Medway Country Manor Skilled Nursing & Rehab Center

Medway Country Manor Skilled Nursing & Rehab Center

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About Medway Country Manor Skilled Nursing & Rehab Center

Medway Country Manor Skilled Nursing & Rehab CenterMedway Country Manor Skilled Nursing & Rehab Center is a for profit, 123-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Medway, Holliston, Milford, Franklin, Medfield, and other towns in and surrounding Norfolk County, Massachusetts.

Medway Country Manor Skilled Nursing & Rehab Centerfocuses on 24 hour care, respite care, hospice care and rehabilitation services.

Medway Country Manor Skilled Nursing & Rehab Center
115 Holliston Street
Medway, MA 02053

Phone: (508) 533-6634
Website: http://www.medwaymanor.com/

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2017, Medway Country Manor Skilled Nursing & Rehab Center in Medway Massachusetts received a rating of 1 out of 5 stars.

Performance Area Rating
Overall Rating 1 out of 5 (Much Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 1 out of 5 (Much Below Average)

Fines Against Medway Country Manor Skilled Nursing & Rehab Center

The Federal Government fined Medway Country Manor Skilled Nursing & Rehab Center in $164,935 on October 26th, 2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Neglect Attorneys inspected government records and discovered Medway Country Manor Skilled Nursing & Rehab Center committed the following offenses:

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interviews, the facility failed to notify the physician of changes in conditions for 2 Residents (#1 and #8), from a total sample of 20 residents. 1. For Resident #8, the facility failed to notify the physician of 3 separate weight gain events (greater than 3 pounds in 1 day), according to the physician’s orders [REDACTED].

Findings include:

Resident #8 was admitted to the facility in 9/2016 with the following pertinent Diagnoses: [REDACTED]. On 10/21/16 at 8:30 A.M., Surveyor #3 interviewed Resident #8. The Surveyor observed that Resident #8 had 3 different beverage cups on his/her table. The Resident said that he/she was extremely thirsty and was drinking as much as possible to help get rid of the infection. The Resident also said that he/she was on fluid pills and used the bathroom a lot, but still had swelling in the arms and legs.

On 10/21/16, review of the physician’s orders [REDACTED]. Review of the Care Plan for potential of [MEDICAL CONDITIONS] due to pacemaker removal (created on 10/19/16 or 1 month after admission), indicated the following: *give cardiac medications as ordered. *monitor lab work. *monitor signs or symptoms of [MEDICAL CONDITION] ([MEDICAL CONDITION], weight gain, increased heart rate, lethargy, disorientation.

Review of the computer generated weights from admission 9/2016 to 10/21/16 indicated the following pertinent weight recordings:

9/20/16- 222.0#
9/27/16- 228# (first notification to the MD @ 6# weight gain with medication change)
10/14/16-233.4# 10/21/16-241# (7.6# gain with no notification)

On 10/21/16 at 11:30 A.M., Surveyor #1 reviewed the weight gains with the UM and the observations of excessive fluids on the Resident’s table.

The Surveyor reviewed the Nursing Progress Notes. There were no notes indicating an MD/NP notification of weight gain between 10/5/16 and 10/21/16 (date the Surveyor interviewed the UM).

Subsequently, after interview with the Dietician, review of the Dietary Progress Note for 10/21/16, indicated that the Dietician was re-assessing the Resident for fluid overload and documented a total weight gain of 19# since admission (some in part attributed to increased appetite). The Dietician’s note indicated that the Resident was to have a more restrictive diet including no cold cuts, chips, bacon or salty foods and was notifying the MD for some guidance.

Review of the Nurse Practitioner Note on 10/24/16 indicated a new order to increase from [MEDICATION NAME] 20 mg. (2 tablets by mouth 2 x/day for a total dose of 40 mg) to a new total dose of 60 mg. for the current weight of 240#, initiate a fluid restriction and plan for a Cardiology follow-up appointment.

Please refer to F282.

2. For Resident #1, the facility failed to notify the physician when the Resident refused the prescribed [MEDICATION NAME] Sprinkles (a medication used to treat [MEDICAL CONDITION] or manic behaviors), thirteen times in 10/2016.

Review of the facility’s Physician/Nurse Practitioner Notification Policy indicates the following: The attending or covering physician or nurse practitioner will be notified of the refusal of treatment or medication after consecutive times and the attending or covering physician or nurse practitioner will be notified when it is part of an order in which it has been specified for a condition or follow up.

Resident #1 was admitted to the facility in 10/2014, with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 7/19/16, and signed as complete on 7/26/16, indicated that a Brief Interview for Mental Status (BIMS) was not conducted for Resident #1. The MDS indicated that Resident #1 was severely impaired with cognitive skills for daily decision making and rarely/never understands verbal content.

Review of the physician orders [REDACTED].#1 was prescribed [MEDICATION NAME] Sprinkles 125 milligrams (mg) once a day related to an anxiety disorder. Review of the Medication Administration Record [REDACTED].

Review of the nurses notes dated 10/1/16 through 10/21/16, indicated that there was no evidence in the documentation that Resident #1’s physician or nurse practitioner was notified of the Resident’s continued refusal of the [MEDICATION NAME] Sprinkles.

The Surveyor interviewed Nurse #1 at 2:45 P.M. on 10/21/16. Nurse #1 said if a Resident refuses a medication it should be documented in the nurses notes. Nurse #1 said the policy is to notify the physician or nurse practitioner if a Resident refuses a medication twice in a row. There was no documentation indicating that the MD/NP was notified of the multiple refusals of the medication.

The surveyor interviewed the Nurse Practitioner (NP) at 11:00 A.M. on 10/25/16. The NP said the nursing staff had not notified her Resident #1 was refusing the physician prescribed [MEDICATION NAME] Sprinkles.

Failed to keep each resident free from physical restraints, unless needed for medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and staff interviews, the facility failed to assess for least restrictive devices for the least amount of time, failed to release and remove restraints per the plan for care, and failed to attempt a restraint reduction for 4 (#4, #6, #12, #17), of 6 applicable sampled residents with restraints in a total sample of 20 residents.

Findings include:

The survey team observed Residents using Broda chairs with lap traps. A Broda chair is similar to the Geri-recliner chair, in that they can be reclined and locked in position. The chairs are webbed and not cushioned.

1. For Resident #12, the facility failed to assess the safety of a restraint device to avoid the risk for injury (entrapment) and remove the restraint timely.

Resident #12 was admitted ,[DATE] for rehabilitation following hospitalization for falls secondary to [MEDICAL CONDITION] (a disorder in which low platelet count which may prolong bleeding times) and urinary tract infection requiring antibiotics.

Review of the initial Minimum Data Set (MDS) assessment with a reference date of 9/22/16, indicated that the resident was cognitively impaired, had demonstrated behavior symptoms directed toward others and was dependent on facility staff for most activities of daily living, including incontinence care. The Resident was coded as receiving anti-psychotic, anti-anxiety and anti-depressant medications and had a restraint (chair that prevents rising). The Resident was coded with a 30 day and 2-6 month history of falls. Review of the Care Plan for restraints initiated 9/28/16, and revised 10/6/16, indicated that the Resident uses a restraint-lap tray on the wheel chair when out of bed, due to danger to self transfer, an unsteady gait and labile alertness. The restraint is to be used when out of bed, release and reposition every 2 hours Approaches included but are not limited to:

– Evaluate the Resident’s restraint use, record continuing risks / benefits of restraint, alternatives to restraint, need for ongoing use, and reason for restraint use. Review of the ADL (activity of daily living) Plan of Care Card dated 9/15/16, which provides guidance to nurse aide staff on the care needs of the Resident, failed to address the Resident’s restraints.

Review of the clinical record indicated that the Resident had 7 falls since admission on the following dates: 9/15/16, 9/29/16, 10/2/16, 10/3/16, 10/6/16, 10/7/16 and 10/23/16. Review of the 3:00-11:00 P.M. shift nurse’s admission note (dated 9/15/16), indicated at 7:30 P.M. the Resident’s daughter found the Resident on the floor by the bed. The nurse implemented a low bed, bed alarms and floor mats, and also obtained an emergency order to place the Resident in a wheel chair with a lap tray for 24 hours subsequent to this fall from the bed.

On 9/27/16, the 11:00 P.M.-7:00 A.M. nurse’s note indicated that the Resident continued to be placed in the chair with the lap tray in place and was making multiple attempts to stand.

On 10/2/16 at 2:00 P.M., the day shift nurse’s note indicated that the Resident slid down off the wheelchair, under the lap tray, and was assisted three times to the sitting position. On 10/25/16, the Director of Nurses (DON) was interviewed and said that she was unaware of incidents when the resident slid under the lap tray. (There was no indication that the effectivness and safety of the use of the lap tray was assessed, risk of possible entrapment and what alternative less restrictive interventions could be considered and tried.)

On 10/5/16, the 11:00 P.M.-7:00 A.M. shift nurses’ note continued to report that the Resident was attempting to slide out of the wheelchair from under the lap tray. Review of the nurses’ note dated 10/6/16, indicated that at 4:30 P.M. the Resident was observed lying on the floor between the wheelchair and the beds. No apparent injury was reported. The nurse indicated that she left a message with the rehabilitation (rehab) department of the fall and to re-evaluate the lap tray on the wheelchair in the morning. On 10/7/16, the rehab department switched the Resident to a low pedal Broda chair with a lap tray and a gel cushion.

On 10/19/16 at 2:00 P.M. the nurse’s note indicated that the Resident was sliding under the lap tray of the wheelchair.

During a facility tour on 10/20/16 at approximately 10:00 A.M., the Director of Nurses (DON) said that Resident #12 was a new admission who had a history of [REDACTED]. During this observation, the Resident was observed in the Broda chair with thigh straps (not a lap tray). At that time, the DON was asked about the purpose of the thigh straps and the DON said she was unaware that the Resident had thigh straps.

During record review, the physical therapist indicated on 10/20/16, to trial a pelvic strap instead of lap tray due to sliding down and bruising on the chest. On 10/24/16 at 3:00 P.M., the Director of Nurses was interviewed and reviewed existing documentation regarding Resident #12’s continued use of restraints without consideration to less restrictive therapeutic interventions.

2. For Resident #4, (A) The facility failed to ensure the least restrictive therapeutic interventions were used prior to the use of a restraint device and only to treat medical symptoms. The facility and failed to re-assess the use of the restraint following a fall or other incident. (B) The facility also failed to ensure that the Resident’s restraints were released and the Resident was repositioned according to the plan of care. A. Resident #4 was admitted to the facility in 3/2016, with [DIAGNOSES REDACTED].

Review of the significant change in status Minimum Data Set (MDS) assessment, due to the Resident’s decline, with a reference date of 7/13/16, indicated that the Resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 1/15 (previously a 13/15 on admission), and coded with mood and behavior indicators which included physical aggression, delusions and hallucinations (new). The Resident was dependent on the facility staff for all activities of daily living, including new bladder incontinence (continent on admission). The Resident was coded as using a daily restraint – chair prevents rising (new), and receiving hospice services. 2. For Resident #4, (A) The facility failed to ensure the least restrictive therapeutic interventions were used prior to the use of a restraint device and only to treat medical symptoms. The facility and failed to re-assess the use of the restraint following a fall or other incident. (B) The facility also failed to ensure that the Resident’s restraints were released and the Resident was repositioned according to the plan of care. A. Resident #4 was admitted to the facility in 3/2016, with [DIAGNOSES REDACTED]. Review of the significant change in status Minimum Data Set (MDS) assessment, due to the Resident’s decline, with a reference date of 7/13/16, indicated that the Resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 1/15 (previously a 13/15 on admission), and coded with mood and behavior indicators which included physical aggression, delusions and hallucinations (new). The Resident was dependent on the facility staff for all activities of daily living, including new bladder incontinence (continent on admission). The Resident was coded as using a daily restraint – chair prevents rising (new), and receiving hospice services.

On 6/10/16 at 7:00 P.M. the evening nurses’ note indicated that she obtained an emergency order for 24 hours for a lap tray in the chair due to an increase in agitation, with consistent attempts at self transferring from the wheelchair, and is at risk for falls (fell on [DATE]). The Resident had increasing paranoia when staff was trying to feed him/her, and saying that staff are trying to hurt him/her.

A review of the Restraint/Positioning Service assessment dated [DATE], indicated that the Resident’s medical status included a history of falls, low blood pressure, postural blood pressure changes, and pain. The plan coded the Resident at risk for a life threatening fall while ambulating and posed a serious hazard to self/others. The assessment identified a lap tray device when in the wheelchair. The assessment failed to identify any other alternatives as per facility policy.

On 6/12/16, the Nurse Practitioner evaluated the Resident and ordered the lap tray to the wheelchair for safety. The nurses’ notes from 6/13/16 – 7/10/16 indicated the Resident had multiple behavioral issues that required antipsychotic and antianxiety medication use. The 7/10/16 nurses’ note for the 11:00 P.M. – 7:00 A.M. shift, indicated the Resident had made multiple attempts to get out of bed and was placed in a Broda Chair. The Resident was brought to the common area where he/she continued with periods of yelling for help. No physician’s order or comprehensive restraint assessment was completed per the policy as required for this new (Broda) restraint device.

Review of a Restraint/Positioning Reduction form dated 7/13/16, completed by the MDS nurse, indicated that Resident #4 had a lap tray on a Broda chair for safety due to labile alertness (was being treated for [REDACTED].

On 7/18/16 the evening shift nurse indicated that the Resident complained of pain in his body, saying that sitting in the chair for long period of time is making him/her sore. Review of the Restraint Care Plan initiated 7/20/16, indicated that Resident #4 required a lap tray for safety with the goal of not having negative outcomes secondary to the restraint. Interventions included:
– Complete a restraint assessment.
– Attempt alternatives to restraints (no alternatives were identified).
– PT/OT evaluation to assess exploring alternatives or least restrictive device (no documented evidence).
– Reassess restraint for reduction at least quarterly or as needed.
– Check restraint every hour, release every 2 hours. Provide repositioning and exercise if able.
– Toilet as needed.
– Chair changed to Broda chair for better positioning (dated 8/12/16).

On 8/10/16, the night nurse’s note indicated that the Resident was at the desk, in a Broda chair after unsuccessful attempts to get to bed. The Resident had escalation in behavior, yelling and screaming for help because staff were next to him/her.

On 8/10/16 at 6:00 P.M. the evening shift nurse indicated that she observed Resident #4 on the floor with the wheelchair (clarified during 10/26/16 interview as Broda chair) on its side and the lap tray still on. The Resident was not injured in this fall. The Resident remained agitated and was medicated with [MEDICATION NAME] ( an antianxiety medication) with effect. The Resident remained awake and positioned in the Broda chair for the first part of the 8/11/16, 11:00 P.M.-7:00 A.M. shift and then allowed staff to put him/her to bed.

Review of the 8/17/16 ADL Plan of Care Card which provides guidance to nurse aide staff on the resident’s care needs indicated that the Resident required positioning every 2 hours, and on 8/12/16 had a new Broda chair with a lap tray, to be released and repositioned every 2 hours, and to toilet with the assistance of 1-2 persons.

Although nurses notes dated 7/10/16 – 8/10/16 indicated the use of the Broda chair and lap tray, there was no physician order obtained until 8/10/16. Review of a 9/24/16 physician progress notes [REDACTED].#4 was upset that he/she was still in the chair.

On 10/14/16 the MDS nurse completed the Resident Restraint/Positioning Device Assessment. The assessment indicated that the Resident required a lap tray on a Broda chair for safety.This assessment was incomplete as it did not assess the Resident’s individual needs as to the resident’s sitting and transfer status (resident is care planned to transfer to the toilet with 2 assists) and failed to identify programs and activities, alternative interventions/devices or referrals (assessment alternatives) that may assist in order to determine least restrictive measures.

On 10/26/16 at 11:30 A.M., Nurse #2 was interviewed about the Resident’s restraint assessment process. Nurse #2 was asked if the use of Resident’s Broda chair was re-assessed for safety following it tipping over with the lap buddy attached on 8/10/16. Nurse #2 said that she left a message with Rehabilitation (rehab) services following the incident and added she was unaware if rehab ever assessed it, because the Resident was now receiving Hospice services. Nurse #2 said that the Resident remains in the Broda chair with the lap buddy and was unaware of any plans for restraint reduction. The Director of Rehab was interviewed regarding an anssessment with Nurse #2 on 10/26/16 at approximately 11:40 A.M The Rehab Director said that an assessment was probably not done because the resident was on hospice services. No additional information was provided during survey. B. The facility also failed to ensure that the Resident’s restraints used were the least restrictive and used for the least amount of time by ensuring the Resident was repositioned every 2 hours as required.

Review of nursing assistant flow sheets and nurses notes dated 10/1 – 10/25/16, indicated that positioning and restraint release was inconsistent and incomplete on 16 of 25 days reviewed. For example: on 18 of 25 days, only the evening shift recorded that they released the restraint as planned. On 10/23/16, there was no documented evidence that Resident #4 got out of bed from midnight (12:00 A.M.) until 4:00 P.M.

On all days of survey, the Resident was repeatedly observed in his/her room or outside his/her room in a Broda chair with a lap tray and with no meaningful interaction with facility staff.

The Surveyors made the following observations:

On 10/20/16 at 4:30 P.M., Resident #4 was observed by the Surveyor seated outside his/her room in the Broda chair with the lap tray on telling staff that he/she wanted to get out of the chair and wanted to speak to the Activity staff.

On 10/20/16 at 5:24 P.M., Surveyor #2, observed the Resident in the same position set up to feed himself/herself.

On 10/24/16 at 9:45 A.M. to 11:30 A.M., the Resident was observed by Surveyor #1 to be seated outside his/her room in the Broda chair with the lap tray on. Review of the nurse aide documentation indicated that the Resident was coded as being weight shifted at 10:00 A.M. This was observed not to be done. According to their positioning records for 12:00 P.M. and at 2:00 P.M., the Resident was only provided a weight shift. There was no documentation that the Resident was removed from the chair and not provided exercise or toileted as planned.

On 10/26/16 at 8:20 A.M., the Resident was observed by the Surveyor(s) seated outside his/her room in the Broda chair with the lap tray on and set up for breakfast. The Resident was heard requesting ginger ale and more toast. At 9:00 A.M., the Resident was observed sleeping in the Broda chair where he/she remained without any observed intervention from staff until 11:40 A.M. when the nurse aide staff were observed toileting the Resident. At 12:00 P.M., Resident #4 was observed seated outside his/her room in the Broda chair with the lap tray reapplied and requesting ice cream from nursing staff. At 2:00 P.M. Resident #4 was observed again seated in the same position and was heard asking the nurse to go to rehab. I need to move more.

3. For Resident #17, the facility failed to ensure that a restraint was not used for staff convenience and the device was the least restrictive therapeutic intervention for the least amount of time to treat the resident’s assessed medical symptom.

Resident #17 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) signed as completed on 9/19/16, indicated that the Resident had impaired vision, scored a 2 of 15 on BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment, and required extensive assistance with transfer, ambulation, dressing and eating. The MDS indicated that the Resident used a walker and wheelchair for mobility and had multiple falls prior to admission.

Review of the clinical record on 10/26/16, indicated that a nurse documented on 9/20/16 at 6:00 P.M. that the Resident had experienced a fall out of bed on 9/19/16 and continued to work with skilled rehab to increase strength and endurance. The nurse further documented that there was a new order for a lap tray to be used at meal time for increased ease of self feeding and also as needed due to danger of Resident self transferring.

Review the medical record indicated a physician’s orders and care plan dated 9/20/16 for the use of the Broda lap tray for meals with increased ease for eating (self feeding) and pain management, also danger secondary to self transfer due to unsteady gait, labile alertness secondary to dementia: release every 2 hours.

Although a physician’s order was obtained for the lap tray device, the Resident Restraint/Positioning Device Assessment completed on 9/20/16, failed to address the use of the lap tray at meal times.

Review of the CNA Care Card indicated that the Resident required assist of 1 staff for ambulation, transfer and toileting, was legally blind and had a lap tray to be used while eating.

The CNA Care Card did not identify that the lap tray should be used on any other occasions.

Review of the nurses’ notes dated 10/6/16, indicated that at 4:30 A.M., Resident #17 was sitting at the nurses’ station most of the shift due to continuously removing alarm and attempting to self ambulate. The nurse further documented that the Resident was constantly attempting to remove the lap tray up and over his/her head, getting their arms pinned under the lap tray. Constant repositioning and redirection by staff given.

On 10/26/16, the Resident was observed at 8:45 A.M., sitting outside their room in the Broda chair with a tray being fed breakfast. When the Resident completed their meal, the staff member left the Resident seated in the Broda chair with the tray attached. At 9:15 A.M. the Resident remained outside their room seated in the Broda chair with a tray. At 9:40 A.M. it was observed that the Resident was taken from outside their room to the dayroom. The Resident remained in their Broda chair with the lap tray attached. The Resident passively participated in the exercise and current event program until 11:00 A.M. When the activity staff member left the room, the Resident was observed remaining in the room unattended until 11:55 A.M The Resident never made any attempts to get up out of the chair.

Nurse #2 was interviewed on 10/26/16 at 12:00 P.M. and said that Resident #17 does not always have the tray attached to the Broda chair, however could not explain why the Resident had it on from 8:45 A.M. to 12:00 A.M. even while under direct supervision of a staff member.

The Director of Nurses was interviewed on 10/26/16 at 3:00 P.M. and said that she ordered low over bed tray tables specifically for the small Broda chairs and the tray should have not been used.

The facility failed to consistently release the lap tray to allow for the least restrictive device for the least amount of time.

4. For Resident #6, the facility failed to assess a lap tray as the least restrictive therapeutic intervention and used for the least amount of time to ensure the resident was free from physical restraints and not used for convenience of staff.

Resident #6 was admitted for long term care with [DIAGNOSES REDACTED].

Record review on 10/20/16, indicated a physician’s order dated 4/30/2015, and a care plan dated 1/13/16 for a Broda chair with lap tray to treat a leaning forward position and labile alertness for dementia and behavioral disturbances. Staff were to check every two hours, release and reposition. The goal was for the resident not to have negative outcomes secondary to lap tray use. The care plan approaches included to complete a restraint assessment, attempt alternatives to restraints, physical or occupational therapy eval to assess for alternatives or least restrictive restraint device. The restraint was to be reassessed quarterly for purpose of reduction, and as needed.

Record review included a restraint assessment dated [DATE] and 9/26/16, these indicated a Broda chair with a lap tray was used for positioning due to leaning forward and labile alertness and the latter reflected that the resident’s status had not changed, and identified that the resident had trunk control problem, continued with an unsteady gait, unable to independently transfer, ambulate or stand and was a moderate fall risk and at risk for injury. The assessment failed to identify what reduction attempts or other less restrictive therapeutic interventions/devices had been tried. This assessment failed to identify when to utilize the lap tray to ensure its use was in place for the least amount of time in order to maintain freedom of unnecessary restraint devices.

Resident #6 was observed on 10/20/16 at 4:30 P.M. seated outside of his/her room in the unit corridor in the Broda chair with lap tray in place. At 5:15 P.M. on 10/20/16, Resident #6 was fed supper while seated in the Broda chair with lap tray in place while the certified nurse aide (cna) sat next to the resident. The cna was observed to get up and leave the resident’s side on two occasions to attend to assist another resident. Resident #6 remained in the corridor, in the Broda with lap tray in place and meal tray in front of him/her. The cna was gone for several minutes each time.

During interview with the Director of Nursing Services (DNS) on 10/21/16, regarding restraint usage in the facility, the DNS said that the facility was in the process of reevaluating residents with restraints. Surveyor #3 informed the DNS that record review of Resident #6 did not include a comprehensive assessment for the Broda chair and lap tray with attempts at reduction according to the plan of care. After discussion, the DNS provided a rehab assessment for Resident #6. This Occupational Therapy (OT) assessment was dated 10/15/2014 (2 years old) and addressed Resident #6’s positioning needs after a healed wrist fracture and indicated that a pedal Broda chair would allow the resident mobility around the unit with a specially fitted lap tray. The purpose of the OT evaluation/treatment was for proper seating/positioning and to encourage proper transfers with staff assistance in and out of the chair; this OT rehab progress note failed to address the use of the chair and tray as a restraint device and not been re-evaluated for 2 years.

On 10/21/16, prior to breakfast service Resident #6 was observed seated in a Broda chair with the lap tray. When the meal was served, and the cna was seated next to the resident, there was no attempt to remove the lap tray device during this time period. The resident sat upright with eyes closed while being fed and did not attempt to get up or lean forward. At 8:55 A.M., the Resident was moved into the resident’s room in the Broda chair with the lap tray in place facing the wall. At 9:50 A.M. Resident #6 remained seated in this Broda chair with the lap tray in place, and transported to the unit corridor and remained there throughout the morning. The Resident was physically moved in the Broda chair with lap tray in place towards the nurses station at approximately 11:00 A.M. This resident was fed his/her lunch while seated in the Broda chair and lap tray for the noon meal. There was no attempt to remove the lap tray during the morning, between breakfast and the noon meal time for any length of time to reduce its usage. After the lunch meal and family visit, this resident was moved to the corridor outside his/her room still positioned in the Broda chair with the lap tray in place.

At approximately 1:20 P.M., nursing staff was observed to remove the lap tray and transferred Resident #6 into a wheelchair. The resident was transported off the unit, into the elevator and to the hairdresser/barber room. Staff did not apply a restraint and/or positioning devices to the resident while seated in the wheelchair; a personal alarm was applied to the back of the wheelchair.

During interview on 10/21/16 at 2:20 P.M., the hairdresser/barber said that she/he did not experience any problems with Resident #6’s positioning such as leaning forward / trunk control nor attempted to get out of the chair while seated in a wheelchair without a lap tray or restraint device.

During interview on 10/21/16, unit nurse #2 said that the Broda chair made it difficult to provide hairdresser/barber services, and was the reason to transport the resident in a regular wheelchair. The nurse #2 had no further explanation for the resident’s success with being restraint free during this time period off the unit.

During interview on 10/21/16 at 4:45 P.M., DNS said that the facility was in the process of reviewing the use of restraints and did not have an explanation for the continuous use of the lap tray on the Resident #6’s Broda chair and that there was no further documentation available of assessments with attempts to reduce the use or alternative approaches.

Resident #6 was observed on 10/25/16 at (8:15 A.M.)(3:25 P.M.) and on 10/26/16 (8:20 A.M. to 9:15 A.M.) and throughout the day positioned in the Broda chair with the lap tray applied when seated alone in his/her room, while in the unit corridor, and during mealtimes. The resident did not exhibit behaviors other than calling out.

There was no documentation to support that the resident’s plan of care to assess and explore alternatives for the least restrictive therapeutic interventions/device utilized for the least amount of time was implemented.

The facility failed to determine if the lap tray used for Resident #6 that was observed in use, constantly throughout the day, when out of bed, was the least restrictive and utilized for the least amount of time to ensure the resident was free of unnecessary restraint devices.

Failed to protect each resident from all abuse, physical punishment, and being separated from others.

Based on staff interviews, record review and review of the Facility’s Incident Report, internal investigation and Abuse Prevention Policy, the facility failed to prevent abuse for 1 Resident (#27) in a sample of 13 Residents.

Findings include:

Review of the Facility’s Abuse Prevention Policy (9/1/2016) indicated the following: *Policy in place to identify events occurrences, patterns and trends that may constitute abuse.

*Identify event incidents that have a pattern, frequency or may constitute abuse. * All personnel, residents, visitors, etc., are encouraged to report any incidents or suspected incident of mistreatment, neglect, abuse, including injuries of unknown source, and misappropriation of resident property. Such resorts may be made without fear of retaliation from the facility or its staff.

Resident #27 was admitted to the facility in 11/2013.

Review of the Minimum Data Set (MDS-most recent Quarterly) indicates that the Resident is dependent on staff for assist with activities of daily living (adl) and is able to make his/her needs known and understands, consistent simple, directive sentences.

Review of the Resident Incident Report dated 12/25/16 indicated the following summary of the incident from witness statements:

Resident #27 alleged that on the morning of 12/25/16, he/she requested assist from the medication Nurse (MN) on duty. The MN said that the CNA would assist him/her with morning care. The Resident refused to receive care from the accused CNA and repeatedly said get him out, he’s bad, he’s mean, I hate him. Despite the Resident’s objections, the MN allowed the CNA to enter the Resident’s room. There was no indication that the nurse attempted to obtain assistance from another staff member and did not provide supervision. The CNA went into the room and closed the door behind him. According to the MN, approximately 6 minutes later, after hearing the Resident yell the MN’s name repeatedly and help me, the MN entered the room. The Resident was crying with a reddened face and nasal discharge. The Resident told the MN that the CNA pinched his/her nose and that it was not the first time. The Resident also said that the CNA squeezed his/her hands to try and break them. The Resident also said that the CNA threw cold water on his/her hair and face and that this was not the first time, it was the third time.

The MN asked the CNA if he had pinched the Resident’s nose and squeezed his/her hands. The CNA replied words to the effect of; I may have pinched his/her nose when I washed his/her face and he/she says these things.

Review of the written statement from the Social Worker indicated that when the MN entered the room, the Resident’s top was not on all of the way, exposing the Resident’s breasts. The MN had to straighten the Resident’s appearance. The CNA was in the Resident’s bathroom cleaning up and had left the Resident in that condition, unattended. The Social Worker’s written statement also indicated that the Resident’s yelling was not typical for him/her. On 1/17/17, review of the CNA’s Personnel file dated 9/19/16 (3 months prior to the abuse allegation) indicated that it contained documentation of verbal counseling. A Record of Verbal Counseling within the file indicated the following written report submitted by the (former 3:00 P.M. to 11:00 P.M.) Nursing Supervisor (NS):

Spoke with CNA about attitude and the care that he gives to his residents. I told him to tell the residents what he is going to do to them and to ask if he can provide care first. The NS told him to make sure that the residents understand him before he cares for them. The CNA thought that maybe he was joking around too much with them. There was no documentation to indicate that there was a plan to re-educate or supervise the CNA.

On 1/17/17 at 11:30 A.M. the former NS (now Infection Control Coordinator/ ICC) was interviewed. At first the ICC said that she did not remember who brought the concerns about the CNA to her attention but just said that the CNA was having issues. Upon further inquiry, the ICC said that residents and families had spoken to her about the CNA. They told her that they did not understand the CNA and did not like the CNA caring for their family members.

The Administrator was interviewed on 1/17/17 at 3:00 P.M. The Surveyor showed the Adminstrator the Supervisor’s Verbal Warning from 9/2016 or (3 months prior to the incident). The Administrator became upset and said I never saw that and if I had, I would not have let the CNA return to the facility.

The Administrator said that he terminated the CNA on 1/1/17 (2 days after returning to work), because of a complaint by another resident and family member. The resident approached the Administrator and said that he/she was afraid of the same CNA.

Failed to Hire only people with no legal history of abusing, neglecting or mistreating residents or report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interviews, record review and review of the facility’s Incident Report, internal investigation and Abuse Prevention Policy, the facility failed to follow their Abuse Prevention Policy, failed to ensure allegations were immediately reported to the Administrator and the state agency, failed to thoroughly investigate incidents with written statements from all staff members and Residents and failed to notify the Resident’s family (HCP) and physician following alleged incidents following an incident of alleged abuse for 2 (#24 & #27) Sampled Residents, from a total sample of 13 Residents reviewed during the follow up survey completed on 1/17/17.

Findings include:

Review of the facility’s Abuse Prevention Policy indicated the following pertinent bullets:

-Identify event incidents that have a pattern, frequency or may constitute abuse.

-All personnel must immediately report any incident or suspected incident of mistreatment, neglect or abuse to facility Administrator immediately.

-When an alleged violation is reported, the Facility Administrator will immediately notify officials in accordance with the State Survey and Certification Agency.

1. Resident #27 was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED] (a progressive [DIAGNOSES REDACTED] characterized by speech impairment), with repetitive speech and anxiety. The Resident’s Health care Proxy was invoked.

Review of the most recent quarterly Minimum Data Set (MDS) indicated that the Resident was dependent on staff for assist with activities of daily living (adl), due to ([DIAGNOSES REDACTED]) cognitive problems with sequencing and follow through with task initiation. He/she was able to make his/her needs known and understands consistent, simple, directive sentences.

Review of the Resident Incident Report dated 12/25/16 indicated the following summary of the incident from witness statements:

Resident #27 alleged that on the morning of 12/25/16, he/she requested assist from the Medication Nurse (MN) on duty, who was passing medications. The MN said that the CNA would assist him/her with morning care. The Resident refused to receive care from the accused CNA and repeatedly said get him out, he’s bad, he’s mean, I hate him. Despite the Resident’s objections, the MN allowed the CNA to enter the Resident’s room. There was no indication that the nurse attempted to obtain assistance from another staff member and did not provide supervision. The CNA went into the room and closed the door behind him. According to the MN, approximately 6 minutes later, after hearing the Resident yell the MN’s name repeatedly and help me, the MN entered the room. The Resident was crying with a reddened face and nasal discharge. The Resident told the MN that the CNA pinched his/her nose and that it was not the first time. The Resident also said that the CNA squeezed his/her hands to try and break them. The Resident also said that the CNA threw cold water on his/her hair and face and that this was not the first time, it was the third time. The MN asked the CNA if he had pinched the Resident’s nose and squeezed his/her hands. The CNA replied words to the effect of; I may have pinched his/her nose when I washed his/her face and he/she says these things.

The written statement from the Social Worker indicated that when the MN entered the room, the Resident’s top was not on all of the way exposing the Resident’s breasts and the MN had to straighten the Resident’s appearance. The CNA was in the Resident’s bathroom cleaning up and had left the Resident in that condition. The Social Worker’s written statement also indicated that the Resident’s yelling was not typical for him/her.

On 1/17/17, review of the CNA’s Personnel file dated 9/19/16 (3 months prior to the abuse allegation) indicated it contained a verbal counseling form. A Record of Verbal Counseling within the file indicated the following written report submitted by the (former 3:00 P.M. to 11:00 P.M.) Nursing Supervisor:

Spoke with CNA about attitude and the care that he gives to his residents. I told him to tell the residents what he is going to do to them and to ask if he can provide care first. The NS told him to make sure that the residents understand him before he cares for them. The CNA thought that maybe he was joking around too much with them. Specifics of the incident were not documented on the counseling record. There was no documented plan for re-education or supervision.

On 1/17/17 at 11:30 A.M. the former Nursing Supervisor (now Infection Control Coordinator/ ICC) was interviewed. At first the ICC said that she did not remember who brought the concerns about the CNA to her attention but just said that the CNA was having issues. Upon further inquiry, the ICC said that residents and families had spoken to her about the CNA. They told her that they did not understand the CNA and did not like the CNA caring for their family members.

On 1/17/17 at 3:00 P.M. Surveyors #1 and #2 interviewed the Administrator. The Administrator said that he was not notified of the incident until 3 hours later, at approximately 12:45 P.M. The Administator said that the Medication Nurse (MN) told him that she did not send the CNA home immediately after the incident because the unit would have been left short-staffed. The Surveyor asked if there was any staff in charge on that day, and the Administrator said no, that he was available by phone.

The Administrator said that the MN was aware that the Resident did not like the CNA. The Administrator also said that the MN never notified the Resident’s family or physician. The Surveyors asked what time the CNA left the building. He said he thought that it was right after his telephone conversation with the MN at 12:45 P.M The Surveyors told the Administrator that the business records indicated that the CNA worked the entire 7:00 A.M.- 3:00 P.M. shift providing care to Residents.

The Administrator said that the CNA was suspended during the investigation. The facility concluded that no conclusive evidence of abuse occurred, therefore the CNA was allowed to return to work.

The Medication Nurse (MN) did not obtain a written statement from all of the staff on the day of the incident. The Administrator was not aware of a previous (9/2016) Supervisor’s written Warning about the manner in which the CNA cared for Residents and allowed the CNA to return to work.

The Surveyor showed the Administrator the CNA’s Verbal Warning from 9/2016. The Administrator became upset and said I never saw that and if I had, I would not have let the CNA return to the facility.

The Administrator said he terminated the CNA on 1/1/17 (2 days after returning to work) due to a family and Resident complaint. The Resident approached him and said that he/she was afraid of the same accused CNA.

The Administrator terminated the medication Nurse on 12/30/16 for failing to follow the facility’s Abuse Prevention Policy. 2. For Resident #24, the facility failed to report an allegation of physical abuse to the State Agency.

Resident #24 was to the facility 12/2016 for long term care following hospitalization for urinary tract infection [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED]. Review of the medical record on 1/17/17 indicated that that the Resident was not his/her own decision maker for health care needs. The 12/30/16 physician’s initial note indicated that the Resident had baseline dementia and declined mentally during hospitalization.

Review of a 1/2/17, 3:34 P.M. nurse’s note indicated that during the Resident’s Rehab therapy session he/she reported an allegation of abuse to the therapy staff. The Nurse discussed the allegation with the Resident when he/she returned from therapy. The Resident said that on the first night in the facility a man punched him in the shoulder during the night hours. The Resident could not identify if the man was white or of color, had an accent or not, or said anything else distinguishing said it was too dark and the man did not speak to him. The Resident complained that his/her shoulder hurt and an shoulder x-ray was completed which was negative. The Resident’s family member (health care agent) was contacted and indicated to staff that the Resident made a similar complaint of being punched in the shoulder prior to admission.

The Resident was visited by the Social Worker on 1/3/17 regarding the Resident’s allegation of abuse. Review of the Social Worker’s interview indicated that the Resident denied any staff being rough with him/her and that the resident felt safe.

The Administrator was interviewed on 1/17/17 at approximately 3:00 P.M. and was asked if he reported the Resident’s allegation of abuse to the state health agency as required, said no.

Failed to provide activities to meet the interests and needs of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record reviews and staff interviews, the facility failed to provide a consistent program of activities designed to meet the needs of 6 sampled Residents (#2, #4, #5, #6, #15 and #17) in accordance with the comprehensive assessment and activity interests for 17 applicable sampled Residents, from a total of 20.

Findings include:

1. During the survey visit 10/20/16 to 10/26/16, multiple general observations included Residents sleeping or sitting idle in chairs often with limited interactions/activities offered by staff. (The facility has an East and West unit on the first floor and a Second floor unit.) Some of these observations include general and specific sampled Resident examples:

a) Observations on the second floor unit during the (10/20/16) afternoon, Residents repeatedly engaged the assistance from the Unit Nurses for what to do, and had multiple requests such as where to put their empty cup, request for drinks, snacks and/or to engage in conversation. The only planned activity occurring on the unit during this time frame included Fall Reminisce which failed to engage their interests. The 10/20/16, the Activity calendar for the afternoon included:
– Voter Registration on East unit at 2:00 P.M.
– Sensory visits at 2:30 P.M.
– Fall Reminisce at 2:30 P.M. on second floor unit
– Crafts at 3:00 P.M. on East
– Bruins (hockey) at 7:00 P.M.

b) The planned activities for 10/21/16 did not meet the needs of Residents residing on the second floor unit. During the morning and afternoon of 10/21/16, three Residents repeatedly sought the attention of Unit Nurses while the nurses were attempting to work from the medication cart and administer medications. The Activity calendar listed:
– Rosary 10:00 A.M. West unit
– News Time 10:45 A.M. West unit
– Lunch Bunch 12:00 P.M. (Activity staff feeding residents)
– Trivia 2:30 P.M. on second floor unit
– Bingo (Main Dining Room) 3:00 P.M.

c) The planned activities for 10/24/16 did not meet the needs of Residents residing on the second floor unit. For example: According to the Activity calendar the activities planned for 10/24/16 included:
– Prayer Service at 10:00 A.M. scheduled on the first floor – East Unit
– Exercise at 10:45 A.M. East Unit – Walking club 2:30 P.M. second floor unit

On 10/24/16 at 9:40- 9:55 A.M. the 2nd floor dining room was observed by the Surveyor. Six Residents were in the dining room; three residents were seated in Broda chairs positioned at a table with their eyes closed, one Resident was at another table holding a doll, and 2 (1 sleeping) other Residents were seated in chairs with no activity program going on. No facility staff entered the room during this time period. At 9:55 A.M. an Activity staff member was observed entering this room and greeted the 6 residents by name and asked if they were ready to exercise. The Activity staff member said that she was assigned to the 2nd floor and offers activities throughout the day and was getting ready to start.

On 10/24/16 at 10:10 A.M., the Surveyor entered the dining room and observed an additional two Residents in the room in wheelchairs (for a total of 8 residents). The Activity staff member was observed seated in a chair doing leg lifts and encouraged the Residents to participate. Only three of the eight Residents present participated.

Immediately after this Exercise activity ended at approximately 10:25 A.M., three Residents were observed congregating at the Nurses’ station while the Medication Nurse was interacting with a family member. One female Resident asked the Surveyor what should I do now; a second Resident (#12) was observed in his/her Broda chair and had entered the nurse’s station, where the Resident sat for several minutes before being redirected to the B hallway. A third Resident was seated in a wheelchair. Additional Residents were observed siting idle, one Resident was seated in a Broda chair at the end of the hall and another Resident was sleeping in a Broda chair outside room [ROOM NUMBER]. The Activity staff member was asked how many residents participate in the 2:30 P.M. Walking club activity and she responded, three Residents.

d) The planned Activity calendar for 10/25/16 morning included:
– 10:00 Sing-a-long with Carol in the Main Dining Room
– Trivia 10:45 A.M.

During a 10/25/16 interview at 10:50 A.M., a unit Nurse (#2) said that consistent activities are not being provided. Nurse #2 said that she had spoken with the Director of Activities that activity programing was not consistent for morning to night activity especially for this challenging population with [DIAGNOSES REDACTED].

e) During interview on 10/25/16 at 1:55 P.M., the Activity Director was asked about the activity program, staffing and the assessing of Residents needs for activities. The Activity Director said she works 20 hours weekly as the Activity Director and 20 hours as a Social Worker in the facility and has done this for one year. The Activity Director explained that she has 3 full time (40 hours) activity persons and one part-time person on the weekends for the entire building. The Activity Director said the activity staff, including herself are tied up from 11:00 A.M. – 1:30 P.M. with feeding residents on the second floor unit for the lunch meal and it takes away from the activity programs. Review of the August and September calendars indicated that on Tuesday, Wednesday and Thursday at 4:45 P.M. Dining with Cyndy is offered which the Director said consists of activity staff helping to feed residents during that time.

2. For Resident #6, the facility failed to involve the Resident in an ongoing program of activities which appealed to his/her preferences and plan of care.

Resident #6 was admitted for long term care with [DIAGNOSES REDACTED]. Record review on 10/20/16, indicated Resident #6’s activity plan of care dated 1/13/2016, identified that the resident is dependent upon staff and responds to 1:1 companionship and touch.

Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had severely impaired cognitive skills for daily decision making, with disorganized thinking, inattentive behaviors and frequent verbal outbursts towards others. The assessment indicated the Resident was dependent upon staff for all activities of daily living and mobility. According to the MDS, the activity preferences included the following: the Resident likes music, simple conversation, sitting outside, family visits, and attends music and religious activities. The goal is not to overwhelm during religious or music activities.

Review of the Social Service history indicated that the Resident worked in a hat shop. Care plan approaches included the need to provide sensory stimulation, such as smell, touch and or music. Staff is to approach the Resident calmly, provide 1:1 or assist the Resident to small group activities on the unit. Also noted, the Resident responds to soft blankets/stuffed animals to calm him/her especially when grabbing out, and requires reassurance that everything is alright.

During the survey period from 10/20/16-10/26/16, Resident #6 was observed not engaged in activities on the unit or at religious or music entertainment taking place in the facility. The only identified activity was daily visits (from a family member) and holding a knitted blanket on the lap tray for sensory stimulation. The Resident was not in attendance of any facility planned activity. This Resident, when not eating a meal or midday family visits, spent idle time asleep in the Broda chair with a lap tray.

During the morning and afternoon on 10/21/2016 and 10/25/2016, there were no activities other than a television viewing in the unit day room. Resident #6 was observed sitting in the corridor in the Broda chair with a lap tray except when he/she left the unit to go to the hairdresser/barber and for an early morning family visit on 10/21/16.

During interview at 12:25 P.M. on 10/21/16, activity staff said that she goes from one thing to another, including assisting in the dining room at meal buffets, helping to transport Residents, feeding Residents on the unit in addition to providing activities. 3. For Resident #2, the facility failed to provide meaningful activities that reflected the individuals interests.

Resident #2 was admitted to the facility in 12/2012 with [DIAGNOSES REDACTED]. A review of the annual MDS assessment dated [DATE], indicated the Resident had severe cognitive impairment for decision making, and required total care for all activities of daily living. The assessment indicated the Resident’s activity preferences were very important to him/her and included listening to music and animals.

The activity plan of care dated 3/4/2016, indicated the Resident was dependent upon staff to provide activities and may be a passive observer and activity preferences were music, pet visits and family. The goal of the plan indicated the Resident would attend 1 group program a week. The care plan’s approaches included to address and smile when approaching, the Resident likes fishing, listens to music, religious choice includes to receive communion and family visits when able.

Resident #2 was observed positioned in a tilt wheelchair, in the corridor throughout the morning and afternoons during the survey visit. Observations on the Resident’s unit on 10/20/16, 10/21/16, 10/25/16 and 10/26/16 revealed Resident #2 was not in attendance at facility planned activities. There were no ongoing activities provided on the Resident’s unit on 10/21/16 and 10/25/16, except for the television in the day room.

The Surveyor observed Resident #2 on 10/20/16 at approximately 4:15 P.M. sitting in the hall at the nurse’s desk with eyes closed and no activity. On 10/21/16, from 10:00 A.M. till the lunch meal service, this Resident was positioned in the hall by the nurse’s desk and his/her eyes closed. On 10/25/16 at 10:30 A.M., Resident #2 was observed seated in a tilt wheelchair outside his/her room in the corridor along the wall. The Resident was not transported to any planned activities and was not offered any individualized attention other than to be fed meals.

Resident had an ipod (electronic portable device) provided by family to listen to music. Observation in the resident’s room revealed that the ipod was not present in the ipod dock on the bedside table. According to a 10/1/2016 Social Service progress note, the ipod was missing on 9/30/16. Review of missing items / grievance forms indicated that the facility could not locate the Resident’s music device. During interview with Social Worker (SW) at 11:30 A.M. on 10/21/16, the SW said that the Resident’s family had loaded music preferences on the ipod. However, no other options to offer music for Resident #2 to listen to were considered.

4. For Resident #4, the facility failed to provide any meaningful activities in accordance with the Resident’s assessed need.

Resident #4 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. According to the initial MDS dated [DATE], the Resident was cognitively intact and required staff assistance with activities of daily living. The Resident identified his/her daily activity preferences as follows:
*very important: keeping up with the news.
*somewhat important: books, newspapers and magazines to read, listen to music, doing things with groups of people, participate in religious activities;
*not very important: being around pets.

Review of the activity care plan dated 7/20/16, indicated that the Resident prefers activities that identify with prior life style with the goal for the Resident to receive communion twice per month.

Approaches included:
-Involve Resident with those who have a shared interests.
-Allow resident to express feelings and desires.
-Provide materials of interest.
-Inform resident of upcoming activity, verbal reminders, escort, and encouragement.
-Provide setting in which activities are preferred.
-Resident enjoys receiving communion.
-Resident is on Hospice and enjoys the pet therapy, music therapy and clergy visits and home health aide.

Review of the Resident Activity Participation Record identified for October 1-25, 2016 identified the Resident’s self directed activities as TV and Hospice.

On 10/26/16 at 8:20 A.M., the Resident was observed by the Surveyor(s) seated outside room [ROOM NUMBER] in the Broda chair with the lap tray on set up for breakfast. The Resident was heard requesting ginger ale and more toast. At 9:00 A.M. the Resident was observed sleeping in the Broda chair where he/she remained without any observed interaction from staff until 11:40 A.M. when the nurse aide staff were observed toileting the Resident.

During this time at 12:00 P.M., Resident #4 was observed seated outside room [ROOM NUMBER] in the Broda chair with the lap tray reapplied and requesting ice cream from nursing staff. At 2:00 P.M. this Resident was observed again seated in the same position and was heard asking the nurse to go to rehab. I need to move more. The nurse, who was busy on the phone at the time, said to the Resident that they’ would be up soon. During this observation the activity aide was observed having a reminiscing activity however no staff was observed inviting Resident #4 to the group.

5. For Resident #5, the facility failed to offer and provide activities to enhance his/her psychosocial well-being.

Resident #5 was admitted to the facility in 12/2015 with the following pertinent Diagnoses: [REDACTED].

Review of the Quarterly MDS for Brief Interview for Mental Status score (BIMS) of 12/15, indicating the Resident’s cognition is moderately impaired. The Resident is alert and oriented and can make his/her needs known.

On 10/25/16 at 10:50 A.M., the Surveyor observed the Resident in a wheelchair in his/her room staring straight ahead at the wall. Surveyor #3 asked the Resident if he/she was going to attend any of the scheduled activities that day. The Resident said that he/she liked the trivia program, but could not see the event calendar because of limited vision. The Surveyor read the activity calendar out loud. The trivia program was scheduled at 10:45 A.M. that same day (5 minutes overdue). The Surveyor observed the Resident become anxious and the Resident said I’m late. The Surveyor asked the Resident if the Activity Aide usually came to get him/her for activities. The Resident said that that they do, unless they are busy.

On 10/26/16 at 2:00 P.M., the Surveyor interviewed the Activities Director (AD). The AD said that an Activity Aide did not get to the Resident’s Unit that morning because they were assisting with feeding Residents in other parts of the facility. She said that aides had to share tasks and float to areas that need assistance. The scheduled 10:45 A.M. trivia activity was not provided because Activity Aides were feeding Residents throughout the facility.

Refer to F353

6. For Resident #15, the facility failed to offer and provide activities based on the Resident’s likes, needs, interests and desires.

Resident #15 was admitted to the facility in 6/2013, with [DIAGNOSES REDACTED]. The MDS with an assessment reference date (ARD) of 8/23/16, and signed as complete on 9/1/16, indicated that Resident #15 scored a 15 on a Brief Interview of Mental Status (BIMS), indicating that he/she was severely cognitively impaired.

Review of the clinical record indicated that there was no activity assessment for Resident #15.

Review of the activity care plan indicated that Resident #15’s preferred activities were: coffee cart, church, family visits and socializing with staff. Care plan interventions included:
*invite and escort Resident #15 to scheduled activities
*Enjoys weekly Eucharistic Ministers

Review of the 10/2016 activity calendar indicated that on 10/26/16 at 10:00 A.M. the East Unit activity would be bean bag and Eucharist Ministers.

On 10/26/16 at 9:30 A.M., Resident #15 was observed sitting in the day room on the East Wing with 5 other Residents. All the Residents, including Resident #15, appeared to be sleeping in his/her wheelchair except for one. The television was on and the volume was extremely low. All the Residents, including Resident #15, were positioned facing away from the television.

The surveyor continued to observe all the Residents sleeping while seated in their wheel chairs, in the day room, from 9:30 A.M. until 10:30 A.M. No staff member interacted with or checked on the Residents until 10:30 A.M. when the activity assistant took 4 Residents out of the day room.

On 10/26/16 at 10:30 A.M., the surveyor asked the activity assistant why the 10:00 A.M. bean bag activity did not occur and the activity assistant said she was feeding Residents and the activity was going to be on the West Unit because there were more Residents on that unit who would attend. Resident #15 was not taken to the activity, she remained in the day room.

On 10/26/16 at 10:35 A.M., two Eucharist Ministers were observed on the East Unit, however, they did not visit with Resident #15 who was now in the day room alone. On 10/26/16 at 10:45 A.M., a CNA removed Resident #15 from the day room.

7. For Resident #17, the facility failed to provide meaningful activities that reflected the individuals interests based on comprehensive assessment.

Resident #17 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the Activity and Spiritual Assessment, completed by the Activity Director on 9/12/16, indicated that the Resident had the [DIAGNOSES REDACTED]. The hobbies listed including classical music, knitting, loves to talk and books on tape. The assessment indicated that the Resident had a Health Care Proxy invoked and had confusion but wanted to participate in Catholic service.

The MDS signed as completed on 9/19/16, indicated that the Resident had impaired vision, scored a 2/15 on BIMS (Brief Interview for Mental Status) indicating cognitive impairment, required extensive assistance with transfer, ambulation, dressing and eating. The MDS also indicated that the Resident used a walker and wheel chair for mobility and had fallen prior to admission. The Resident also received an antipsychotic and antidepressant medication daily.

On 10/25/16 the Resident was observed at 4:00 P.M., sitting in the Broda chair in the dayroom, unattended. It was then observed that the nurse went to get the Resident and wheeled him/her to their room to be toileted.

On 10/26/16 the Resident was observed at 8:45 A.M., sitting outside their room in a Broda chair with a tray being fed breakfast. When the Resident completed their meal, the staff member left the Resident seated in the Broda chair with the tray attached. At 9:15 A.M. the Resident remained sitting outside their room seated in the Broda chair with a tray holding on to what appeared to be a piece of cloth. The surveyor asked a CNA who was walking by what that cloth item was, and she said it was a memory board, a piece of cloth with hooks and rings, however the Resident was not using it as intended. At 9:40 A.M. it was observed that the Resident was wheeled into the dayroom and placed on the perimeter of the room. The Resident remained in their Broda chair with a tray. Although the Resident was physically in the room, the activity staff person was not observed attempting to engage the Resident in the either the exercise or current event program. At 11:00 A.M. the activity staff member left the room where the Resident was observed unattended until 11:55 A.M. softly singing to him/herself in Italian.

The Activity Director was interviewed on 10/26/16 at 2:00 P.M. and said that Nurse #3 contacted the Resident’s Health Care Proxy on 10/22/16 to bring in the Resident’s Books on Tapes from home. The Activity’s Director said although she identified Books on Tape on the initial Activities assessment dated [DATE], she failed to contact the family member to bring in the books on tape and magazines in braille.

Failed to Provide housekeeping and maintenance services.

Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for 2 of 3 Resident’s Units.

Findings include:

The facility’s environment was observed during the survey visit from 10/20/16 to 10/26/16 for 2 (East Unit and Second Floor) of 3 Resident units. Multiple Resident rooms (203, 248 and 250) on the second floor had damaged wall surfaces behind the head boards. The wall surfaces contained faded and yellowing wallpaper with wall surfaces that were worn, torn and/or separating at the seams. Shower rooms on 2 of 3 units contained soiled linen containers and Resident’s care equipment and were not maintained as homelike.

The Residents men’s and women’s restrooms on the east unit were in disrepair. The women’s restroom wall had holes in wall board with exposed pipes. The men’s rest room had cardboard covering the toilet and contained excessive storage of care equipment which included wheelchair, hoyer lift, walker, and soiled linen containers, which prevented access to the room. There was no signage to indicate the room / toilet was not functional. The activity room on the lower level had wall surfaces in disrepair.

Interviews with families indicated that the facility environment was looking tired and in need of updating.

Interview with the Administrator on 10/26/16, said that the facility’s capital plans for environmental improvements were expected from HUD (Housing and Urban development) disbursements over several years but not to be dispersed for two years. The building had old, leaking pipes in need of repair resulting in water damage in the building. The Administrator could not provide any specific time line for facility improvements.

Failed to make sure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the facility failed to meet professional standards of nursing quality by not following the facility’s policy for RN Pronouncement of Death for 1 (#19) of 20 sampled Residents.

Findings include:

For Resident #19, the facility failed to ensure that the RN assessed the Resident at the time of death.

The facility’s policy for RN Pronouncement of Death indicated that the nurse must obtain a physician’s orders [REDACTED].

A review of the closed record indicated the Resident had been admitted in 6/2016 to the facility with [DIAGNOSES REDACTED].

A review of the nurses’ note dated 7/17/16 indicated, patient passed away at 9:37. Family, Dr. (name of physician) and Hospice notified. There was no documentation of how the nurse assessed the Resident’s at time of death.

During record review and interview on 10/26/16 at 10:30 A.M., the Staff Development Coordinator said the nurse should have written more about the Resident when he/she found the Resident. She said there was no details written in the record.

Failed to provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interviews, the facility failed to follow the Plan of Care and physician’s orders for monitoring weight gain parameters (greater than 3 pounds in 1 day and 5 # in one week) for one Resident (#8), from a total sample of 20 residents.

Findings include:

Resident #8 was admitted to the facility in 9/2016 with the following pertinent Diagnoses: [REDACTED].

On 10/21/16 at 8:30 A.M., Surveyor #3 interviewed Resident #8. The Surveyor observed that Resident #8 had 3 different beverage cups on his/her table. The Resident said that he/she was extremely thirsty and was drinking as much as possible to help get rid of the infection. The Resident also said that he/she was on fluid pills and used the bathroom a lot, but still had swelling in the arms and legs.

Review of the Care Plan for potential of [MEDICAL CONDITIONS] due to pacemaker removal (created on 10/19/16 or 1 month after admission), indicated the following:
*give cardiac medications as ordered.
*monitor lab work.
*monitor signs or symptoms of [MEDICAL CONDITION] ([MEDICAL CONDITION], weight gain, increased heart rate, lethargy, disorientation.

On 10/21/16, review of the Physician’s Orders for 9/2016 and 10/2016 indicated to weigh the Resident daily and call the MD/NP if weight goes up 3 pounds in one day and 5 pounds in one week.

Review of the computer generated weights from admission (9/2016) to 10/21/16 indicated the following pertinent weight recordings:
9/20/16- 222.0 pounds (#)
9/27/16- 228# (notification to the MD @ 6# weight gain with medication change)
10/14/16-233.4# 5.4# weight gain
10/18/16-237# 3.6# weight gain
10/21/16-241# ( 7.6 # weight gain with no notification)

On 10/21/16 at 11:30 A.M., Surveyor 1 reviewed the weight gains with the UM and the observations of fluids on the Resident’s table.

The Surveyor reviewed the Nursing Progress Notes. There were no notes indicating an MD/NP notification of weight gain between 10/14/16 and 10/21/16 (date the Surveyor interviewed the UM).

Review of the Dietary Progress Note for 10/21/16, indicated that the Dietician was re-assessing the Resident for fluid overload and documented a total weight gain of 19# since admission (some in part attributed to increased appetite). The Dietician’s note indicated that the Resident was to have a more restrictive diet including no cold cuts, chips, bacon or salty foods and was notifying the MD for some guidance.

Review of the Nurse Practitioner Note on 10/24/16, indicated a new order to increase [MEDICATION NAME] 20 mg. (2 tablets by mouth 2 x/day) to 3 x/day for the current weight of 240#, initiate a fluid restriction and plan for a Cardiology follow-up appointment.

Failed to provide necessary care and services to maintain the highest well being of each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation and interviews, the Facility failed to ensure for 1 of 13 sampled Residents (Resident #4), received effective pain management when the Resident complained of a toothache that began on 12/25/16.

Findings include:

For Resident #4, the facility failed to provide effective pain management when the Resident complained of a toothache that began on 12/25/16.

Resident #4 was admitted to the facility in 3/2016 and had active [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment with a reference date of 1/1/17, indicated that the Resident was cognitively impaired, had daily behaviors, was coded with pain and was receiving hospice services.

Review of the clinical record dated 12/25/16 on the 11-7 shift indicated that the Resident began complaining about a toothache. Further review of the Nurse’s notes from 12/25-12/28/16 indicated that the Resident continued to complain about the toothache and received Tylenol PRN (as necessary) which the nurses’ indicated was effective.

On 12/29/16 the 11:00 P.M.-7:00 A.M. nurse’s note indicated that the Resident was awake all night complaining about mouth pain, was yelling out and crying for help. The nurse medicated the Resident for agitation at 2:08 A.M. with the PRN antianxiety medication, AB gel ([MEDICATION NAME] (antianxiety) with [MEDICATION NAME] ([MEDICATION NAME]) along with the antipsychotic medication, [MEDICATION NAME] gel PRN and a narcotic, [MEDICATION NAME] 5 milligrams orally PRN which were all assessed as ineffective (all of the medications listed above were previously ordered medications.)

Review of the Medication Administration Record [REDACTED].M.-7:00 A.M. shift nurse administered PRN AB gel with the [MEDICATION NAME] gel and PRN [MEDICATION NAME] that she assessed as ineffective. The location of the pain was not documented. Review of the corresponding nurse’s note for 1/1/17 at 3:53 A.M. indicated that the Resident was yelling, screaming and swearing, no hallucinations at this time. Continue to monitor. On 1/1/17 at 6:25 A.M. the nurse continued to report that the Resident was yelling, screaming, crying and hitting with ineffective medication administration.

On 1/7/17 at 2:39 P.M. the Nurse’s note indicated that the Resident was administered the PRN [MEDICATION NAME] at 10:30 A.M., assessed as ineffective results and then at 2:40 P.M. administered the [MEDICATION NAME] gel for general discomfort and increase in agitation. There was no assessment of the location of the pain and no further assessment if the Resident’s increase in agitation corresponded with the Resident’s prior complaints of a toothache.

On 1/11/17 the facility social service progress note indicated that a Hospice meeting was held on January 4 and that the Resident had declined mentally in the past 2 weeks where (he/she) is having more hallucinations .PRN meds are ordered and given as needed. The Social Worker made no mention of the Resident’s complaints of tooth/mouth pain or need for pain medication.

On 1/11/17 at 3:00 P.M. the interim charge nurse (ICN) was interviewed and reviewed existing nursing documentation with the surveyor. The ICN said that she was unaware that the Resident was complaining of a toothache. The ICN said that the MD progress note of 12/25/16 did not indicate that the physician was made aware of the Resident’s initial complaint of a toothache the previous night and there was no further documentation by the MD in the clinical record. The ICN said that nursing staff were documenting that the Resident had generalized pain but did not identify the location of the pain. The ICN was asked if the nursing staff had assessed if the Resident’s escalation in behaviors was due to being in pain and said she was unsure if that was considered. The ICN said she was going to contact the physician to have the Resident assessed.

On 1/12/17 at 11:30 A.M. the ICN followed up with the Surveyor and indicated that the Physician had visited earlier that morning (no note was made available during the survey) and indicated that the Resident currently had no acute pain but ordered a dental consult. The ICN said that a dental consult would be completed sometime next week but no date was given.

On 1/12/17 at 12:00 P.M. the family member was interviewed and said that the Resident had been complaining about a toothache beginning a couple of weeks ago and that he/she tried to get a dental appointment but the insurance would not cover it.

On 1/17/17 at approximately 10:30 A.M. the Interim Charge Nurse (ICN) reported that Resident #4 was visited by the Dentist on 1/16/17. The ICN said that the Dentist indicated that the Resident had no acute pain but had a fractured tooth which required a procedure for the dentist to smooth over the tooth (to prevent jagged edges).

Failed to assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interviews, the facility failed to ensure necessary care and services was provided for one resident (#6) with chronic skin impairment who was dependent for grooming and hygiene needs from a total sample of 20 residents.

Findings include:

For Resident #6, the facility failed to ensure alternative care approaches for bathing were attempted to avoid skin impairments.

Resident #6 was admitted for long term care with [DIAGNOSES REDACTED]. Record review on 10/20/16, indicated Resident #6’s plan of care dated 1/13/2016, identified that the resident was at risk for skin breakdown due to incontinence and limited mobility; and required extensive assistance for grooming, dressing and hygiene. A medical progress note dated 4/23/16, indicated Resident #6 had a chronic impaired skin area under left breast; the area was noted as a fungal infection that required treatment. The nurse aide care card updated 8/21/16, indicated the resident required the assistance of one staff person for bathing, to avoid certain undergarments (bra), and the family does the Resident’s laundry.

A 9/9/16 nurses note indicated 3 new red spots, under right breast. The Nurse Practitioner (NP) was notified and an order for [REDACTED].

Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated this Resident had severely impaired cognitive skills for daily decision making, with disorganized thinking, inattentive behaviors and frequent verbal outbursts towards others. The assessment indicated the Resident was dependent upon staff for all activities of daily living.

On 9/23/16, a physician progress notes [REDACTED]. There were no new approaches in the plan of care for the Resident’s impaired skin other than to provide a topical treatment to the area.

A nurse’s note dated 10/4/16, indicated the area under Resident #6’s right breast was red and excoriated; a new order from the NP obtained to apply Interdry daily.

On 10/16/16, the nurses note indicated impaired skin areas for Resident #6, under right breast, moist and red; a treatment was ordered (Interdry for 7 days). There were no new approaches in the plan of care for the Resident’s impaired skin other than to provide a topical treatment to the area.

Although Resident #6 was scheduled for a whirlpool bath on Tuesday nights, Unit Nurse #2 said during interview on 10/21/16 at 10:00 A.M., that Resident #6 did not receive a weekly whirlpool bath per request.

On 10/21/16 at 1:05 P.M., certified nurse aide #3 (cna) said Resident #6 is given a bed bath only, early in the morning when she/he works; and was aware of a new rash area on shoulders, but only the licensed staff treat the area. The cna #3 said that Resident #6’s impaired skin areas occur under the breast on occasion possibly due to moisture/sweat. The cna was not aware of any alternative bathing considerations.

Observation on 10/25/16 at approximately 11:00 A.M., Surveyor #4 was given permission from Resident #6’s family member, to view the skin rash on the Resident’s back. The skin rash covered half of the Resident’s back (upper half) and consisted of pink areas, approximately two centimeters in diameter, with a red pinpoint in the center.

On 10/26/16 at approximately 1:30 P.M., to follow-up with DNS for Resident #6’s care and lack of alternative approaches (bathing frequency, trial of hand held shower, sensitivity to the use of any new linen/laundry products, skin care products, or staffing practices) as part of the facility’s infection control monitoring and tracking of skin rashes for prevention.

Failed to make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interviews, the facility failed to conduct a comprehensive assessment of bladder function and ensure that Residents receive appropriate treatment and services to restore as much normal bladder function as possible for 1 (#13) of 20 sampled Residents.

Findings include:

For Resident #13, the facility failed to assess and develop a plan of care for a Resident who frequently requested to be toileted.

Unit Manager #1 was interviewed on 10/25/16 at 3:30 P.M. and discussed the Resident’s fall on 10/18/16 which occurred in the bathroom when the Resident attempted to toilet unassisted. The Unit Manager said that Resident #13 has severe dementia with poor recall, no greater than 10 minutes, but the Resident wants to stay continent. The surveyor asked if the Resident had been assessed to establish a bladder pattern to assist the Resident in staying continent, and UM #1 said no. UM#1 said they bring the Resident to the bathroom whenever he/she asks to go.

The Resident’s clinical record was reviewed on 10/25/16.

Resident #13 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the initial Bladder and Bowel Assessment, dated on 8/30/16, indicated that the Resident was occasionally incontinent of bowel and bladder.

The CNA Care Card was reviewed on 10/25/16 and indicated that the Resident required limited assist of one staff to transfer to the toilet.

Further review of the clinical record indicated no documented evidence of a Toileting Schedule/Determining Urinary Patterns tool to establish a urinary pattern to assist the Resident in staying continent and prevent the Resident from attempting to self transfer him/herself to the toilet.

The Director of Nurses was interviewed on 10/26/16 at 10:20 A.M. and said that the facility does not have a Policy/Procedure on evaluating and monitoring Resident’s bladder status. She said the facility does have a tool titled Toileting Schedule/Determining Urinary Patterns, however the Director said one was not completed for Resident #13.

Refer to F323

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, facility policies and staff interview, the facility failed to ensure that effective interventions were initiated and put in place to provide adequate supervision/oversight to prevent falls with injury for 5 Residents (#1, #3, #12, #13 and #17) in a total sample of 20 Residents.

Findings include:

Review of the facility policies related to falls, incident reporting, fall risks, Fall Prevention Program indicates that a fall assessment and incident report are to be completed.

The Fall Prevention Program indicates the following: Policy statement -To prevent falls and injuries related to falls Fall Risk assessment -To be completed on admission, quarterly, annually, with any significant change of status and after a fall. A quarterly review is done at the PI/QA meetings to determine trends of injuries and falls.

The Falls Investigation Report included, but not limited to:
* Interdisciplinary review
* Care Plan updated
* Certified Nurse Assistant (CNA) care plan updated

1. For Resident #3, the facility failed to complete comprehensive assessments and implement effective interventions to prevent 11 falls in a 4 month period (6/2016 through 10/2106) with one fall resulting in a right femur fracture.

Resident #3 was admitted to the facility in 1/2016 with multiple [DIAGNOSES REDACTED]. A clinical record review indicated that on 6/5/16 at 1:30 P.M., the Resident fell while independently ambulating with a walker sustaining a right distal femur fracture. Resident #3 was then hospitalized and had an open reduction internal fixation surgical intervention (ORIF) of the right hip and returned to the facility on [DATE].

After the fall with injury, the facility failed to follow their fall policies, to comprehensively assess the Resident’s status in relation to this injury by not completing the fall incident / investigations, did not update the Residents care plan, and did not update the Certified Nursing Assistant Care Card. The Resident then sustained 10 more falls with another fall with injury on 9/2/16, that resulted in another hip fracture with ORIF.

– On 6/14/16 at 7:15 A.M., the Resident was found on the floor (FOF) right next to the bed. Resident explained he/she wanted to go to the bathroom. *No incident report/investigation was completed by the facility and no changes were made to the plan of care for falls.

– On 6/19/16 at 2:30 P.M., it was noted that the Resident had increased agitation, increased pain and was noted to be out of bed (OOB) on mat next to bed. Resident complained of increased pain, and was sent out to the emergency room . X-Ray was negative for fracture. *No incident report/investigation was completed by the facility and no changes were made to the plan of care for falls.

– On 6/20/16 on the day shift (7:00 A.M. – 3:00 P.M.) the Resident was noted to be OOB on the floor next to the bed three times. The Resident’s behavior was noted to be agitated and paranoid and yelling. The Resident was incontinent of loose stools 6 times. *No incident report/investigation was completed by the facility and no changes were made to the plan of care for falls.

On 7/19/16 at 7:00 P.M., the Resident was FOF next to bed. It was noted that the Resident had increased agitation and that the Resident made herself/himself slip OOB onto the floor.

*The incident report / investigation was incomplete. The care plan for falls indicated on 7/7/16, the facility instituted mats on the floor by the bed. The plan of care was revised 7/12/16 to include interventions of using a low bed, supervision, physical therapy consult, toileting assistance and provide 1:1 supervision as necessary.

– On 7/22/16 at 8:00 P.M., the Resident had been noted to attempt to get OOB several times. The facility implemented a 1:1 ratio with good effect. Once the staff member left the Resident, the Resident was noted to be OOB next to the bed on the floor mats. *The incident report/investigation was incomplete.

– On 7/24/16 at 5:00 P.M., the Nurse found the Resident sitting on the mat next to the bed.
*The incident report/investigation was incomplete.
– On 7/30/16 at 6:00 P.M. the Resident was FOF on mat next to bed, screaming and on his/her back.

*The incident report/investigation was incomplete and the last change to the fall plan of care was 7/12/16. The Resident continued to have more falls. – On 8/13/16 at 8:00 P.M., Resident very agitated and anxious through out shift. Frequent attempts to get OOB with assist and put self on floor. Resident was found on the floor mat 3 times.

* No incident/investigation was completed. – On 8/22/16 on the 7:00 A.M. to 3:00 P.M. shift (7-3), placed self on mattress on the floor at 7:00 A.M. and 12:00 P.M. (two times).

*No incident report/investigation completed. -On 8/22/16 on the 3:00 P.M. to 11:00 P.M. shift (3-11) placed self on mattress on floor at 9:30 P.M.

*No incident report/investigation completed -On 9/2/16 at 5:35 A.M. the Resident was found on floor on his/her knees next to the bed, alarm was sounding. The Resident stated I had to go to the bathroom.

*The incident report/investigation was incomplete. -On 9/2/16 at 4:30 P.M. the Resident was FOF. Incident Report had indicated that the Resident had self transferred from the wheelchair to the bed. The Resident was sent out to the emergency room and was admitted to the hospital with [REDACTED].

-On 9/10/16 at 6:00 P.M. the Resident was noted to slide OOB with an Activities Aide present, Resident was noted to be incontinent of stool, no injury was sustained. *The incident report/investigation was incomplete.

-On 10/22/16 at 1:50 P.M. the Resident was FOF with the clip alarm still attached to the Resident. The incident report indicated that the pad alarm failed due to improper functioning. *The incident report/investigation was incomplete. The plan of care for falls had no information of an intervention for the use of the clip alarm. -The fall risk assessments completed by the facility on the Resident indicated that the Resident consistently scored over 13 which indicated the Resident was at moderate to high risk for falls and the following interventions were put in place:

Mat on floor next to bed
Bed in low position
Personal alarms
Sensor alarms
Education on call bell use (as appropriate)
Scheduled toileting The Sensor alarms and Personal alarms were never added to the Resident’s plan of care or the CNA’s care card.

The above interventions were never evaluated for their effectiveness, plan of care was not changed to ensure Resident safety and investigations / incident documentation were incomplete and not evaluated for effectiveness which resulted in the Resident having continued falls, with one fall resulting in a right femur fracture.

Clinical record review on 10/24/16 and 10/25/16 indicated the facility failed to complete comprehensive assessments as per facility policy/protocol.

On 10/27/16 at 12:15 P.M., the Director of Nurses (DON) said that the investigations / incident reports were incomplete, with some not being completed at all. The facility failed to complete appropriate comprehensive assessments resulting in ineffective interventions to prevent the Resident from falling resulting in injury.

2. For Resident #1, the facility failed to follow the plan of care requiring two assist with transfers to prevent the Resident from falling resulting in a comminuted fracture of the right ischium (hip) and two acute fractures of the right inferior pubis ramus (pubic bone).

Resident #1 was admitted to the facility in 10/2014, with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 7/19/16, and signed as complete on 7/26/16, indicated that a Brief Interview for Mental Status (BIMS) was not completed indicating that Resident #1 was severely impaired with cognitive skills for daily decision making and rarely/never understands verbal content. The MDS indicated that Resident #1 required extensive assistance with two person physical assist for transfer and was assessed at high risk for falls.

Review of the fall risk care plan dated 7/26/16, indicated that Resident #1 requires the following interventions:
– give frequent verbal reminders not to ambulate/transfer without assistance
– provide toileting assistance as needed
– wear appropriate shoes or non-skid socks when transferring or ambulating
– provide 1:1 supervision

Review of the fall risk care plan dated 7/26/16, indicated that the care plan was not updated after Resident #1 fell and sustained an injury on 9/13/16.

Review of the nursing flow sheet, used by the nurse aide staff to document care provided to the Resident, dated September 2016, prior to the Resident’s fall on 9/13/16, indicated that Resident #1 was a two person transfer and required extensive assist for toilet use. Review of the fall incident report, dated 9/13/16 at 4:30 P.M., indicated that a certified nurse aide (CNA) was assisting Resident #1 in the bathroom and the Resident was standing holding the grab bar with both hands. The CNA was behind the Resident pulling the wheelchair close to the Resident. The Resident became agitated, turned swiftly and fell . Review of the nurses note dated 9/13/16 at 4:30 P.M., indicated that Resident #1 was found sitting on the floor with legs straight outwards complaining of right sided pain, hit his/her head, and had increased swelling above the right ear. The Resident was sent to the hospital and was admitted with a fracture of the right ischium and 2 acute fractures of the inferior pubis ramus. The responsible family member elected for no corrective surgery and the Resident returned to the facility the evening of 9/14/16.

Review of the ADL plan of care card, used by a Certified Nurse Aid (CNA) to know what kind of care to provide to a Resident, dated 10/14/16 continued to indicate that Resident #1 required a two person assist for transfer.

Surveyor #4 interviewed the Director of Nurses (DON) at 3:00 P.M. on 10/21/16. The DON said she did not re-educate the CNA, or refer the CNA to the Staff Development Coordinator for re-education, regarding transferring the Resident with only one assist when Resident #1 required a two person assist for transfers, or that the CNA allowed the Resident to stand alone while she pulled the wheelchair closer to the Resident.

Surveyor #4 interviewed Unit Manager #2 at 12:00 P.M. on 10/25/16 Unit Manager #2 said there was only one CNA in the bathroom with Resident #1 when he/she fell and there was supposed to be two CNAs. Unit Manager #2 said Resident #1 has not walked since the fall on 9/13/16, and requires a wheelchair for mobility.

3. For Resident #13, the facility failed to provide effective interventions to prevent falls for a Resident at high risk for falls. The Resident’s clinical record was reviewed on 10/25/16. Resident #13 was admitted to the facility in 8/2016 with diagnose that included Rhabdomyolysis, dementia, high blood pressure, chronic kidney disease, dysphasia, adult failure to thrive and a history of repeated falls.

The Fall Risk Assessment Tool was inaccurately completed by a nurse on 8/30/16 which indicated that the Resident was at moderate risk for falls, when the Resident was actually at high risk for falls. Further review indicated that the tool was inaccurate for the questions pertaining to medication and fall history. Interview with Unit Manager #1 on 10/25/16 at 12:00 P.M. confirmed the inaccuracy of the assessment and said that the Resident should have been triggered at high risk for falls when the assessment was initially completed on 8/30/16.

A new care plan was developed on 9/8/16 and indicated that the Resident was at moderate risk for falls related to Rhabdomyolysis, deconditioning and unaware of safety needs as a result of confusion. Interventions include:
1. Ensure that Resident is wearing appropriate footwear (white sneakers, non skid socks) when ambulating or mobilizing in wheel chair.
2. Evaluate for appropriate adaptive equipment. Reevaluate as needed for the continued appropriates and to ensure the least restrictive device or restraint.
3. PT evaluation and treat.

Review of the nursing notes dated 10/18/16 indicated at 1:50 A.M. the Resident was found sitting on the bathroom floor in front of the toilet. The Resident pulled the bathroom call light. The fall was unwitnessed and the bed pad alarm did not sound. The nurse documented that she could not determine if the Resident shut off the alarm or if the alarm was broken. The Resident had a large hematoma (a swelling of clotted blood within the tissues) on his/her left side of the forehead.

Review of the facility incident report dated 10/18/16 indicated that the Resident fell in the bathroom, resulting in a hematoma on the left side of the Resident’s forehead. The incident report indicated that prior to the fall the Resident had a low bed, mats on the floor next to their bed, but the bed pad alarm was not working. The incident report did not elaborate on this finding nor were there any documented staff interview that were working that shift, on the unit, at the time of the fall.

Unit Manager #1 was interviewed on 10/25/16 at 3:30 P.M. and said that the Resident would frequently ask to go to the bathroom, approximately every 15 minutes, but due to poor memory issues the Resident would forget that they just were toileted. The surveyor asked if the Resident had been evaluated and a care plan developed for a Toileting plan or establish a bladder pattern. Unit Manager #1 said no. Unit Manager #1 did say that staff placed a wheel chair next to the Resident’s bed at night in case he/she got up, he/she would transfer themselves to the wheel chair and not try to ambulate, however the Resident required assist of one staff to transfer. the Care plan did not address the frequent toileting needs of the Resident.

4. For Resident #17, the facility failed to provide supervision and effective interventions to prevent four falls.

The Resident’s clinical record was reviewed on 10/26/16.

Resident #17 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED].

The Fall Risk Assessment Tool was completed by a nurse on 9/9/16 which indicated that the Resident was at high risk for falls.

Review of the initial care plan dated 9/9/16 indicated that the Resident was at risk for falls but did not identify any interventions to prevent falls.

The Minimum Data Set (MDS) assessment signed as completed on 9/19/16, indicated that the Resident had severely impaired vision, scored a 2 of 15 on BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment, and required extensive assistance with transfer, ambulation, dressing and eating. The MDS also indicated that the Resident used a walker and wheelchair for mobility and had fallen prior to admission. The Resident also received an antipsychotic and antidepressant medication daily.

A new care plan was developed on 9/16/16 that indicated that the Resident was at risk for falls related to dementia with decrease safety awareness, reconditioning, gait/balance problems and psychoactive drug use.

The interventions included:
1. Be aware that (Resident) does not use call light.
2. Ensure that Resident is wearing appropriate footwear when transferring or mobilizing in wheel chair.
3. Alarm in place when in bed or wheel chair.
4. Follow facility fall protocol.
5. PT (Physical Therapy) to evaluate and treat as ordered or PRN (as needed).
6. Resident needs a safe environment with floors free from spills and/or clutter, adequate glare-free light, bed in low position at night, siderails as ordered, handrails.

Review of the nurse’s notes dated 9/19/16 indicated that the Resident was found lying next to the bed on the floor mats wrapped in their blanket. The Resident was assisted to the bathroom to void then returned back to bed. There were no injuries noted. Review of the facility incident report dated 9/19/16 indicated that the Resident’s alarm did not sound because the Resident was sitting on it (which was not clarified on the incident report). The documented interventions included Resident education, pad alarm, fall mats, bed in low position and slipper sox. There were no new interventions identified after the fall.

On 9/25/16 the nurse documented that at 5:30 A.M. the staff heard an alarm sounding and found the Resident sitting on the floor mats next to the bed. The Resident was assisted to the bathroom and voided. There were no injuries noted.

Review of the facility incident report dated 9/25/16 indicated that the Resident was provided education and to continue with low bed, mats on floor, alarms and to consider a video monitor, however there were no change to the care plan and providing education to a cognitively impaired resident was ineffective.

On 10/14/16 the nurse documented that at 10:30 P.M. the Resident was found sitting on the floor on the mat next to the bed. The nurse documented that the Resident was toileted and returned to bed.

Review of the facility incident report dated 10/14/16 indicated that the the Resident most likely needed Toileting and the CNAs were doing rounds and just next door to the Resident’s room. The investigation did not identify if the alarms were sounding at the time of the fall. There were no new interventions put into place after this fall.

On 10/22/16 the nurse documented that the Resident had a fall on the unit in the hallway at 3:00 P.M. The Resident was attempting to stand without assistance.

Review of the facility incident report dated 10/22/16 indicated that the Resident had a fall in the hallway at 3:00 P.M. The report further indicates that the Resident removed his/her body alarm, so it did not sound during the fall. Interventions indicated were to reattach the body alarm and contact the Rehab Department.

In addition to the 4 falls, the nurses documented 13 times between 9/10-10/22/16 that the Resident was up frequently during the 11:00 P.M.-7:00 A.M. shift and had to be brought out to the nurse’s station for supervision due to insomnia and agitation. Although Psychiatric Consult identified insomnia on the 9/22/16 visit there was no interventions to assist the resident in keeping safe.

The Director of Nurses was interviewed on 10/26/16 at 3:00 P.M. and said that she was aware of the third fall and that the Resident should have been toileted sooner. The surveyor asked if the Resident had a Toileting plan based on a three day Toileting pattern, and the DON said no but that would be a good idea.

5. For Resident #12, who had 7 falls within 5 weeks, the facility failed to implement effective interventions and adequate supervision to prevent falls. Resident #12 had 7 falls, 6 of the 7 were unwitnessed, in 5 weeks.

Resident #12 was admitted ,[DATE] for rehabilitation following hospitalization for falls secondary to [DIAGNOSES REDACTED] (a disorder in which low platelet count which may prolong bleeding times) and urinary tract infection requiring antibiotics.

Review of the initial Minimum Data Set (MDS) assessment with a reference date of 9/22/16, indicated that the resident was cognitively impaired, had demonstrated behavior symptoms directed toward others and was dependent on facility staff for most activities of daily living, including incontinence care. The Resident was coded as receiving anti-psychotic, anti-anxiety and anti-depressant medications and had a restraint (chair that prevents rising).The Resident was coded with a 30 day and 2-6 month history of falls. Review of the Care Plan for fall initiated 9/28/16 and revised 10/6/16 (the DON interviewed on 10/25/16 said that their interim care plan did not include falls) included the following interventions:

– Blue chip alarm when in bed or wheelchair
– Safe environment, free from clutter
– Be aware that resident does not use the call light properly
– A monitor is in place when in bed (later identified as baby monitor)

Review of a Restraint Care Plan initiated 9/28/16 and revised 10/6/16 identifies that the restraint – a lap tray on a wheelchair- was initiated when out of bed due to danger to self with attempt to self transfer and unsteady gait with labile alertness.

Review of the ADL (activities of daily living) Plan of Care Card dated 9/15/16 which provides guidance to nurse aide staff on the care needs of the Resident and identified that the Resident was a high fall risk with an alarm (type not specified), low bed and mats on the floor. The ambulation/bed and transfers were emphasized as moderate amount of care needed with 2 persons, toileting was emphasized but left blank and restraints were not identified.

Review of the clinical record indicated that the Resident had 7 falls since admission on the following dates 9/15/16, 9/29/16, 10/2/16, 10/3/16, 10/6/16, 10/7/16 and 10/23/16. Review of the 3:00-11:00 P.M. shift nurse’s admission note (dated 9/15/16), indicated at 7:30 P.M. the Resident’s family member found the Resident on the floor by the bed. The nurse implemented a low bed, bed alarms and mats and obtained an emergency order to place the Resident in a wheel chair with a lap tray for 24 hours.

On 9/27/16 the 11:00 P.M.-7:00 A.M. nurse indicated that the Resident was in the chair with the lap tray in place to help maintain safety and was making multiple attempts to stand.

On 9/29/16 the 7:00 A.M.-3:00 P.M. nurse indicated that at 8:10 A.M. the Resident was found lying on the floor next to the bed with the alarm sounding. No injury was incurred. No new interventions were initiated.

On 10/2/16 at 2:00 P.M. the day shift nurse’s note indicated that the Resident slid down off the wheelchair, under the lap tray and was assisted three times to the sitting position. There was no incident investigation.

On 10/3/16 at 3:50 A.M. the 11:00 P.M.-7:00 A.M. nurse heard a noise and found the Resident on the floor next to the bed. Review of the incident report indicated that the alarm was not working. Review of the care plan with the nurse indicated that no new revisions were implemented. Review of the nurse’s note dated 10/6/16, indicated that at 4:30 P.M. the Resident was observed lying on the floor between the wheelchair and the beds. No apparent injury was reported. The nurse indicated that she left a message with the rehabilitation (rehab) department of the fall and to re-evaluate the lap tray on the wheelchair in the morning.

On 10/7/16 at 6:00 A.M. the Resident was found on the floor next to the bed with the alarm sounding. No injury was identified.

On 10/7/16 the rehab department switched the Resident to a low pedal Broda chair with a lap tray and a gel cushion. The fall care plan and nurse aide care card did not include this intervention.

On 10/10/16 the health care agent gave approval for video monitoring set up of the Resident’s room (provides direct observation of the Resident). The fall care plan and nurse aide care card did not include this intervention.

On 10/23/16 at 4:50 A.M. staff responded to the alarm sounding and the nurse aide witnessed the Resident standing between the bed and window and then fall to the floor. The incident report failed to indicate if the video monitoring of the Resident was functioning. The resident sustained [REDACTED].

On 10/24/16 at 3:00 P.M. the Director of Nurses was interviewed and reviewed existing documentation regarding Resident #12’s multiple falls. The DNS said that she had no information regarding the 9/15/16 and 10/2/16 falls. The DON said that she could not explain why interventions were not implemented as indicated on the incident reports.

Refer to F353.

Failed to Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interviews, the facility failed to assess for migration of a Midline (vascular access device), for one (#18 ) Resident receiving intravenous antibiotics from a total sample of 20 Residents . Additionally, after the removal of the vascular device there was no documentation of assessing the integrity and measuring total length of the Midline.

Findings include:

For Resident #18, the facility failed to assess for the possible migration of the Midline device after documenting a difference with the measurement of the external catheter length from that of the hospital.

Resident #18 was a closed record review and was admitted to the facility 8/2016, following a hospitalization [MEDICAL CONDITION] secondary to Staphylococcus aureus bacteremia and possible source of pneumonia. The medical record indicated the Resident had multiple [DIAGNOSES REDACTED].

The hospital discharge summary dated 8/11/16 indicated the Resident would receive [MEDICATION NAME] 2 grams IV (intravenous) with [MEDICAL TREATMENT] and last dose was noted to be 8/20/16. The hospital paperwork included the vascular line placement information dated 8/5/16 that noted the Midline placement in the right arm was a total length of 20 cm (centimeters), the right arm circumference measured 26 cm and the zero external length measurement documented at hospital.

A review of the nurses’ note dated 8/12/16, the second day of admission, the nurse indicated the first dressing change was done for the Midline and noted 7.5 cm catheter exposed. There was no other documentation that the nurse assessed the difference with the external catheter measurements that was exposed 7.5 cm. and possible migration of the vascular line.

The medical record indicated the Midline device was removed on 8/22/16 and the nurse documented, the Midline removed the am. There was no information to review for a description of the line and/or what the total length was removed from the arm to ensure the entire line was removed.

During record review and interview on 10/26/16 at 8:40 A.M., the Staff Development Coordinator (SDC) said the Infusion company must have removed the Midline and proceeded to search for the company documentation. The record had no documentation and then she said all the nurses in the facility can pull the lines, but was unsure of who had removed the line. The SDC could not find any information of who had removed the Midline. During interview on 10/26/16 at 9:20 A.M., Unit Manager #2 said she could find no documentation as to who had removed the Midline but would probably call the nurse who wrote the nurses’ note. There was no other information provided to the surveyor regarding this Resident’s Midline removal.

Failed to have enough nurses to care for every resident in a way that maximizes the resident's well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation and staff and family interviews, the facility failed to ensure that there was sufficient nursing staff, available on a daily basis through the facility, to meet the needs for nursing care in a manner which promotes each Resident’s physical, mental and psychosocial well being, thus enhancing their quality of life.

Findings include:

1. Nursing Staff a. Following the entrance to the facility on [DATE], the Administrator and the Director of Nurses (DON) said that the 3:00-11:00 P.M. RN Supervisor, who was also responsible for Infection Control, had retired as of 9/30/16. The Administrator also said that the existing Unit Nurse Manager (UM) position on the 2nd floor was also vacant and had been for 15 months, but they were actively recruiting a replacement. The DON said she was covering both the duties related to the vacant UM position and the Infection Control Program.

b. During the initial facility tour of the 2nd floor unit on 10/20/16 at approximately 9:15 A.M. with the DON, multiple Residents were observed in the hallway seated in Broda chairs and or wheelchairs, several of which had lap trays (a restraint) applied. The DON said that several of the Residents are receiving Hospice services, which includes a Broda chair for comfort. One Resident (#3) was observed in bed with his her legs hanging over the perimeter mattress of the bed. The DON said that the Resident was recovering from a [MEDICAL CONDITION] due to a fall. The DON summoned the assigned Certified Nurse Aide (CNA) to have the Resident repositioned in the presence of the Surveyor and the Resident was observed to have a saturated urine soaked pull-up on. The CNA told the DON that she was waiting for therapy to get the Resident up. The 2 Medication Nurse(s) were repeatedly observed trying to redirect multiple Residents away from the nurses’ station including an agitated Resident in a Broda chair and another Resident asking what she should do now. The nurses were observed shuffling between administering morning medications, answering multiple phone calls, and completing paper work. The DON said that she was just given approval that morning to hire the existing vacant Unit Nurse Manager position.

c. On 10/25/16 at 10:50 A.M. Nurse (#2) was interviewed and said that she had spoken with the Administrator on several occasions beginning 2 to 3 months ago about the vacant Unit Nurse Manager’s position. Nurse #2 said that since the position has been vacant (15 months) she has assumed multiple new tasks that have increased her workload for example; dealing with multiple physician/clinical staff providers when there are changes in the Resident’s status, overseeing feeding of 15 Residents (the census was 35 of 40 Residents), and dealing with families who have concerns about their family members. Nurse #2 said that these additional duties have impacted her ability to pass medications on time. Nurse #2 said the Administrator indicated that it was a lot to manage but that he would send help. Nurse #2 was asked if the activities program helped provide diversion for the Residents, especially those observed with agitating behavior and she said that consistent activities are not being provided. Nurse #2 said that she had spoken to the Director of Activities (also functions as 20 hours Activities Director/20 hours Social Worker) that activity programs are not consistent especially for those Resident’s with the [DIAGNOSES REDACTED].#2 was asked if there was sufficient nursing staff and she said that the unit is usually staffed with 3-4 CNA’s with regular assignments. Nurse #2 said that the fifth CNA assignment (that was previously filled by float staff) was only filled today.

Review of the staffing sheets from 10/16/16 to 10/20/16 indicated the following:
7:00 A.M.-3:00 P.M. shift 2 to 4 CNA’s were providing care
3:00-11:00 P.M. shift 2 to 3 CNA’s were providing care
11:00 P.M.-7:00 A.M. shift 2 CNA staff were providing care

The staffing scheduler was interviewed on 10/26/16 at 9:00 A.M. and said that the goal for staffing for CNA’s on the 2nd floor consisted of: 7:00 A.M.-3:00 P.M. day shift staff 4-5 CNA’s, 3:00-11:00 P.M. evening shift 3-4 CNA’s 11:00 P.M.-7:00 A.M. night shift 2 CNA’s

The scheduler indicated that there were holes in the current schedule and that is supplemented with agency and per diem staff. The scheduler said that the staffing assignments are based on the morning meeting census and is determined by the Administrator Observations on the second floor during the (10/20/16) afternoon, Residents repeatedly approaching the Unit Nurses at the medication cart and the nursing desk with multiple requests including, to go to the bathroom, where to put their empty cup, request for drinks, snacks and/or to engage in conversation. The only planned activity occurring on the unit during this time frame included Fall Reminisce which failed to engage their interests.

It was observed by a surveyor on 10/21/16 and 10/25/16, (morning and afternoon) there were no activities other than a television viewing in the second floor unit day room.

On 10/25/16 at 10:50 A.M., the Surveyor observed Resident #5 in a wheel chair in his/her room staring straight ahead at the wall. The Surveyor asked the Resident if he/she was going to attend any of the scheduled activities that day. The Resident said that he/she liked the trivia program, but could not see the event calendar because of limited vision. The Surveyor read the activity calendar out loud. The trivia program was scheduled at 10:45 A.M. that same day (5 minutes overdue). The Surveyor observed the Resident become anxious and the Resident said I’m late. The Surveyor asked the Resident if the Activity Aide usually comes to get him/her for activities. The Resident said that that they do, unless they are busy.

On 10/26/16 at 2:00 P.M., the Surveyor interviewed the Activities Director (AD). The AD said that all Activity Aides were unavailable for activity programs between 11:00 A.M. to 1:30 P.M. daily because they were required to help with Residents feeding needs.

2. Family concerns:

a) During interview on 10/20/16 at 12:30 P.M., a family member of Resident #6 said that he/she was concerned about the lack of nursing staff, not enough CNAs and there has been no (second unit) nurse manager for a long time. The family member said that he/she has spoken with the Administrator of these staffing concerns. During the morning and afternoon on 10/21/2016 and 10/25/2016, Resident #6 was observed sitting in the corridor in the Broda chair with a lap tray except when he/she left the unit to go to the hairdresser/barber and for an early morning family visit on 10/21/16.

b) On 10/26/16 at 10:30 A.M., Surveyor #3 interviewed Resident #14’s spouse. The spouse said that he/she was in the facility everyday and stayed through lunch because the facility does not have enough staff to feed all the Residents. He/she said that the staff were very good, but that the facility needed more of them. Surveyor #3 asked for a specific example of a lack of staff. The Resident’s spouse said that he/she frequently toilets the Resident because there is never a staff member available and on more than one occasion, the Resident had an accident on the floor, while the spouse was out trying to find assistance. The spouse also said that on weekends the facility is shorter staffed and said specifically for CNA’s. He/she said that Saturdays are hectic.

3. The facility failed to ensure that food was served at the appropriate temperatures for 2 of 2 test trays served on the 2nd floor unit.

Observations of the 10/21/16 breakfast meal delivery service identified that the second floor resident unit meal trays were being distributed at 8:25 A.M. After twenty minutes, several (4)meal trays sat unserved on this second food cart and at 8:45 A.M. the unit nurse instructed nurse aides to deliver the remaining trays to resident rooms, who were still in need of feeding assistance.

4. The facility failed to release and remove restraints per the plan for care for 4 sampled Residents (#4, #6, #12, #17) For example: for Resident #4, the Surveyors made the following observations:

On 10/20/16 at 4:30 P.M., Resident #4 was observed by the Surveyor seated outside his/her room in the Broda chair with the lap tray on telling staff that he/she wanted to get out of the chair.

On 10/20/16 at 5:24 P.M., Surveyor #2, observed the Resident in the same position set up to feed himself/herself.

On 10/24/16 at 9:45 A.M. to 11:30 A.M., the Resident was observed by Surveyor #1 to be seated outside his/her room in the Broda chair with the lap tray on. According to their positioning records for 12:00 P.M. and at 2:00 P.M., the Resident was only provided a weight shift. There was no documentation that the Resident was removed from the chair and not provided exercise or toileted as planned.

On 10/26/16 at 8:20 A.M., the Resident was observed by the Surveyor(s) seated outside his/her room in the Broda chair with the lap tray on and set up for breakfast. At 9:00 A.M., the Resident was observed sleeping in the Broda chair where he/she remained without any observed intervention from staff until 11:40 A.M. when the nurse aide staff were observed toileting the Resident. At 12:00 P.M., Resident #4 was observed seated outside his/her room in the Broda chair with the lap tray reapplied. At 2:00 P.M. Resident #4 was observed again seated in the same position and was heard asking the nurse to go to rehab. I need to move more.

5. The facility failed to ensure that effective interventions were initiated and to provide adequate supervision/oversight to prevent falls with injury for 5 sampled Residents (#1, #3, #12, #13, #17).

For example: for Resident #1, on 9/13/16 at 4:30 P.M., the resident fell in the bathroom while being assisted by a CNA while the Resident was standing, holding onto the grab bar with both hands. The CNA was standing behind the Resident, pulling the wheelchair close to the Resident. The Resident became agitated, turned quickly and fell resulting in a [MEDICAL CONDITION] ischium and 2 fractures of the pelvis requiring corrective surgery. Review of the CNA care card indicated that the Resident required a 2 person assist for transfer.

6. The facility failed to provide sufficient staff to ensure that routine drugs were administered timely, for 5 (#1, #2, #4, #15, #16) of 20 sampled Residents. Review of these residents medical record indicated a pattern of nursing not able to administer the residents’ medications timely on various dates.

A. On 10/20/16 at approximately 1:15 P.M. and throughout the day, the facility SDC (Staff Development Coordinator) was interviewed by the Surveyor and said that she was responsible for training, related to the new electronic medical record (EMR) which was implemented 7/22/16. The SDC said that the EMR is able to track late administration of medications (beyond 1 hours of the scheduled administration time.) The SDC was asked if the facility is tracking late administration times since the implementation of the new EMR said that she had not.

B. During a 10/25/16, 10:50 A.M. interview Nurse (#2) said that she had spoken with the Administrator many times beginning 2 to 3 months ago about the vacant Unit Nurse Manager’s position. Nurse #2 said that since the position has been vacant (15 months) she has assumed multiple new tasks that have increased her workload and impacted her ability to pass medications on time. Nurse #2 said that she and Nurse # 3 approached the Administrator again 2 to 3 weeks ago to reiterate their concerns.

C. During the QA (Quality Assessment) interview on 10/26/16 at 3:20 P.M. the Administrator was asked if the facility had completed audits for late administration of medications said that the SDC was completing audits for the QA process.

1. For Resident #4, the facility failed to administer timely medications as ordered by the Resident #4 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the medical record included the the Resident had physician’s orders [REDACTED].

– AB gel 1/50 ([MEDICATION NAME] with [MEDICATION NAME]) to be given with [MEDICATION NAME] twice daily (for agitation) scheduled at 8:00 A.M. and 5:00 P.M. – [MEDICATION NAME] gel 100 milligrams twice daily (for agitation) scheduled at 8:00 A.M. and 5:00 P.M. – Fludrocortisone Acetate 0.1 give 2 tablets twice daily (steroid) scheduled at 7:30 A.M. and 12:00 P.M. – Potassium Chloride ER (extended release) 10 meq three times daily scheduled at 8:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the 9/16 through 10/24/16 Medication Administration Record (MAR) indicated that the nurses administered the following medications late. – AB gel: 7 times – [MEDICATION NAME]: 7 times – Fludrocortisone acetate: 17 times – Potassium Chloride: 8 times Including, but not limited to, the following examples: – 9/16/16 – All four medications listed above scheduled for 7:30 A.M. and 8:00 A.M., were administered at 9:25 A.M. – 10/1/16 – All four medications listed above scheduled for 7:30 A.M. and 8:00 A.M., were administered at 9:28 A.M. – 10/14/16 – All four medications listed above scheduled for 7:30 and 8:00 A.M., were administered at 9:32 A.M.

2. For Resident #1, the facility failed to administer scheduled medications timely as ordered by the physician.

Resident #1 was admitted to the facility in 10/2014, with [DIAGNOSES REDACTED]. Review of the medical record indicated that Resident #1 had a physician order [REDACTED]. Review of the Medication Administration Audit Report (MAAR), from 10/1/16 through 10/21/16, indicated that nursing staff administered the cardiac medication late 13 times. Including, but not limited to, the following examples:

– 10/3/16 – [MEDICATION NAME] scheduled for 9:00 A.M. administered at 11:44 A.M.
– 10/8/16 – [MEDICATION NAME] scheduled for 9:00 A.M. administered at 11:19 A.M.
– 1011/16 – [MEDICATION NAME] scheduled for 9:00 A.M. administered at 10:57 A.M.
– 10/17/16 – [MEDICATION NAME] scheduled for 9:00 A.M. administered at 11:26 A.M.
– 10/19/16 – [MEDICATION NAME] scheduled for 9:00 A.M. administered at 11:02 A.M.

3. For Resident #15, the facility failed to administer scheduled medications timely as ordered by the physician. Resident #15 was admitted to the facility in 6/2013, with [DIAGNOSES REDACTED]. Review of the medical record indicated that Resident #15 had a physician order [REDACTED].

Review of the Medication Administration Audit Report (MAAR), from 10/1/16 through 10/23/16, indicated that nursing staff administered the pain medication late 15 times. Including, but not limited to, the following examples:
– 10/1/16 – [MEDICATION NAME] scheduled for 8:00 A.M. administered at 9:29 A.M.
– 10/6/16 – [MEDICATION NAME] scheduled for 8:00 A.M. administered at 9:30 A.M.
– 10/11/16 – [MEDICATION NAME] scheduled for 8:00 A.M. administered at 9:34 A.M.
– 10/18/16 – [MEDICATION NAME] scheduled for 8:00 A.M. administered at 9:27 A.M.
– 10/20/16 – [MEDICATION NAME] scheduled for 8:00 A.M. administered at 9:30 A.M.

4. For Resident #2, the facility failed to administer scheduled medications timely as ordered by the physician.

Resident #2 was admitted to the facility in 12/2012 with [DIAGNOSES REDACTED]. Record review indicated that the Resident had physician orders [REDACTED]. -[MEDICATION NAME] 5 milligram (mg) / 5 milliliter (ml), to administer 1 ml twice a day at 8:00 A.M. and 8:00 P.M.

-[MEDICATION NAME] 25 mg (one half tab 12.5 mg), twice a day at 8:00 A.M. and 8:00 P.M. Review of the 10/2016 MAR and the Medication Administration Audit Report indicated that the nurses administered the following medications late:
-[MEDICATION NAME]- administered late 8 times
-[MEDICATION NAME]-administered late once Including but not limited to the following examples:
10/1/16 [MEDICATION NAME] scheduled for 8:00 A.M. was administered at 9:36 A.M.
10/3/16 [MEDICATION NAME] scheduled for 8:00 A.M. was administered at 9:26 A.M.
10/11/16 [MEDICATION NAME] scheduled for 8:00 A.M. was administered at 9:44 A.M.
10/17/16 [MEDICATION NAME] scheduled at 8:00 A.M. was administered at 9:14 A.M.

5. For Resident #16, the facility failed to administer scheduled medications timely as ordered by the physician. Resident #16 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. Record review indicated that the Resident had physician order’s which included the following medications: [REDACTED]

– [MEDICATION NAME] (antidiabetic) 5 mg (give 0.5 mg tablet ) one time at 7:30 A.M. – [MEDICATION NAME] (anticonvulsant) [MEDICATION NAME] 50 mg (give 1 tablet twice a day) with [MEDICATION NAME] Sodium Extended (1 capsule 100 mg tablet twice a day) to equal 150 mg twice a day.

– [MEDICATION NAME] (diuretic) 20 mg tab (give 3 tablets) to equal 60 mg, every morning (8:00 A.M.) and evening (5:00 P.M.). -[MEDICATION NAME] ([MEDICATION NAME] pain relief) 5 mg/ 5 ml solution (give 1 ml ) two times a day (8:00 A.M. and 5:00 P.M.) Review of the 10/2016 MAR and the Medication Administration Audit Report indicated that the nurses administered the following medications late: -[MEDICATION NAME] medication, late 10 times.
-[MEDICATION NAME] medication was administered by the nurses late 10 times.
-[MEDICATION NAME] medication was administered late 5 times.
-[MEDICATION NAME] medication was late 5 times. Included but not limited to the following examples: 10/2/16 [MEDICATION NAME] administered 1 hour and 45 minutes late 10/3/16 [MEDICATION NAME] administered 1 hour and 27 minutes late 10/8/16 [MEDICATION NAME] administered 2 hours and 7 minutes late 10/9/16 [MEDICATION NAME] administered 1 hour and 59 minutes late 10/14/16 [MEDICATION NAME] administered 1 hour and 23 minutes late 10/18/16 [MEDICATION NAME] administered 2 hours and 47 minutes late 10/22/16 [MEDICATION NAME] administered 1 hour and 53 minutes late 10/24/16 [MEDICATION NAME] administered 2 hours and 4 minutes late 10/8/16 [MEDICATION NAME] administered 1 hour and 36 minutes late 10/8/16 [MEDICATION NAME] Sodium Extended Capsules 1 hour and 38 minutes late 10/9/16 [MEDICATION NAME] administered 1 hour and 29 minutes late 10/9/16 [MEDICATION NAME] Sodium Extended Capsules 1 hour and 31 minutes late 10/22/16 [MEDICATION NAME] administered 1 hour and 23 minutes late

10/22/16 [MEDICATION NAME] Sodium Extended Capsules 1 hour and 23 minutes late
10/23/16 [MEDICATION NAME] administered 1 hour and 30 minutes late
10/23/16 [MEDICATION NAME] Sodium Extended Capsules 1 hour and 31 minutes late
10/24/16 [MEDICATION NAME] administered 1 hour and 49 minutes late
10/24/16 [MEDICATION NAME] Sodium Extended Capsules 1 hour and 49 minutes late
10/9/16 [MEDICATION NAME] administered one hour and 30 minutes late
10/18/16 [MEDICATION NAME] administered 2 hours and 18 minutes late
10/25/16 [MEDICATION NAME] administered 1 hour and 32 minutes late
10/8/16 [MEDICATION NAME] administered 1 hour and 39 minutes late
10/24/16 [MEDICATION NAME] administered 2 hours late

Failed to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with staff, the facility failed to ensure that meals served to dependent residents on 1 of 3 units were served at the appropriate temperatures for 2 of 2 test trays (breakfast observation) served with unpalatable food temperatures.

Findings include:

During interviews at the time of survey visit, 10/20/16 to 10/26/16, unit nurses (#2 and #3) stated that there were at least fifteen residents that required staff assistance and were fed their meals on the second floor long term care unit. Observations on the second floor unit during the 10/21/16 breakfast service indicated that multiple trays (6) sat unserved on the long term care unit’s first and second food cart until staff were available to serve and feed the residents. According to the facility’s meal truck schedule, the second floor unit delivery time for breakfast was at 7:40 A.M. and 8:10 A.M. Observations of the 10/21/16 breakfast meal delivery service identified that the second floor resident unit meal trays were being distributed at 8:25 A.M. After twenty minutes, several (4)meal trays sat unserved on this second food cart and at 8:45 A.M. the unit nurse instructed nurse aides to deliver the remaining trays to resident rooms, who were still in need of feeding assistance.

A breakfast meal tray was tested on [DATE], at the time nursing staff was ready to feed the last resident from this second food truck at 8:58 A.M. The meal tray was sampled and included the following temperatures: the scrambled eggs registered 103 degrees Fahrenheit (F) and tasted cool (tepid) to taste. The hot cereal registered 119 degrees (F) and was luke warm to taste; the thickened juice beverage was 63 degrees (F).

On 10/26/16, as the last resident was served a breakfast tray at 8:47 A.M. a meal tray was sampled. The test tray results were as follows: the scrambled eggs registered 80 degrees Fahrenheit (F) and tasted cold; the hot cereal had a thick congealed top layer, indicative of sitting and cooling which registered 106 degrees (F) and was cool to taste. Cold beverages were warm with the thickened juice beverage at 70 degrees (F), the fortified shake at 64 degrees and thickened milk at 62 degrees (F).

During interview on 10/26/16 at 1:40 P.M., the Food Service Manager (FSM) said that the facility did not conduct test trays to monitor for acceptable food temperatures and agreed that the food temperatures from test tray results were unacceptable.

Failed to provide routine and 24-hour emergency dental care for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and Resident interview, the facility failed to ensure that for 1 Resident (#4), out of a total sample of 13 Residents, received timely consultative dental services when the Resident complained about a toothache.

Findings include:

Resident #4 was admitted to the facility 3/2016 and had active [DIAGNOSES REDACTED]. Review of the clinical record dated 12/25/16 on the 11:00-7:00 A.M. shift indicated that the Resident began complaining about a toothache that became progressively worse from 12/27/16 – 1/1/17 with unabated pain due to ineffective pain management. On 1/11/17 the facility’s Social Service progress note indicated that a Hospice meeting was held January 4 and that the Resident had declined mentally in the past 2 weeks where (he/she) is having more hallucinations .PRN meds are ordered and given as needed. The Social Worker made no mention of the Resident’s complaints tooth/mouth pain or need for pain medication.

On 1/11/16 at 3:00 P.M. the interim charge nurse (ICN) was interviewed and reviewed existing nursing documentation with the surveyor. The ICN said that she was unaware that the Resident was complaining of a toothache. The ICN was asked if a dental consult had been ordered and she said no. The ICN said that she planned to contact the physician to assess the Resident and obtain a dental consult.

On 1/12/17 at 11:30 A.M., following Surveyor inquiry the Physician visited the Resident earlier that morning (no note was made available during the survey) and indicated that the Resident currently had no acute pain, but ordered a dental consult. The ICN said that a dental consult would be completed sometime next week but no date was given.

On 1/12/17 at 12:00 P.M. Resident #4 was observed seated in a Broda chair in the hallway adjacent to the Nurses’ desk conversing with a family member (identified as the responsible person.) The Resident and family member were greeted by the Surveyor and was asked how he/she was doing and he/she replied I’m good with a big smile. The Resident was asked if he/she still had a toothache and he/she replied I’m okay right now. The family member said that the Resident had been complaining about a toothache beginning a couple of weeks ago and that he/she tried to get a dental appointment but the insurance would not cover. The family member said that the Social Worker had spoken with him/her earlier and ensured the family member that the facility would make the necessary arrangements. On 1/17/17 at approximately 10:30 A.M. the Interim Charge Nurse (ICN) reported that Resident #4 was visited by the Dentist on 1/16/17. The ICN said that the Dentist indicated that the Resident had no acute pain but had a fractured tooth which required a procedure for the dentist to smooth over the tooth (to prevent jagged edges).

Failed to safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide sufficient staff to ensure that routine drugs were administered timely, for 5 (#1, #2, #4, #15, #16) of 20 sampled Residents. Review of these residents medical record indicated a pattern of nursing not able to administer the residents’ medications timely on various dates.

Findings include:

A. On 10/20/16 at approximately 1:15 P.M. and throughout the day, the facility SDC (Staff Development Coordinator) was interviewed by the Surveyor and said that she was responsible for training, related to the new electronic medical record (EMR) which was implemented 7/22/16. The SDC said that the EMR is able to track late administration of medications (beyond 1 hours of the scheduled administration time.) The SDC was asked if the facility is tracking late administration times since the implementation of the new EMR said that she had not.

B. During a 10/25/16, 10:50 A.M. interview Nurse (#2) said that she had spoken with the Administrator many times beginning 2 to 3 months ago about the vacant Unit Nurse Manager’s position. Nurse #2 said that since the position has been vacant (15 months) she has assumed multiple new tasks that have increased her workload and impacted her ability to pass medications on time. Nurse #2 said that she and Nurse # 3 approached the Administrator again 2 to 3 weeks ago to reiterate their concerns.

C. During the QA (Quality Assessment) interview on 10/26/16 at 3:20 P.M. the Administrator was asked if the facility had completed audits for late administration of medications said that the SDC was completing audits for the QA process. 1. For Resident #4, the facility failed to administer timely medications as ordered by the physician.

Resident #4 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the medical record included the the Resident had physician’s orders [REDACTED].
– AB gel 1/50 (Ativan with Benadryl) to be given with Seroquel twice daily (for agitation) scheduled at 8:00 A.M. and 5:00 P.M.
– Seroquel gel 100 milligrams twice daily (for agitation) scheduled at 8:00 A.M. and 5:00 P.M.
– Fludrocortisone Acetate 0.1 give 2 tablets twice daily (steroid) scheduled at 7:30 A.M. and 12:00 P.M.
– Potassium Chloride ER (extended release) 10 meq three times daily scheduled at 8:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the 9/16 through 10/24/16 Medication Administration Record (MAR) indicated that the nurses administered the following medications late.
– AB gel: 7 times – Seroquel: 7 times – Fludrocortisone acetate: 17 times –

Potassium Chloride: 8 times Including, but not limited to, the following examples: – 9/16/16
– All four medications listed above scheduled for 7:30 A.M. and 8:00 A.M., were administered at 9:25 A.M.
– 10/1/16 – All four medications listed above scheduled for 7:30 A.M. and 8:00 A.M., were administered at 9:28 A.M.
– 10/14/16 – All four medications listed above scheduled for 7:30 and 8:00 A.M., were administered at 9:32 A.M.

2. For Resident #1, the facility failed to administer scheduled medications timely as ordered by the physician. Resident #1 was admitted to the facility in 10/2014, with [DIAGNOSES REDACTED]. Review of the medical record indicated that Resident #1 had a physician order [REDACTED].

Review of the Medication Administration Audit Report (MAAR), from 10/1/16 through 10/21/16, indicated that nursing staff administered the cardiac medication late 13 times. Including, but not limited to, the following examples:

– 10/3/16 – Metoprolol Tartrate scheduled for 9:00 A.M. administered at 11:44 A.M. – 10/8/16 – Metoprolol Tartrate scheduled for 9:00 A.M. administered at 11:19 A.M. – 1011/16 – Metoprolol Tartrate scheduled for 9:00 A.M. administered at 10:57 A.M. – 10/17/16 – Metoprolol Tartrate scheduled for 9:00 A.M. administered at 11:26 A.M. – 10/19/16 – Metoprolol Tartrate scheduled for 9:00 A.M. administered at 11:02 A.M.

3. For Resident #15, the facility failed to administer scheduled medications timely as ordered by the physician. Resident #15 was admitted to the facility in 6/2013, with [DIAGNOSES REDACTED]. Review of the medical record indicated that Resident #15 had a physician order [REDACTED].

Review of the Medication Administration Audit Report (MAAR), from 10/1/16 through 10/23/16, indicated that nursing staff administered the pain medication late 15 times. Including, but not limited to, the following examples: – 10/1/16 – Gabapentin scheduled for 8:00 A.M. administered at 9:29 A.M. – 10/6/16 – Gabapentin scheduled for 8:00 A.M. administered at 9:30 A.M. – 10/11/16 – Gabapentin scheduled for 8:00 A.M. administered at 9:34 A.M. – 10/18/16 – Gabapentin scheduled for 8:00 A.M. administered at 9:27 A.M. – 10/20/16 – Gabapentin scheduled for 8:00 A.M. administered at 9:30 A.M.

4. For Resident #2, the facility failed to administer scheduled medications timely as ordered by the physician. Resident #2 was admitted to the facility in 12/2012 with [DIAGNOSES REDACTED]. Record review indicated that the Resident had physician orders [REDACTED]. -Methadone 5 milligram (mg) / 5 milliliter (ml), to administer 1 ml twice a day at 8:00 A.M. and 8:00 P.M. -Seroquel 25 mg (one half tab 12.5 mg), twice a day at 8:00 A.M. and 8:00 P.M. Review of the 10/2016 MAR and the Medication Administration Audit Report indicated that the nurses administered the following medications late: -Methadone- administered late 8 times -Seroquel-administered late once

Including but not limited to the following examples: 10/1/16 Methadone scheduled for 8:00 A.M. was administered at 9:36 A.M. 10/3/16 Methadone scheduled for 8:00 A.M. was administered at 9:26 A.M. 10/11/16 Methadone scheduled for 8:00 A.M. was administered at 9:44 A.M. 10/17/16 Seroquel scheduled at 8:00 A.M. was administered at 9:14 A.M. 5. For Resident #16, the facility failed to administer scheduled medications timely as ordered by the physician. Resident #16 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. Record review indicated that the Resident had physician order’s which included the following medications: [REDACTED] – Glipizide (antidiabetic) 5 mg (give 0.5 mg tablet ) one time at 7:30 A.M. – Phenytoin (anticonvulsant) Infatabs 50 mg (give 1 tablet twice a day) with Phenytoin Sodium Extended (1 capsule 100 mg tablet twice a day) to equal 150 mg twice a day. – Furosemide (diuretic) 20 mg tab (give 3 tablets) to equal 60 mg, every morning (8:00 A.M.) and evening (5:00 P.M.). -Methadone (analgesic pain relief) 5 mg/ 5 ml solution (give 1 ml ) two times a day (8:00 A.M. and 5:00 P.M.) Review of the 10/2016 MAR and the Medication Administration Audit Report indicated that the nurses administered the following medications late: -Glipizide medication, late 10 times.

-Phenytoin medication was administered by the nurses late 10 times. -Furosemide medication was administered late 5 times. -Methadone medication was late 5 times. Included but not limited to the following examples: 10/2/16 Glipizide administered 1 hour and 45 minutes late 10/3/16 Glipizide administered 1 hour and 27 minutes late 10/8/16 Glipizide administered 2 hours and 7 minutes late 10/9/16 Glipizide administered 1 hour and 59 minutes late 10/14/16 Glipizide administered 1 hour and 23 minutes late 10/18/16 Glipizide administered 2 hours and 47 minutes late 10/22/16 Glipizide administered 1 hour and 53 minutes late 10/24/16 Glipizide administered 2 hours and 4 minutes late 10/8/16 Phenytoin Infatabs administered 1 hour and 36 minutes late 10/8/16 Phenytoin Sodium Extended Capsules 1 hour and 38 minutes late 10/9/16 Phenytoin Infatabs administered 1 hour and 29 minutes late 10/9/16 Phenytoin Sodium Extended Capsules 1 hour and 31 minutes late 10/22/16 Phenytoin Infatabs administered 1 hour and 23 minutes late 10/22/16 Phenytoin Sodium Extended Capsules 1 hour and 23 minutes late 10/23/16 Phenytoin Infatabs administered 1 hour and 30 minutes late 10/23/16 Phenytoin Sodium Extended Capsules 1 hour and 31 minutes late 10/24/16 Phenytoin Infatabs administered 1 hour and 49 minutes late 10/24/16 Phenytoin Sodium Extended Capsules 1 hour and 49 minutes late 10/9/16 Furosemide administered one hour and 30 minutes late 10/18/16 Furosemide administered 2 hours and 18 minutes late 10/25/16 Furosemide administered 1 hour and 32 minutes late 10/8/16 Methadone administered 1 hour and 39 minutes late 10/24/16 Methadone administered 2 hours late

Failed to have a program that investigates, controls and keeps infection from spreading.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, staff interviews, facility policy and infection control line list review, the facility failed to maintain an effective Infection Prevention and Control Program (ICP), in order to correctly identify infections and control and monitor the potential spread of infection within the facility, for 3 sampled and 1 non-sampled Residents (#2, #6, #9, and NS#1), from a total of 20 residents. Specifically, the facility failed to:

1. follow McGeer’s Criteria (standard that facility indicated it endorsed for their infection control program) by incorrectly identifying true infections based on antibiotic use and not resident reported symptoms

2. identify and monitor for the potential spread of Clostridium Difficile on one unit and

3. analyze, track and trend for the spread of rashes (12 residents on one unit). The failure to maintain an effective ICP has the potential to effect all residents in the facility.

Findings include:

1. On 10/21/16 at 1:50 P.M., Unit Manager (UM) #1 was interviewed following Surveyor identification that a Resident from the initial tour, had an active urinary tract infection (uti), but was not reported as having a uti. (The Surveyor later identified that the same resident was not listed on the facility’s 9/2016 line listing for urinary tract infections.) Surveyor #3 requested the unit’s line list of infections. The UM said that she did not maintain a list of residents with infections. She said that the evening supervisor had retired and now there was no actual plan.

On 10/21/16 at 3:00 P.M., following observation of breaches in infection control, Surveyor #3 interviewed the Director of Nursing Services (DNS). The DNS said that she was the designated person overseeing the infection control program. The DNS said that until 9/30/16, the evening supervisor was overseeing the infection control program, but had retired (3 weeks prior to survey). The DNS provided the Surveyor with line listings for 6/2016-9/2016, but could not provide a line listing for the month of October because she said that it wasn’t completed. She also said that she was bringing the (retired) evening supervisor back to the facility to pull everything together for the October line listings. The DNS could not provide the Surveyor with the most recent quarterly infection rates of the facility.

On 10/26/16 at 11:30 A.M., the survey team interviewed the former evening supervisor, who had been previously acting as the Infection Control Nurse (ICN). The former ICN said that she did not attend the Quality Improvement meetings while working at the facility (which is a requirement of the facility’s ICP program). The former ICN said that she had attended some IC programs through the facility’s laboratory services. The survey team then asked the ICN how she identified and monitored infections in the facility. She said that she followed the McGeer Criteria for surveillance. (McGeer’s Criteria is the national standard for infection surveillance in long term care, which defines the resident symptoms and other clinical criteria used to meet infection definitions for proper surveillance). The ICN also said that she determined which residents had infections based on a computer generated antibiotic list, which was printed every morning (this is not consistent with current McGeer Criteria which defines specific symptoms and the need for cultures before treating a true infection).

According to the CDC’s Infection Surveillance Guidance Tips in Long-Term Care Facilities : The line list should be monitored and updated regularly to identify clusters, outbreaks, and other unusual infection patterns. Infection cues that an Infection Preventionist (IP) can use to determine whether a resident may have an infection include: * Antibiotic starts; while this can be a helpful trigger for tracking possible infections, it is not enough information to determine if an infection is present or the type of infection.

* Residents’ signs and symptoms of infection: nursing personnel’s recognition, assessment, documentation, and communication of resident symptoms impact the Infection Preventionist’s ability to apply infection surveillance definitions, as they are based on specific symptom criteria. Review of the IC line listings with the former evening supervisor/ ICN, from 4/2016-9/2016 indicated the following: *Indications of incorrectly identified infections (with one or blank symptoms listed and therefore, not according to McGeer’s constitutional criteria), but treated with antibiotics without cultures or, treated despite negative cultures.

*No inclusion of the Scabies infection or 12 rashes from the same unit which, according to McGeer Criteria and facility policy, should be included under skin/soft tissue infections. On 10/26/16 at 11:30 A.M., during interview with the former ICN, the Surveyor asked if the facility was tracking/trending skin rashes. She said that there were no outbreaks in the facility and that skin conditions (rashes, scabies) are not included on the infection line listings, but tracked on a separate Weekly Skin Check Tool.

The ICN and the DNS did not provide documentation to indicate that increased surveillance, increased environmental cleaning or staff in-servicing was implemented for highly contagious cases (Scabies) or possible identified trends higher than the historical rate for the facility. Line listing examples indicate infections with no documentation of tracking/trending, in-servicing or an inter-disciplinary action plan to decrease the possible spread of infections which include the following examples: *7/2016 on 1 unit: 6 new Healthcare Acquired Infections (HAIs)-1 pneumonia with positive Methicillin-Resistant Staphylococcus Aureus (MRSA), 1 new GI infection not specified, 2 urinary tract infections (uti) and 1 lower respiratory infection; * 8/2016 on 1 unit: 7 new HAIs (1 with continued pneumonia, 3 with new pneumonias, 3 with respiratory infections and 1 UTI.)

2. For Resident #9, the facility failed to ensure that environmental cleaning was provided according to facility policy and CDC guidelines, while on Clostridium Difficile (C-diff) precautions. (Clostridium Difficile is an infection of the colon caused by a spore forming bacterium, which symptoms may include abdominal pain, fever and watery diarrhea). The[DIAGNOSES REDACTED] spore can survive for up to 6 months on environmental surfaces such as floors, bed rails and toilet seats and transmission may occur via the hands of healthcare workers. (Weber & Rutala. Infect Control Hosp Epidemiolol 2011; 32: 207-209.)

The CDC recommends the following interventions to prevent the spread of[DIAGNOSES REDACTED]: -Contact Precautions with dedicated equipment, use of an EPA-approved sporicidal disinfectant (1:10 sodium hypochlorite solution) and hand hygiene with soap and water after glove removal (alcohol based hand hygiene is not effective in eradicating[DIAGNOSES REDACTED].)

Resident #9 was admitted to the facility in 8/2016 with symptomatic Clostridium Difficile Infection (with active symptoms of diarrhea, cramping and intermittent bowel incontinence). The facility failed to follow the IC Policy Statement and CDC recommendations for preventing the spread of[DIAGNOSES REDACTED]) by not consistently wearing gloves and gowns upon entering the room, not providing dedicated equipment to remain in the room and not providing the appropriate disinfection with an EPA approved disinfectant, effective against[DIAGNOSES REDACTED] spores.

On 10/20/16 during the unit tour with UM #1, the Surveyor observed a precaution cart outside of the Resident’s room. Surveyor #1 observed that there were no gloves on the precaution cart. Following Surveyor observation, the UM went to the utility room and placed a new box of gloves on the precaution cart. (Strict adherence to glove use is the most effective means of preventing hand contamination with [DIAGNOSES REDACTED]icile spores because spores may be difficult to remove from hands even with hand washing, according to the CDC).

Surveyor #1 then observed a pile of soiled linen on the floor of the Resident’s room during the initial tour. The observation was shared with the UM. The UM went to the CNA at that time and the linens were put into a dirty linen bag.

On 10/20/16, after the unit tour, Surveyor #3 observed a Housekeeper cleaning Resident #9’s room. The Surveyor interviewed the Housekeeper and asked what product he/she was using to clean the room. The Housekeeper brought over a bottle of Quaternary Ammonia-based detergent with ingredients that did not include Sodium Hypochlorite (bleach). Commonly used cleaning agents, such as quaternary ammonium-based and other surfactant-based detergents, are not sporicidal and may in fact encourage sporulation. Disinfection with a 1:10 dilution of concentrated sodium hypochlorite (i.e., bleach) has been shown to be effective in reducing environmental contamination in patient rooms and in reducing CDI rates.

The Housekeeper then demonstrated with a mop that she cleaned the floors with the product. The Surveyor asked what she used to clean the tray table and high touch items. The Housekeeper picked up a container of Micro Kill wipes from the precaution cart, outside the door of the Resident’s room. Micro Kill wipes are a registered EPA disinfectant containing [MEDICATION NAME] Alcohol, but are not effective against[DIAGNOSES REDACTED] spores (the Resident’s room and equipment has been being cleaned for 2 months with an ineffective cleaning agent).

On 10/21/16 at 8:05 A.M., Surveyor #3 observed CNA #2 carrying soiled linen through the hall to a soiled linen cart. The CNA was observed to not wash their hands after disposing of the soiled linens (gloves should be worn when handling soiled linens to prevent skin and mucous membrane exposures and contamination of clothing and to avoid transfer of pathogens to other patients and/or the environment. On 10/21/16 at 9:45 A.M., Surveyor #3 observed CNA #3 enter Resident #9’s room without gloves or gown. The CNA picked up the Resident’s breakfast tray, left the room without washing hands and then left the tray at the nursing station (the tray truck had been returned to the kitchen). CNA #3 answered a call light for another Resident, who resided directly across from the nurse’s station without washing his/her hands. The CNA came out of the room without performing hand hygiene, again picked up Resident #9’s breakfast tray and left the unit with the tray.

On 10/26/16 at 3:00 P.M., the Surveyor shared the infection control observations and staff interviews with the facility Administrator.

3. For Residents #2, #6 and Non Sampled Resident #1 (NS #1), the facility failed to maintain an effective infection control program which included identification, tracking and prevention for the spread of infection when multiple residents had documented skin rashes, with at least two residents treated for [REDACTED]. Scabies (a contagious skin infestation caused by a female mite which burrows under the skin and causes a pimple-like, itchy rash, which is transferred by direct skin-to-skin contact). On 10/20/16, during survey tour, the Surveyor observed a Scabies public health fact sheet form posted on the staff bathroom wall. The form indicated the symptoms of scabies, how scabies was spread, diagnosed and treated. The Surveyor interviewed UM #1 and asked why the form was posted. The UM said that it was there as a precaution for the community The survey team was also notified during the survey by the facility’s Ombudsman, of a suspected Scabies outbreak. The infection control line listing did not indicate these skin infections or any other skin rashes (12 rashes identified from 5/2016-9/2016 were not on the line listing) and were therefore, not tracked or trended.

Review of the Centers for Disease Control prevention guidelines for scabies (11/2/10) indicated early detection, treatment, and implementation of isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes may be scabies, and skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. Infection control practices include treating exposed individuals and potentially exposed persons at the same time as the suspected individual to prevent exposure. Additionally, personal protective items (gloves, gowns) and avoidance of skin contact should be used when providing hands on care to someone who may have scabies.

a. Non sampled Resident #1 (NS #1) was identified by the ICN during interview on 10/26/16 at 11:30 A.M., as a resident that had been treated for [REDACTED]. The ICN said that she did not recall whether any skin outbreaks were reported to the Department, and said that facility followed guidelines for prevention that included cleaning rooms, treating bedding, linens, bagging belongings, and monitoring roommates with skin checks.

A Nurse Practitioner note dated 9/2/16 indicated NS#1 had a recurrent itchy rash on trunk and was started on [MEDICATION NAME] (topical treatment for [REDACTED]. The NP noted that NS#1 was not appropriate for a dermatology consult due to severe dementia. A nurses note dated 9/7/16 indicated NS#1 exhibited itchy symptoms on upper extremities. On 9/9/16 a treatment of [REDACTED]. A nurse note dated 9/10/16, indicated the [MEDICATION NAME] cream was not effective, and the physician was called for an order for [REDACTED]. On 9/15/16, a nurse note indicated NS#1 had increased restlessness due to itchiness and scratching.

On 9/16/16, a NP follow-up note indicated the rash continued on NS#1’s arms and trunk. Although the NP documented that the distribution of rash was inconsistent with scabies presentation, but due to this Resident’s history of Scabies treatment in April/May, the NP indicated that treatment to relieve the distressful symptoms of the rash out weighed the risk of adverse effects related to treatment. The NP prescribed another 2 dose course of Ivermectin (antiparasitic) medication. A nurses note dated 9/19/16 indicated NS#1’s rash continued, no itching noted. After treatment with the Ivermectin medication, the nurses notes dated 9/22/16 and 9/23/16 indicated improvement in the Resident’s rash areas.

The second dose of Ivermectin was administered on 10/1/16. Nursing notes dated 10/9/16, 10/12/16 and 10/14/16 indicated the rash continued. On 10/16/16, the rash areas were reported as improved, with some scabbed areas. Although the NP note, dated 10/25/16, reported the rash did not appear consistent with Scabies, however due to a history of prior treatment for [REDACTED].

During interview, the ICN said that rashes were not included on the facility’s infection control line listings, and therefore the information was not analyzed for trends or tracking to prevent further rashes or potentially affecting other residents and staff. The former (retired) ICN said that she did not report the scabies and skin rashes to DPH, but said that she put an asterisk next to the room number of people with rashes for tracking. The Surveyor asked if the facility’s floor plan outline for the unit was utilized to trend for staffing and possible cross-contamination or for room-mate trending, due the method of spreading (skin-to-skin contact). The former ICN said that she never thought to do that. Review of the Weekly Skin Check Tool for 4/2016 indicated that 2 of 12 residents with skin rashes, were treated for [REDACTED].

The Surveyor asked if the skin rashes and scabies were discussed at the QI meetings. The ICN said that she did not attend the QI meetings and that she passed information along to the DNS. The former ICN also said that the skin issues discussed at Risk Meetings were more about pressure injuries and not skin rashes.

b. Resident #2 was admitted to the facility 12/2012 with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE], and quarterly dated 8/21/16, indicated this Resident had severe cognitive impairment for decision making, and required total care for all activities of daily living. This assessment indicated the Resident had disorganized thinking, inattentive behaviors with frequent verbal outbursts towards others and rejection of care. The Resident was at risk for skin breakdown, had no pressure areas or impairments.

Resident #2 was observed positioned and fed meals in a tilt wheelchair, in the corridor throughout the morning and afternoons during the survey visit 10/20/16, 10/21/16, 10/25/16 and 10/26/16.

Record review indicated Resident #2 had a rash on 4/1/16. The rash was identified as raised red, scattered with some scabs on his/her arms and chest area. A physician’s orders [REDACTED]. Treatment with [MEDICATION NAME] (4/4/16-4/11/16) was unsuccessful. A Nurse Practitioner (NP) note dated 4/4/16, indicated the resident has a rash, 10 mm raised bumps, red areas papules on shoulders and upper arms and pinpoint areas on chest and thighs. Resident is not a candidate for dermatology, the plan included to treat with Ivermectin (a broad spectrum anti parasitic drug) with 2 rounds for Scabies. Nursing documentation on 4/9/16 indicated Resident #2 had a rash area on trunk and thighs and exhibited discomfort and itch. On 4/12/16, the Resident had increased agitation and itch which continued to 4/14/16 when the Resident had increased restlessness, scratching and removing clothing.

Physician orders [REDACTED]. Record review indicated Resident #2 had a rash area on his/her trunk and thighs and was exhibiting discomfort and itch. Review of physician progress notes [REDACTED].#2 was receiving treatment for [REDACTED]. Nursing documentation indicated improvement of rash and skin areas on 5/2/16 and 5/8/16 and monitoring was discontinued on 5/13/16.

Further record review for Resident #2, indicated that on 10/14/16 new excoriated areas were noted on his/her back. During interview on 10/26/16 at 11:15 A.M., the (retired) infection control nurse (ICN) said she returned to the facility on the first day of survey 10/20/16, to help out. The ICN said that the facility’s line listings of infections did not include skin rashes occurring in the facility.

Review of the 10/2016 weekly skin sheet, weekly skin check tool, a new rash tool identified by the ICN used to track skin areas (not pressure), had not identified Resident #2 with a skin impairment as documented in a 10/14/16 nurses note. The ICN said that since she had retired, it was likely the DNS that would be documenting the infections and rash areas as there was not a Unit Manager on the second floor unit. The ICN said that the she had been monitoring whether or not weekly skin assessments were being done and had put an asterisk next to a resident room number to indicate a rash was noted during the weekly skin check. Any further documentation of rashes was done on the weekly skin sheet, treatment record, or a new rash tool. The Unit Manager and or DNS was responsible for monitoring.

Surveyor #2 interviewed the DNS on 10/26/16 at 1:30 P.M., following the IC interview. The DNS said that the facility did not track/trend skin infections/rashes. The DNS also said that the facility’s Wound Consultant (WC) was asked to evaluate some of the skin rashes which started in 4/2016. Although the DNS said that discussions had occurred at morning meetings regarding residents with rashes, the DNS said that there was no documentation of the discussions. The survey team repeatedly requested the list of residents assessed by the WC, but did not receive a list before survey exit conference.

c. For Resident #6, the facility’s infection control monitoring was ineffective as Resident #6’s rash area was not noted (asterisk) until 10/23/16, on the weekly skin check tool until 13 days after identified in a 10/10/16 nurses note. Resident #6 was admitted for long term care with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated this Resident had severely impaired cognitive skills for daily decision making; required total assistance from staff for all care needs. The Resident had no recent falls, identified with no skin impairments, and used a physical restraint that prevented rising out of a chair.

Record review on 10/20/16 indicated Resident #6 was receiving (10/8-10/19/16) antibiotic ointment for a right eye infection and also indicated reoccurring skin irritations. Review of the plan of care dated 1/13/16, Resident #6 was at risk for skin breakdown due to incontinence and limited mobility. A medical progress note dated 4/23/16, indicated Resident #6 had a chronic impaired skin area under left breast; the area was noted as a fungal infection that required treatment. A nurse aide care card updated 8/21/16 indicated the Resident required the assistance of one for bathing, to avoid certain undergarments (bra), and family does laundry. Daily application of skin lotion cream to bilateral lower extremities. A 9/9/16 nurses note indicated three new red spots noted under right breast. The Nurse Practitioner (NP) was notified and an order for [REDACTED]. On 9/18/16, the area was noted as cleared.

On 9/23/16, the physician progress notes [REDACTED].

A nurses note dated 10/4/16, indicated the area under Resident #6’s right breast was red and excoriated; a new order from the NP was obtained to apply Interdry daily. Although weekly skin documentation dated 10/2/16, 10/9/16, and 10/16/16 did not identify any rash areas, the nurses notes dated 10/10/16, indicated Resident #6 had a pink rash area on upper back; treatment continued to the Resident’s impaired (red and moist) skin area under right breast. On 10/16/16, the nurses note indicated impaired skin areas for Resident #6, under right breast, moist and red again; a treatment was ordered Interdry for 7 days. On 10/19/16 nursing documentation indicated rash area continued on Resident #6’s upper back area. A new treatment order in place for 7 days ([MEDICATION NAME] cream 0.1% twice a day).

A medical progress note, dated 10/22/16, indicated impaired (rash) skin areas across the Resident’s shoulder blades. A follow up note on 10/24/16, indicated the rash area was found on the Resident’s upper back with slightly scabbed areas, treat with cream as ordered.

Review of the weekly skin check tool, according to interview with the ICN on 10/26/16 at 11:30 A.M., said that it was designed for auditing whether weekly resident skin checks were completed by nursing staff. The ICN would asterisk a resident’s room number if aware of a rash. However the information was obtained through review of the day-night report book, skin sheets or rash tool on the unit which are completed by the Unit Mangers. The second floor unit does not have a Unit Manager.

The facility’s skin / rash tool was not updated timely for an effective infection control monitoring as Resident #6’s rash area was not identified (asterisk) until 10/23/16, on the weekly skin check tool until 13 days after first documented in a 10/10/16 nurses’ note. On 10/25/16 at approximately 11:00 A.M., Surveyor #4 observed, with permission from Resident #6’s family member, the skin rash on the Resident’s back. The skin rash covered half of the Resident’s back (upper half) and consisted of pink areas, approximately two centimeters in diameter, with a red pinpoint in the center.

On 10/26/16 at approximately 1:30 P.M., followed-up with the DNS who had not attended the infection control discussion with surveyors at 11:30 A.M. that day. Although the DNS said that discussion occurred regarding rashes, there was no documentation that the facility had identified a root cause or tried alternative approaches (bathing frequency, trial of hand held shower, sensitivity to the use of any new linen/laundry products, skin care products, or staffing practices) for rash prevention.

Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

Based on staff interviews and policy review, the facility’s Quality Assessment (QA) program, failed to effectively monitor, evaluate and determine root cause analyses to improve conditions for this facility with ongoing problems with the infection control program, falls and restraints that affected the resident’s quality of care.

Findings include:

During interview on 10/26/16 at 3:20 P.M., the Administrator said he was the coordinator of the facility’s quality assurance activities and said the committee met on a quarterly basis. The Administrator said the quarterly meetings are attended by the Medical Director, Director of Nursing, some department heads and representatives from the laboratory services, X-Ray company and the pharmacy consultant. The last quarterly meeting was held two weeks prior to the start of this survey on 10/20/16.

A review of the facility’s policy statement for Quality Assurance and Performance Improvement Plan (QAPI) indicated the facility shall develop, implement, and maintain an ongoing QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care and resolve identified problems. The policy last approved 1/7/16, indicated the QAPI Coordinator would help other committees, individuals, departments, and/or services, develop quality indicators, monitoring tools, criteria, and assessment methodologies, and help them identify and evaluate concerns impacting resident care and safety.

During this survey 10/20/16 – 10/26/16, the survey team found deficient practice with on-going falls in which the facility required investigation and assessment was not being completed (See F323); restraints were not assessed and removed as planned, as well as consideration of alternative and least restrictive interventions (See F221); and a lack of infection control practices including tracking of skin rashes and conditions (See F441). The Administrator said the facility was concerned last summer with the number of falls in the facility and had implemented changes to decrease the falls. He could not explain how the QAPI committee was involved and said they were just starting to use audit tools this year. Per the Fall Management and Assessment policy, a quarterly review is done at the QAPI meetings to determine trends of injuries and falls.

The Director of Nurses said they were also concerned with other Quality measures of weight loss, urinary tract infections, pain and restraints. The facility’s QAPI policy indicated that one of the Quality Measures data was restraints and needed to be monitored and evaluated by the committee. The Director of the Nurses could not explain information for conducting root cause analyses of the restraint usage that had triggered high quality measures of 98 %.

The Director of Nurses said the infection control program will now oversee skin issues and needed to hire a person for that position. She said none of the skin rashes and treatments had been incorporated into the infection control data and was not analyzed by the QAPI committee. Per the Infection Control policy and procedure, the Quality Assessment and Assurance Committee shall oversee implementation of infection control policies and practice with the input from the contracted lab and the infection control nurse. The lack of skin condition data was never identified to QAPI committee. The Administrator and the Director of Nurses were asked if the QAPI program was an effective method and the Administrator said we are struggling with trying to get to the root cause of issues and need to evaluate any planned implementation of programs.

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Page Last Updated: December 14, 2017

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