titration of the oxygen flow rate in order to achieve an acceptable range of SpO2 (a measure of the amount of oxygen carried in the blood) values, i.e., 88-92%. In most cases, pulse oximetry is the preferred method of measuring blood oxygen values. -O2 tubing must be labeled (using tape) with nurse initials and date when changed. -Keep O2 tubing in plastic bag when not in use. -Change O2 tubing weekly on Wednesday 11-7 shift. -Nebulizer setup/tubing must be labeled (using tape) with the nurse initials and date when changed. -Keep nebulizer setup/tubing in plastic bag when not in use. 1. Resident # 41 was admitted to the facility January 2022. Review of the March 2022 physician's orders indicated Resident #41 had an order to administer O2 via nasal cannula (a tube placed in the nostril from which a mixture of air and oxygen flows) may titrate 1-5 liter (L) to maintain POX (pulse oximetry-measure of the amount of oxygen carried in the blood) at 90% or above every shift. On 3/29/22 at 8:28 A.M., the surveyor observed Resident #41 in bed. An oxygen concentrator set at 1.5 L was at the bedside. The concentrator was not running. A humidification bottle was attached to the concentrator, the nasal cannula was not dated and was on the floor. On 3/29/22 at 4:52 P.M., the surveyor observed Resident #41 in bed. The oxygen concentrator at the bedside was not running, and the unlabeled nasal cannula tubing was on the floor. On 3/30/22 at 7:34 A.M., the surveyor observed Resident #41 in bed wearing a nasal cannula with the oxygen concentrator running at 1.5 L per minute. The nasal cannula was dated 3/30/22. Review of the Search Vitals Results report, dated 12/1/2021-3/30/2022, indicated Resident #41 had POX measurements on 1/14/22, 1/15/22, 1/16/22, 1/17/22, 1/18,22, and 1/27/22. Results of the oxygen saturations ranged from 93% to 98%. Further review of the report indicated no POX was taken prior to the administration of oxygen on 3/30/22. During an interview on 3/30/22 at 11:38 A.M., Unit Manager (UM) #2 said oxygen saturation monitoring should have been done prior to administering O2 and it had not been. UM #2 said the nasal cannula should have been dated and had not been. 2. Resident #38 was admitted to the facility in January 2022. Review of the Minimum Data Set (MDS), dated [DATE], indicated the Resident used O2 in the facility. On 3/29/22 at 9:05 A.M., the surveyor observed the Resident in his/her room with O2 at 2 L via nasal cannula. The O2 tubing was not labeled with a date to indicate when it had been changed. Review of the March 2022 physician orders indicated no orders in place for oxygen use. Review of the March 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated no evidence that O2 was in use. On 3/30/22 at 7:49 A.M., the surveyor observed the Resident in his/her room with O2 at 3 L via nasal cannula. The O2 tubing was labeled 3/30/22. During an interview on 3/30/22 at 7:51 A.M., UM #2 said the Resident didn't have O2 orders prior to that morning and should have. 3. Resident #85 was admitted to the facility March 2022. Review of the March 2022 physician's orders indicated an order for budesonide suspension for nebulization; 0.5 milligrams (mg)/2 milliliters (ml); inhalation twice a day; 8:00 A.M. and 8:00 P.M. Review of the March 2022 MAR indicated that Resident #85 received budesonide suspension for nebulization; 0.5 mg/2 ml inhalation, as ordered, from 3/1/22-3/30/22. On 3/30/22 at 7:32 A.M., the surveyor observed Resident #85 receiving medication via nebulization. On 3/30/22 at 8:04 A.M., the surveyor observed the nebulizer inhalation mouth piece and tubing in the top drawer of the nightstand, not bagged or labeled. During an interview on 3/30/22 at 8:07 A.M. UM #2 said the nebulizer inhalation mouth piece and tubing should be in a bag when not in use and should be labeled with the date it was opened, and it was not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure that as needed (PRN) psychotropic medications included a 14 day documented stop date for two Residents (#27 and #74), out of a total sample of 19 residents. Findings include: 1. Resident #27 was admitted to the facility in October 2021 with diagnoses including chronic obstructive pulmonary disease, depression and psychotic disorder with delusions. Review of a physician's order, dated 10/18/21, indicated; Ativan (antianxiety medication) 0.5 milligrams (mg) twice daily as needed for anxiety. Review of the March 2022 Medication Administration Record (MAR) indicated PRN Ativan had not been administered. During an interview on 3/30/22 at 10:17 A.M., Unit Manager (UM) #1, said she did not know the PRN Ativan required a stop date and would notify the physician. 2. Resident #68 was admitted to the facility in November 2021 with diagnoses including dementia with behavioral disturbances and schizoaffective disorder ( a mental health condition including schizophrenia and mood disorder symptoms). Review of a physician's order, dated 3/11/22, indicated; Ativan Intensol 0.5 mg (0.25 milliliters) sublingual every four hours PRN for shortness of breath, anxiety, agitation, insomnia and/or nausea. Review of the March 2022 MAR indicated the PRN Ativan Intensol had not been administered since being ordered. During an interview on 3/31/22 at 11:50 A.M., the Director of Nurses said that PRN psychotropic medications needed to be limited to 14 days or longer if documented by the physician. She said neither Resident #27's nor Resident #87's PRN Ativan medication orders did not include a stop date when ordered but should have.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to update the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) for one Resident (#67), out of a total sample of 19 residents. Findings include: Resident #67 was admitted to the facility in November of 2021 with a diagnosis of End Stage Renal Disease (decreased normal kidney function resulting in the inability to remove waste and excess fluid from the body). During an observation and interview on 3/29/22 at 9:23 A.M., the Resident said that he/she had surgery on his/her left arm. The Resident was observed to have an incision in his/her left upper extremity. Review of the progress note dated 3/18/22 indicated the Resident had returned to the facility after having an arteriovenous (AV) fistula (a surgical connection of blood vessels that provides blood flow for hemodialysis (a process for purifying the blood of a person whose kidneys don't function normally) placed to his/her left upper extremity. Review of the Resident's MOLST, signed by his/her Healthcare Proxy and dated 11/26/21, indicated the Resident did not wish to receive hemodialysis treatments. During an interview on 3/31/22 at 10:52 A.M.,the Director of Nurses said that the MOLST had not been updated to reflect the Resident's current wishes to receive dialysis treatments, but it should have been updated.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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2. The facility failed to store food in accordance with professional standards for food service safely in two out of two unit kitchenettes. Review of the undated Food Receiving and Storage Policy indicated the following: -Refrigerated Storage- Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. A. On 3/31/22 at 9:17 A.M., the surveyor observed Unit 1 kitchenette, and the following items were in the refrigerator: -Thickened water, open, undated. -Thickened dairy drink, open, undated. -V-8 splash, open, undated. -Minute Maid lemonade, open, undated. -A take out container on the top of the refrigerator with a foul smell. Further observation indicated the microwave without the glass turntable plate. The interior finish was discolored and flaking. During an interview on 3/31/22 at 9:35 A.M., Unit Manager (UM) #1 said the open containers in the refrigerator should have been dated when opened and were not. UM #1 said the takeout container should not have been on top of the refrigerator. During an interview on 3/31/22 at 10:16 A.M. the Food Service Director (FSD) said the microwave should be replaced. B. On 3/31/22 at 9:50 A.M., the surveyor observed the Unit 2 kitchenette, and the following items were in the refrigerator: -Orange juice, open, dated 3/16. -Thickened dairy drink, open, dated 10/19, best by date December 2021. -Thickened lemonade, open, dated 11/20, use by date 3/21/22. -Thickened dairy drink, open, undated, best by date 12/20/21. -Thickened dairy drink, not open, best by date November 2021. During an interview on 3/31/22 at 10:06 A.M., Nurse #5 said the thickened dairy drinks, open orange juice, and thickened lemonade, should have been removed and had not been. Based on observation, document review and interview, the facility failed to ensure proper food storage and operation of the dishmachine in accordance with professional standards for food service safety to help minimize the risk of food borne illnesses. Findings include: Review of the facility's Food Receiving and Storage Policy, undated, indicated the following; Desired practices include managing the receipt and storage of dry food, removing food not safe for consumption, keeping dry food products in closed containers and rotating supplies. During a tour of the kitchen with the Food Service Director (FSD) on 3/31/22 at 7:36 A.M., the following concerns were observed: -On a lower shelf of a food preparation table the following items were undated when opened and required refrigeration when opened: A one gallon bottle of soy sauce (half full) and two one gallon bottles of teriyaki sauce (both half full). -A 48 ounce box of salt stored on a shelf was opened to the air. -The dishmachine was observed running for several consecutive cycles with the final rinse (FR) temperatures were 176 degrees F, 167 degrees F and 168 degrees F. The instructions listed on the machine indicated the required wash temperature was 150 degrees F or greater and the FR temperature was 180 degree F or greater. Review of the January 2022 High Temperature Dishmachine Log indicated the following days/meals when the FR temperatures were below the required 180 degrees F: -Breakfast: 1/24/22 and 1/25/22. -Lunch: 1/21/22. -Supper: 1/20/22. Review of the February 2022 High Temperature Dishmachine Log indicated the following days/meals when the FR temperature were below the required 180 degrees F: -Breakfast: 2/1/22. -Lunch: 2/1/22, 2/2/22 and 2/3/22. -Supper: 2/11/22. Further review of the February 2022 High Temperature Dishmachine Log indicated the following days/meals when the wash temperature were below the required 150 degrees F: -Breakfast: 2/1/22 -Supper: 2/1/22, 2/4/22, 2/6/22, 2/7/22, 2/23/22 and 2/24/22. The February 2022 temperature log also had undocumented temperatures on 2/9/22, 2/14/22, 2/15/22, 2/16/22, 2/25/22 and 2/28/22. Review of the March 2022 High Temperature Dishmachine Log indicated the following days/meals when the FR temperature was below the required 180 degrees F: -Breakfast: 3/2/22-3/6/22, 3/8/22, 3/9/22, 3/11/22-3/23/22 . -Lunch: 3/3/22-3/14/22 and 3/18/22-3/21/22. -Supper: 3/22/22 and 3/28/22. Further review of the March 2022 High Temperature Dishmachine Log indicated the following days/meals when the wash temperature was below the required 150 degrees F: -Breakfast: 3/25/22 -Supper: 3/22/22-3/30/22. The March 2022 temperature log also had undocumented temperatures at supper on 3/1/22 through 3/22/22. During an interview on 3/31/22 at 8:20 A.M., the FSD said the dishmachine wash temperatures should have always been 150 degrees F or higher and the FR temperatures should have been 180 degrees F. He said, after reviewing the January, February and March 2022 temperature logs, that there were many days/meals when the temperatures were below the required levels. He also said the staff should have been documenting wash and FR temperature for all days and all meals, and not left have the log incomplete. He said the food requiring refrigeration should not have stored on the shelf after opening and they would need to be discarded.

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis in a prominent place readily accessible to residents and visitors, as required. Findings include: On 3/30/22 at 7:17 A.M., the surveyor observed the nurse staff posting on a clip board in the front lobby, hanging on the wall beside the elevator. The paper was dated December 8, 2021, and titled Odd [NAME] Home of Massachusetts, Daily Staffing Sheet. During an interview on 3/30/22 at 7:20 A.M., the Administrator and the surveyor observed the daily staffing sheet that was posted in the lobby. The Administrator said the staffing sheet was out of date and the scheduler must not have updated the staffing posting in a long time, but should have posted it daily.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 44% turnover. Below Massachusetts's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 3 harm violation(s), $106,301 in fines, Payment denial on record. Review inspection reports carefully.
• 36 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
• $106,301 in fines. Extremely high, among the most fined facilities in Massachusetts. Major compliance failures.
• Grade F (20/100). Below average facility with significant concerns.

Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Odd Fellows Home Of Massachusetts's CMS Rating?

CMS assigns ODD FELLOWS HOME OF MASSACHUSETTS an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Massachusetts, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Odd Fellows Home Of Massachusetts Staffed?

CMS rates ODD FELLOWS HOME OF MASSACHUSETTS's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 44%, compared to the Massachusetts average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Odd Fellows Home Of Massachusetts?

State health inspectors documented 36 deficiencies at ODD FELLOWS HOME OF MASSACHUSETTS during 2022 to 2024. These included: 3 that caused actual resident harm, 30 with potential for harm, and 3 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Odd Fellows Home Of Massachusetts?

ODD FELLOWS HOME OF MASSACHUSETTS is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 100 certified beds and approximately 87 residents (about 87% occupancy), it is a mid-sized facility located in WORCESTER, Massachusetts.

How Does Odd Fellows Home Of Massachusetts Compare to Other Massachusetts Nursing Homes?

Compared to the 100 nursing homes in Massachusetts, ODD FELLOWS HOME OF MASSACHUSETTS's overall rating (2 stars) is below the state average of 2.9, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Odd Fellows Home Of Massachusetts?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Odd Fellows Home Of Massachusetts Safe?

Based on CMS inspection data, ODD FELLOWS HOME OF MASSACHUSETTS has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Massachusetts. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Odd Fellows Home Of Massachusetts Stick Around?

ODD FELLOWS HOME OF MASSACHUSETTS has a staff turnover rate of 44%, which is about average for Massachusetts nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Odd Fellows Home Of Massachusetts Ever Fined?

ODD FELLOWS HOME OF MASSACHUSETTS has been fined $106,301 across 1 penalty action. This is 3.1x the Massachusetts average of $34,142. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Odd Fellows Home Of Massachusetts on Any Federal Watch List?

ODD FELLOWS HOME OF MASSACHUSETTS is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 100
Avg. Residents: 87
Occupancy: 87.8%
Ownership: Non profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
3 Actual Harm citations: -15
36 Deficiencies: -10
Fines ($106,301): -15
Final Score: 20/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 225439