Every finding on record at Adviniacare at Provincetown

Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 13 of 13 residents attending the resident group meeting during the survey, the facility failed to ensure their grievance policy included notification that residents and their representatives have the right to file grievances anonymously, should they choose not to alert a staff member of their concern(s), and failed to include the contact information of the grievance official with whom a grievance can be filed, that is, business address (mailing and email) and business phone number, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system.Findings include:Review of the facility's policy titled Grievances, last revised 10/2022, failed to indicate residents and/or their representatives had the right to file grievances anonymously, contact information (business address and phone number) of the grievance official and contact information of independent entities with whom grievances may be filed.On 3/31/26 at 9:00 A.M., the surveyor toured the facility's only unit and observed a poster mounted on the wall across from the nursing station titled Resident Rights. The section titled Grievances indicated:-You have the right to voice grievances to this facility or other agency concerning your care, treatment, behavior of staff and/or other residents as well as other concerns about your stay without fear of discrimination or reprisal.-You have the right to information on how to file a grievance or complaint.-You have the right to prompt resolution of grievances.The Resident Rights poster failed to indicate residents had the right to file grievances anonymously, failed to include contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system.On 4/1/26 at 10:57 A.M., the surveyor held a resident group meeting with 13 residents in attendance. Thirteen of 13 residents said that they were not aware of their right to file a grievance anonymously, who the grievance officer was and were not aware of any other entities with whom grievances could be filed. They said if they have an issue, they have to go to the Resident Council President or a staff member about it. The residents said if they were to fill out a grievance form, there was nowhere to file it to remain anonymous.During an interview with the Administrator and Regional Nurse Educator on 4/1/26 at 1:40 P.M., they reviewed the grievance policy and said it does not include the required notification that residents or their representatives have the right to file grievances anonymously and does not include contact information (business address and phone number) of the grievance official and contact information of independent entities with whom grievances may be filed as required.

Based on observation, interview, and record review, the facility failed to provide a dignified existence for three Residents (#14, #16, #24) who were observed receiving care/treatment by health care professionals, out of a total sample of 13 residents. Specifically, the facility failed:1. For Residents #14 and #16, to provide privacy of his/her body during a blood draw; and2. For Resident #24, to provide privacy of his/her body while in bed during the application of a pain patch to his/her lower back. Findings include:Review of the facility's policy titled Dignity, last revised 1/2022, indicated but was not limited to:-Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.-Residents shall be treated with dignity and respect at all times.-Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures and use of telemedicine when applicable.1A. Resident #16 was admitted to the facility in March 2026 and had diagnoses including atrial fibrillation and hyperlipidemia.Review of the Minimum Data Set (MDS) assessment, dated 3/11/26, indicated Resident #6 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15 and was dependent of staff for activities of daily living.On 3/31/26 at 9:16 A.M., the surveyor observed Resident #16 sitting in a wheelchair in the unit's dayroom watching television with seven other residents in the room. A Laboratory Technician approached the Resident and said she was there to draw his/her blood. She retrieved a tourniquet and blood draw supplies from her cart and began to conduct the blood draw. At no time did the Laboratory Technician ask the Resident to go to his/her room or to a private location to perform the blood draw or ask if the Resident wanted his/her blood drawn in the room with seven other residents.B. Resident #14 was admitted to the facility in June 2025 and had diagnoses including dementia.Review of the MDS assessment, dated 3/30/26, indicated Resident #14 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15 and was dependent of staff for activities of daily living.On 3/31/26 at 9:35 A.M., the surveyor observed Resident #14 sitting in a wheelchair in his/her room at the bedside facing the doorway and clearly visible from the hallway. At this time, the Laboratory Technician entered the Resident's room and told him/her that she was going to draw his/her blood. She retrieved a tourniquet and blood draw supplies from her cart and began to conduct the blood draw. At no time did the Laboratory Technician ask the Resident if he/she wanted the door to remain open or move him/her to a location within the room that would provide the Resident privacy during the blood draw.During an interview on 4/1/26 at 11:55 A.M., Nurse #1 said either facility staff or the Laboratory Technician should have brought Resident #16 to his/her room or another private location to provide the Resident with privacy during the blood draw. She said the Laboratory Technician should have closed Resident #14's door so he/she was provided with privacy and not visible to passersby in the hallway.2. Resident #24 was admitted to the facility in November 2025 and had diagnoses including Alzheimer's disease and a history of falls.Review of the MDS assessment, dated 3/30/26, indicated Resident #24 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15 and required staff assistance for all activities of daily living.On 4/1/26 at 9:18 A.M., the surveyor observed Nurse #2 from the hallway applying a transdermal analgesic patch to Resident #24's lower back. The privacy curtain was not pulled, the door was wide open, and the care being provided to the Resident was easily observed by any passerby in the hallway. During an interview on 4/1/26 at 9:23 A.M., Nurse #2 said she did not realize the Resident's body was exposed and visible from the hallway. She said if a resident's body is exposed, either the privacy curtain should be pulled or the door closed.

Based on record review and interview, the facility failed to implement written policies and procedures for an allegation of abuse for one Resident (#34), out of a total sample of 13 residents. Specifically, the facility failed to initiate their abuse policy after an allegation of abuse was documented and reported on 3/4/26.Findings include:Review of the facility's policy titled Abuse, revised 10/23/22, indicated but was not limited to:-The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident patient property by anyone, including staff.-The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property.-Abuse: -The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Instances of abuse of all residents, irrespective of any mental or physical condition caused physical harm, pain or mental anguish. -It includes verbal abuse. -Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.-Verbal: -Use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. -Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident. -Identification: -Instruct staff, resident/patient, family, or visitor to report immediately, without fear of reprisal any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. -Identify events such as suspicious bruising resident/patient occurrences, patterns, and trends that may indicate abuse, neglect and/or mistreatment and investigate.-Protection: -The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in process. -Any employee who is accused of resident abuse, neglect, exploitation or misappropriation of property will be suspended upon identification immediately. The accused employee will not be permitted to enter the facility unless at the discretion and under the direct supervision of the Administrator or Director of Nursing.-Investigate: -All alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. -The facility will initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interviewable and have information regarding the allegation. -The conclusion must include whether the allegation was substantiated or not and what information supported the decision. The conclusion/summary must take into account an objective overview of the facts and a reason or basis for the decision to substantiate or not substantiate the allegation. -Employee Suspension: -Anytime an allegation is made involving abuse and neglect or mistreatment of a resident/Patient which names a specific employee. The employee is suspended until the completion of the investigation. The employee must be relieved of his/her duty until the allegation is complete. If the allegation is substantiated, the facility will determine continuing employment status based on the facts and the outcome of the investigation.-Reporting: -Staff should notify the shift supervisor, charge nurse, or manager immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. -Once the allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator or Director of Nursing immediately and initiate gathering requested information. An investigation MUST be directed by the Administrator or designee immediately. -Notify the local law enforcement and appropriate State Agency(s) immediately (no later than two hours after allegation or identification of the allegation) by Agency's designated process after identification of alleged/ suspected incident. The facility will report allegations to local police and initiate process according to the Elder Justice Act and State specific regulations. Report results of investigation to the proper authorities as required by State law.-Responding/Follow Through: -The facility shall ensure that the appropriate corrective, remedial or disciplinary actions occur in accordance with local, state and federal law in response to the findings resulting from the investigation. The administrator or designee should inform the resident and his/her representative of the results of the investigation and corrective action taken. The facility will take all necessary corrective actions depending on the results of the investigation.Resident #34 was admitted to the facility in October 2023 with diagnoses including depression and anxiety.Review of the Minimum Data Set (MDS) assessment, dated 1/29/26, indicated Resident #34 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15.Review of the facility's Grievance Book, on 3/31/26, indicated but was not limited to:-Grievance/Concern and Comment Form -When did the incident happen and to whom: 3-11 shift -Date and time: 3/4/26 at 10:00 A.M. -Your Name and Relation to Resident: Family Representative #2 -Concern: - Family Representative #2 came into Social Work Office to report she was on the phone with Resident #34, who was left on the toilet too long, which resulted in Resident #34 calling Family Representative #2 to call the nurse's desk and request someone to come in to assist Resident #34. When said Certified Nursing Assistant (CNA) arrived, Resident felt CNA was rude and yelled at the Resident for his/her Family Representative needing to call the nurse's desk for assistance. - If you suspect any form of Abuse/Neglect/Mistreatment, please notify the nurse or a Manager immediately.-All concerns must be referred to the Department Head for review.-Department Head review and action taken, Department Head signature, and date were left blank.-Follow up must be made with the resident and/or individual who voiced/wrote the concern: Name of Individual contacted: Family Representative #2 Date: 3/5/26 -Comments: -CNA #5 was removed from the resident care assignment and was educated by staff. All staff were educated with Abuse/Neglect Policies, and a new CNA was assigned to Resident #34's care going forward. -Name of staff and date completed follow-up: Social Worker 3/6/26 -Signed by the Administrator on 3/5/26 -Response to Education, dated 3/10/26, indicated CNA #5 was re-educated on the facility policy titled Resident Rights and Privacy, Providing Care and Services, Abuse, Neglect, and Mistreatment, in response to satisfy Resident #34's grievance and to ensure continued resident safety and security from abuse, neglect, and mistreatment.During an interview on 3/31/26 at 4:27 P.M., with Resident #34 and Family Representative #2, Resident #34 said he/she preferred the surveyor to speak with his/her Family Representative. Family Representative #2 said on 3/4/26 they reported to the Social Worker about the incident that occurred the evening before (3/3/26) when Resident #34 called him/her from their cell phone and asked Family Representative #2 to call the nurses' station and ask for someone to come and help Resident #34 off of the toilet. Family Representative #2 said Resident #34 was on the toilet for a long time and was uncomfortable. Family Representative #2 said when CNA #5 came in to assist Resident #34 he/she yelled at CNA #5 first because he/she was uncomfortable. Then, CNA #5 yelled at Resident #34 to not talk to her like that and not to have his/her daughter call the nurses' station. Family Representative #2 said Resident #34 felt bad and apologized to CNA #5. Family Representative #2 said the follow-up was for CNA #5 to be counseled and all staff will be re-educated. During an interview on 4/1/26 at 11:11 A.M., the Director of Nursing (DON) said there were no incident/accident reports or investigations for Resident #34 for the past three months.During an interview on 4/2/26 at 2:51 P.M. and 4:45 P.M., the Social Worker said verbal abuse includes yelling at residents or making them feel bad or not respected. The Social Worker reviewed the Grievance/Concern and Comment Form, dated 3/4/26, and said Resident #34's Family Representative came in and reported the incident from the previous evening, 3/3/26, of Resident #34 being yelled at by CNA #5 to her and she completed a grievance form with them. She said CNA #5 no longer takes care of Resident #34 and was re-educated about abuse. She said Resident #34 being yelled at was considered abuse. She said she notified the Administrator and they treated it as a grievance and did not investigate it.During an interview on 4/2/26 at 3:17 P.M., the DON reviewed the Grievance/Concern and Comment Form, dated 3/4/26, and said he was unaware of the incident until the surveyor inquired about it. He said Resident #34's report of being yelled at was an allegation of abuse and should have been reported to the police right away and to the State Agency within two hours, then an investigation should have been conducted, but there was not one done.During an interview on 4/2/26 at 4:25 P.M., the Administrator said verbal abuse is yelling and shouting at a Resident. He said once abuse was reported the police must be notified, it must be reported to the State Agency, and an investigation started. He reviewed the Grievance/Concern and Comment Form, dated 3/4/26 and said on 3/4/26 the Social Worker called him into her office, and they met with Family Representative #2 where they reported that the previous evening that Resident #34 was yelled at by CNA #5. He said CNA #5 was sent home and did not return until 3/17/26, removed from Resident #34's assignment and re-educated about abuse. He said the facility did not follow their policy and the incident was not reported to the Police or State Agency and investigation had not been conducted.Refer to F609, F610

Based on record review and interviews, the facility failed to report an allegation of abuse to the state agency for one Resident (#34), out of a total sample of 13 residents.Findings include: Review of the facility's policy titled Abuse, revised 10/23/22, indicated but was not limited to:-The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident patient property by anyone, including staff.-The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property.-Abuse: -The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Instances of abuse of all residents, irrespective of any mental or physical condition caused physical harm, pain or mental anguish. -It includes verbal abuse. -Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.-Verbal: -Use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. -Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident.-Reporting: -Staff should notify the shift supervisor, charge nurse, or manager immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. -Once the allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator or Director of Nursing immediately and initiate gathering requested information. An investigation MUST be directed by the Administrator or designee immediately. -Notify the local law enforcement and appropriate State Agency(s) immediately (no later than two hours after allegation or identification of the allegation) by Agency's designated process after identification of alleged/ suspected incident. The facility will report allegations to local police and initiate process according to the Elder Justice Act and State specific regulations. Report results of investigation to the proper authorities as required by State law. Resident #34 was admitted to the facility in October 2023 with diagnoses including depression and anxiety.Review of the Minimum Data Set (MDS) assessment, dated 1/29/26, indicated Resident #34 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15.Review of the facility's Grievance Book, on 3/31/26, indicated but was not limited to:-Grievance/Concern and Comment Form -When did the incident happen and to whom: 3-11 shift -Date and time: 3/4/26 at 10:00 A.M. -Your Name and Relation to Resident: Family Representative #2 -Concern: - Family Representative #2 came into Social Work Office to report she was on the phone with Resident #34, who was left on the toilet too long, which resulted in Resident #34 calling Family Representative #2 to call the nurse's desk and request someone to come in to assist Resident #34. When said Certified Nursing Assistant (CNA) arrived, resident felt CNA was rude and yelled at the Resident for his/her Family Representative needing to call the nurses desk for assistance. - If you suspect any form of Abuse/Neglect/Mistreatment, please notify the nurse or a Manager immediately.-Signed by the Administrator on 3/5/26 Review of the Health Care Facility Reporting System (HCFRS-system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 3/31/26, failed to indicate the facility submitted a report on 3/4/26 for an allegation of abuse. During an interview on 4/2/26 at 3:17 P.M., the Director of Nursing (DON) reviewed the Grievance/Concern and Comment Form, dated 3/4/26, and said he was unaware of the incident until the surveyor inquired about it. He said Resident #34's report of being yelled at was an allegation of abuse and should have been reported to the police right away and to the State Agency within two hours. During an interview on 4/2/26 at 4:25 P.M., the Administrator said verbal abuse includes yelling and shouting at a resident. He said once abuse was reported it must be reported to the State Agency within two hours. He reviewed the Grievance/Concern and Comment Form, dated 3/4/26, and said the allegation of abuse from Resident #34 and Family Representative #2 was not reported until 4/2/26, 29 days after being reported.Refer to F610

Based on interviews and record review, for one Resident (#34), of 13 sampled residents, the facility failed to ensure an allegation of verbal abuse was thoroughly investigated. Findings include:Review of the facility's policy titled Abuse, revised 10/23/22, indicated but was not limited to:-The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident patient property by anyone, including staff.-The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property.-Abuse: -The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Instances of abuse of all residents, irrespective of any mental or physical condition caused physical harm, pain or mental anguish. -It includes verbal abuse. -Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.-Verbal: -Use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. -Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident.-Protection: -The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in process. -Any employee who is accused of resident abuse, neglect, exploitation or misappropriation of property will be suspended upon identification immediately. The accused employee will not be permitted to enter the facility unless at the discretion and under the direct supervision of the Administrator or Director of Nursing.-Investigate: -All alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. -The facility will initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interviewable and have information regarding the allegation. -The conclusion must include whether the allegation was substantiated or not and what information supported the decision. The conclusion/summary must take into account an objective overview of the facts and a reason or basis for the decision to substantiate or not substantiate the allegation. -Reporting: -Once the allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator or Director of Nursing immediately and initiate gathering requested information. An investigation MUST be directed by the Administrator or designee immediately.-Responding/Follow Through: -The facility shall ensure that the appropriate corrective, remedial or disciplinary actions occur in accordance with local, state and federal law in response to the findings resulting from the investigation. The administrator or designee should inform the resident and his/her representative of the results of the investigation and corrective action taken. The facility will take all necessary corrective actions depending on the results of the investigation.Resident #34 was admitted to the facility in October 2023 with diagnoses including depression and anxiety.Review of the Minimum Data Set (MDS) assessment, dated 1/29/26, indicated Resident #34 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15.Review of the facility's Grievance Book, on 3/31/26, indicated but was not limited to:-Grievance/Concern and Comment Form -When did the incident happen and to whom: 3-11 shift -Date and time: 3/4/26 at 10:00 A.M. -Your Name and Relation to Resident: Family Representative #2 -Concern: - Family Representative #2 came into Social Work Office to report she was on the phone with Resident #34, who was left on the toilet too long, which resulted in Resident #34 calling Family Representative #2 to call the nurses' desk and request someone to come in to assist Resident #34. When said Certified Nursing Assistant (CNA) arrived, Resident felt CNA was rude and yelled at the Resident for his/her Family Representative needing to call the nurses' desk for assistance. - If you suspect any form of Abuse/Neglect/Mistreatment, please notify the nurse or a Manager immediately.-All concerns must be referred to the Department Head for review.-Department Head review and action taken, Department Head signature, and date were left blank.-Follow up must be made with the resident and/or individual who voiced/wrote the concern: Name of Individual contacted: Family Representative #2 Date: 3/5/26 -Comments: -CNA #5 was removed from the resident care assignment and was educated by staff. All staff were educated with Abuse/Neglect Policies, and a new CNA was assigned to Resident #34's care going forward. -Name of staff and date completed follow-up: Social Worker 3/6/26 -Signed by the Administrator on 3/5/26 -Response to Education, dated 3/10/26, indicated CNA #5 was re-educated on the facility policy titled Resident Rights and Privacy, Providing Care and Services, Abuse, Neglect, and Mistreatment, in response to satisfy Resident #34's grievance and to ensure continued resident safety and security from abuse, neglect, and mistreatment.During an interview on 3/31/26 at 4:27, with Resident #34 and Family Representative #2, Resident #34 said he/she preferred the surveyor to speak with his/her Family Representative. Family Representative #2 said on 3/4/26 they reported to the Social Worker about the incident that occurred the evening before (3/3/26) when Resident #34 called him/her from their cell phone and asked Family Representative #2 to call the nurse's station and ask for someone to come and help Resident #34 off of the toilet. Family Representative #2 said Resident #34 was on the toilet for a long time and was uncomfortable. Family Representative #2 said when CNA #5 came in to assist Resident #34 he/she yelled at CNA #5 first because he/she was uncomfortable, then CNA #5 yelled at Resident #34 not to talk to her like that and not to have his/her daughter call the nurse's station. Family Representative #2 said Resident #34 felt bad and apologized to CNA #5. Family Representative #2 said the follow-up was for CNA #5 to be counseled and all staff will be re-educated. During an interview on 4/1/26 at 11:11 A.M., the Director of Nursing (DON) said there were no incident/accident reports or investigations for Resident #34 for the past three months.During an interview on 4/2/26 at 3:17 P.M., the DON reviewed the Grievance/Concern and Comment Form, dated 3/4/26, and said he was unaware of the incident until the surveyor inquired about it. He said Resident #34's report of being yelled at was an allegation of abuse and an investigation should have been conducted, and a final report should have been submitted to the State Agency within five business days, but there was not one done.During an interview on 4/2/26 at 4:25 P.M., the Administrator said verbal abuse is yelling and shouting at a resident. He reviewed the Grievance/Concern and Comment Form, dated 3/4/26. He said on 3/4/26, he and the Social Worker met with Family Representative #2 who reported that Resident #34 was yelled at by CNA #5 the previous evening. He said CNA #5 was sent home and did not return until 3/17/26, removed from Resident #34's assignment, and re-educated about abuse. He said we made a mistake and did not conduct an investigation but should have.

Based on document review and interview, the facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the Physician/Nurse Practitioner and were reviewed and responded to in a timely manner for two Residents (#25 and #6), out of a total sample of 13 residents. Specifically, the facility failed:1. For Resident #25, to ensure:a. an October 2025 consultant pharmacist's recommendation to clarify a medication allergy for a medication currently being administered to the Resident was acted upon; andb. a February 2026 consultant pharmacist's recommendations for laboratory test due to an increased risk of the Resident taking the antipsychotic medication Risperdal was acted upon; and2. For Resident #6, to ensure the October 2025, December 2025, and February 2026 consultant pharmacist's recommendations to re-evaluate the continued use of as needed (PRN) psychotropic medication, Trazodone (antidepressant medication), note the medical justification for continued use in a progress note, and specify the number of days the order was to continue.Findings include: Review of the facility's policy titled Pharmacy Consultant Med Review, last revised 12/2025, indicated but was not limited to: -The facility shall employ/contract and maintain the services of a licensed pharmacist (pharmacy consultant), who shall review the medication regimen review (MRR) of each resident at least monthly and more frequently as needed. -The primary purpose of this review is to assist the facility in maintaining each resident's highest practicable level of functioning and quality of life, by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. -The pharmacy consultant will document his/her findings and recommendations on the monthly drug/regimen review report. -The Director of Nurses will give the unit manager/designee a copy of the monthly pharmacy consultant report. -The unit manager/designee will make sure: a. All recommendations are acted upon b. All of the recommendations are reported to the resident physicians c. There is documentation in the resident chart that notification and follow-up occurred d. Notify the resident's physician of the pharmacy consultant's recommendations and document in the resident's chart that it was done e. Remind the resident's physician to sign the resident's consultant report that is filed in the resident's chart/Electronic Health Record. -The unit manager/designee will return the copy of the consultant's report to the Director of Nursing when notifications, follow-ups and documentation have been completed. -The Director of Nursing will notify the facility's medical director if the resident physician does not follow through on the consultant's recommendations. 1. Resident #25 was admitted to the facility in April 2025 and had diagnoses including dementia with behaviors, Parkinson's disease, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 1/29/26, indicated resident #25 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status Score (BIMS) of 8 out of 15 and received antipsychotic and antianxiety medication daily. Review of Resident #25's medical record indicated he/she was allergic to Midazolam (sedative). Review of Physician's orders indicated but was not limited to: - Lorazepam (Ativan) 0.5 milligrams (mg). Give 1 tablet by mouth four times a day (last renewed 3/24/26) - Risperdal 0.5 mg. Give 1 tablet by mouth three times a day (last renewed 1/2/26) a. Review of Resident #25's MRR recommendation, dated 10/13/25, indicated the following: -This resident has an allergy to Midazolam but currently receives Ativan. Please clarify and if there is no issue, suggest having medical staff override allergy. The response section of the MRR recommendation was blank and unsigned by the Physician/Nurse Practitioner. b. Review of Resident #25's MRR recommendation, dated 2/8/26, indicated the following: -Resident is receiving the following antipsychotic medication: Risperdal. Please consider monitoring lipids & A1c due to potential for metabolic syndrome (a cluster of conditions that together increase the risk of heart disease, stroke, and type 2 diabetes). The response section of the MRR recommendation was blank and unsigned by either the Physician or Nurse Practitioner (NP). Review of Physician and NP documentation from October 2025 through April 2026 failed to indicate either the Physician or Physician Extender had reviewed and addressed the consultant pharmacist's recommendations dated 10/13/25 and 2/8/26. Further review of the medical record failed to indicate facility staff notified the Resident's Physician or NP of the pharmacy consultant's recommendations and document in the resident's chart that it was done. During an interview on 4/1/26 at 1:34 P.M., the Director of Nursing (DON) said he reviewed Resident #25's medical record and said he could not find any evidence that the Physician or NP reviewed or addressed the pharmacy recommendations. He said he did not document anything about the pharmacy recommendations in the medical record either. During an interview on 4/2/26 at 11:35 A.M., the NP said when the Consultant Pharmacist makes a recommendation, the forms are placed on his desk in his office. He said when he comes into the facility, he addresses them, signs/makes notations on the forms, documents in the medical record and places it in a folder at the nurse's station for them to enter the orders. He reviewed Resident #25's medical record and said neither he nor the Physician ever received the 10/13/25 and 2/8/26 MRR recommendations and therefore were not addressed. 2. Resident #6 was admitted to the facility in November 2024 with diagnoses including anxiety, dementia, and depression. Review of the MDS assessment, dated 1/1/26, indicated Resident #6 had a severe cognitive deficit as evidenced by a staff interview. Further review of Resident #6's MDS indicated he/she received an antidepressant medication. Review of Resident #6's current Physician's Orders indicated but was not limited to: -Trazodone 25 mg tab by mouth every 24-hours as needed in the evening for agitation/anxiety, dated 10/9/25 Review of the medical record indicated but was not limited to: -10/12/25 Pharmacy Note- Medications reviewed. Please see the Consultant Pharmacist's report for the recommendations. -12/8/25 Pharmacy Note- Medications reviewed. Please see the Consultant Pharmacist's report for the recommendations. -2/8/26 Pharmacy Note- Medications reviewed. Please see the Consultant Pharmacist's report for the recommendations. Review of the MRR, dated 10/12/25, 12/8/25, and 2/8/26, indicated but was not limited to: -Note to Attending Physician/Prescriber: -Resident is receiving the following PRN psychotropic medication. These medications are required to be re-evaluated after 14 days. If therapy is to continue beyond 14 days, please note medical justification for continued use in progress note and specify number of days the PRN order is to continue. -Trazodone -Signed by the prescriber on 10/14/25, 12/9/25, and 2/10/26. Further review of the medical record failed to indicate Resident #6's Trazodone was re-evaluated, medical justification for continued use was documented in a progress note, and an order for a specific number of days to continue the PRN Trazodone. During an interview on 4/2/26 at 12:28 P.M., the NP reviewed the MRRs and Resident #6's medical record. He said the MRR are left for him or the physician to review, after he documents if he agrees or disagrees with the recommendation and writes a note, he returns the MRR to the nurse. He said he signed off the MRR recommendation, dated 10/14/25, 12/9/25, and 2/10/26, but the medical justification for continued use was not documented and an order for a specific number of days to continue the PRN Trazodone was missed. During an interview on 4/2/26 at 2:21 P.M., Nurse #1 said if she received the signed MRR from the Physician or NP, she would put in an order for the number of days to continue the Trazodone, but the Physician or NP was responsible for writing a progress note for medical justification to continue the PRN Trazodone. During an interview on 4/2/26 at 12:18 P.M., the DON said he receives the Consultant Pharmacist's recommendations and leaves them for the Physician/NP to review. Once they are reviewed and addressed, they get filed away in the resident's chart. He said the MRR recommendations were missed but should have been addressed to include a duration of use for the Trazodone and a progress note should have been written to address the medical justification of use.

Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of two nurses observed during a medication pass made three errors out of 25 opportunities, resulting in a medication error rate of 12%. Those errors impacted three Residents (#1, #19 and #6), out of seven residents observed.Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following:Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers.Review of the facility's policy titled Medication Administration, last revised November 2025, indicated but was not limited to:- Medications must be administered in accordance with the orders, including any required time frame.1. For Resident #1, Nurse #3 administered:-Tamsulosin (used to treat symptoms of an enlarged prostate such as difficulty urinating, weak stream, and urgency) at the incorrect time.On 4/1/25 at 9:07 A.M., the surveyor observed Nurse #3 prepare and administer medications to Resident #1 including:-Tamsulosin 0.4 milligrams (mg) 1 capsuleReview of the medication card indicated but was not limited to:- Tamsulosin 0.4 mg capsule daily at bedtimeReview of Resident #1's current Physician's Orders indicated but was not limited to:-Tamsulosin 0.4 mg capsule at bedtime, dated 2/10/26During an interview on 4/1/26 at 1:47 P.M., Nurse #3 said she administered Tamsulosin to Resident #1 during morning medication administration. She reviewed Resident #1's physician's orders and said she thought the Tamsulosin was scheduled for the morning and not at bedtime. She said she did not look at the instructions on the medication card when she was preparing Resident #1's medications. She said she should have reviewed Resident #1's physician's orders and reviewed the instructions on the Tamsulosin medication card, but she did not.2. For Resident #19, Nurse #2 administered:-the incorrect dose of Calcium Carbonate (a supplement to support bone density and muscle function).On 4/1/26 at 9:22 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #19 including:-Calcium Carbonate 750 mg tabletReview of Resident #19's Physician's Orders indicated but was not limited to:-Calcium Carbonate 500 mg tablet daily in the morning, dated 3/25/26During an interview on 4/1/26 at 1:45 P.M., Nurse #2 showed the surveyor a bottle of Calcium Carbonate 750 mg and said she administered it to Resident #19 during the morning medication pass. She reviewed Resident #19's physician's orders and said she should have administered Calcium Carbonate 500 mg as ordered by the Physician.3. For Resident #6, Nurse #2 administered:-the incorrect formula of Synthroid (a prescription medicine used to treat hypothyroidism (underactive thyroid)).On 4/1/26 at 9:42 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #6 including:-Levothyroxine 75 Micrograms (mcg) tabletReview of the medication card indicated but was not limited to:-Levothyroxine 75 mcg, Generic for: Synthroid-Give 1 tab daily in the morning, Brand Name only, No Substitutions-Dispensed on 3/18/26Review of Resident #6's Physician's Orders indicated but was not limited to:-Synthroid 75 mcg (Levothyroxine), 1 tab daily, BRAND NAME ONLY, NO SUBSTITUTIONS, dated 1/10/25During an interview on 4/2/26 at 11:06 A.M., the Nurse Practitioner said Resident #6's Resident Representative requested Resident #6 be administered Synthroid brand name only because the generic Levothyroxine is not as effective for him/her as the brand name form.During a telephonic interview on 4/2/26 at 11:23 A.M., the Pharmacist reviewed Resident #6's physician's orders and allergies and said Resident #6 does not have an allergy to Levothyroxine. She said some people's bodies do not metabolize Levothyroxine as well as Synthroid, making Levothyroxine not as effective as it should be.During an interview on 4/2/26 at 11:37 A.M., Resident Representative #3 said Resident #6 can only take the brand name Synthroid, because the generic form of Levothyroxine is not as effective for him/her. Resident Representative #3 said when Resident #6 would take Levothyroxine his/her hair will thin and fall out and his/her laboratory levels can be off.During an interview on 4/2/26 at 12:18 P.M., the Director of Nursing said medication must be administered per physician's orders and should be given as ordered. He said they must be administered in the correct time, dose, and the correct formula.

Based on observation and interview, the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles for one of one unit. Specifically, the facility failed to secure drugs and biologicals during a medication pass when medications were left unattended and were improperly disposed of in an unsafe manner.Findings include:Review of the facility's policy titled Medication Storage, revised December 2025, indicated but was not limited to:-The center will have medications stored in a manner that maintains the integrity of the product, ensures safety of the residents, and is in accordance with the Department of Health guidelines.-All medications including emergency drug kits will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel.Review of the facility's policy titled Medication Administration, Revised November 2025, indicated but was not limited to:-During administration of medications no medications are kept on top of the cart.a. On 4/1/26 at 9:13 A.M., the surveyor observed Nurse #3 prepare the following medications for Resident #1 and bring them into his/her room:-Tamsulosin 0.4 milligrams (mg) (used to treat symptoms of an enlarged prostate such as difficulty urinating, weak stream, and urgency) capsule-Multivitamin with Minerals tablet (mineral supplements)-Vitamin C 500 mg tablet (boosts the immune system, acts as a powerful antioxidant to protect cells from damage)-Oxycodone 5 mg tablet (an opioid pain reliever)-Guaifenesin 400 mg tablet (thins mucus in the chest)-Ferrous Sulfate 325 mg tablet (iron supplement)-Docusate Sodium 100 mg capsule (stool softener)Nurse #3 left Resident #1 holding the medication cup with four pills in it and went out into the hall. Nurse #3 stepped out into the hallway with her back to Resident #1 and the medication cup with four medications in it.During an interview on 4/1/26 at 1:47 P.M., Nurse #3 said she should not have left Resident #1 holding the medication cup unattended. She said medication must be in view of the nurse.b. On 4/1/26 at 9:30 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #32 including but not limited to:-Escitalopram 10 mg tablet (antidepressant medication)The Escitalopram tablet fell on the floor. Nurse #2 picked up the tablet and disposed of it into an opened, uncovered, and unsecured trash receptacle on the medication cart.On 4/1/26 at 11:20 A.M., the surveyor observed the opened, uncovered, and unsecured trash receptacle on Nurse #2's medication cart containing the trash bag containing the Escitalopram tablet.During an interview on 4/1/26 at 2:29 P.M., Nurse #2 said she disposed of the Escitalopram tablet into the uncovered and unsecured trash receptacle. She said medications should be disposed of in a secure manner without allowing residents access to unsecured medications.c. On 4/1/26 at 1:23 P.M., the surveyor observed the following:-Nurse #3 prepare and administer medications to Resident #14.-Nurse #3 left a medication card containing eight Amiodarone (a potent antiarrhythmic medication used to treat life-threatening heart rhythm) 400 mg tablets on top of the medication cart in the hallway unattended and unsecure with her back to the medication cart.On 4/1/26 at 1:47 P.M , Nurse #3 said she should not have left the medication card of Amiodarone unattended and unsecured in the hallway allowing anyone who walks by access to it.During an interview on 4/1/26 at 2:22 P.M., the Director of Nursing said medication should not be left unattended and unsecure in a resident's room or in the hallway. He said medication should not be disposed of in an unsecured and uncovered trash receptacle. He said medication must be disposed of in a safe and secure manner and medications must remain in view of the nurse.

Based on interviews and record reviews, the facility failed to maintain accurate documentation of the consent or declination of the pneumococcal vaccine, including education regarding the benefits and potential risks associated with the vaccine for three Residents (#20, #24 and #26), out of a sample of five residents. Findings include: Review of facility's policy titled Pneumococcal Vaccination, dated 7/2019 and last revised 9/10/25, indicated but was not limited to the following:- All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections- Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.- Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination.- Administration of the pneumococcal vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Review of the medical record for Resident #20, admitted [DATE], failed to include any documentation to indicate the Resident had an opportunity to either consent or decline the Pneumococcal vaccine and did not include an Immunization Consent form. Further review of the medical record failed to indicate the Pneumococcal vaccination status for Resident #20. 2. Review of the medical record for Resident #24, admitted [DATE], failed to include any documentation to indicate the Resident had an opportunity to either consent or decline the Pneumococcal vaccine and did not include an Immunization Consent form. Further review of the medical record failed to indicate the Pneumococcal vaccination status for Resident #24. 3. Review of the medical record for Resident #26, admitted [DATE], failed to include any documentation to indicate the Resident had an opportunity to either consent or decline the Pneumococcal vaccine and did not include an Immunization Consent form. Further review of the medical record failed to indicate the Pneumococcal vaccination status for Resident #26. During an interview on 4/1/26 at 9:30 A.M., Nurse #1 said consents for vaccinations were scanned into the electronic medical record. Nurse #1 and the surveyor reviewed the medical record and did not locate a Pneumococcal consent form for Resident #20, Resident #24 or Resident #26. Nurse #1 said consent forms should have been completed with the residents/representatives and placed in the medical record.Nurse #1 and the surveyor further reviewed the medical record for Resident #20, Resident #24 and Resident #26 for Pneumococcal vaccination status. Nurse #1 said the vaccines are documented in the electronic medical record under the immunization tab. Nurse #1 said the Pneumococcal vaccine for Resident #20, Resident #24 and Resident #26 were not documented. During an interview on 4/2/26 at 11:00 A.M., the Infection Control Preventionist (ICP) said she was overseeing the vaccination program for both residents and staff. The ICP said she was behind on obtaining consents for the Pneumococcal vaccine. The ICP said the Pneumococcal consent form had not been reviewed with Resident #20, Resident #24 and Resident #26. During an interview on 4/2/26 at 12:42 P.M., the Director of Nurses (DON) said there had not been a focus on Pneumococcal vaccinations by the last administration. The DON reviewed the most recent CDC guidance for Pneumococcal vaccination for people over [AGE] years old and did not observe documentation in any of the sampled Resident records to demonstrate the guidelines had been met.

Based on observation, record review and interviews, the facility failed to implement and revise individual care plans for one Resident (#17) out of a total sample of 13 residents. Specifically, the facility failed to revise the plan of care to ensure care approaches were effective, individualized, and appropriate for Resident #17 who was at risk for falls. Findings include: Review of the facility's policy, titled Fall Prevention and Management (revised 1/2023), indicated but was not limited to the following:- The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence- The staff will implement goals and interventions with resident/patient/family for inclusion in the interdisciplinary care plan based on the resident's individual needs- If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions-Residents who continue to fall with interventions in place will be assessed for changes in or additions to interventions Resident #17 was admitted to the facility in September 2025 with diagnoses that included dementia and anxiety. Review of the Minimum Data Set (MDS) Assessment, dated 1/1/26, indicated Resident #17 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had moderate cognitive impairment. Further review of the MDS indicated Resident #17 had two or more falls. Review of the care plan, initiated 10/16/25, indicated Resident #17 was at risk for falls. The goal identified was that Resident #17 will not sustain a fall related injury by utilizing fall precautions through the next review. Interventions included but were not limited to the following:-10/16/25 Resident educated on safety needs while in room: call bell in reach and call for assist with transfers-10/16/25 Invite, encourage, remind, escort to activity program consistent with resident's interests to enhance physical strengthening needs-10/16/25 Provide environmental adaptations:-Low/platform bed-Call light within reach-Adequate glare free lighting-Area free of clutter-10/16/25 Report falls to physician and responsible party-12/22/25 Resident will wear appropriately sized pants that are cuffed at the bottom-12/15/25 Sign reminder Remember to use your Walker on the walker and white board-10/16/25 Use of fall screen to identify risk factors Review of the care plan, initiated 10/1/25, indicated Resident #17 requires assist with Activities of Daily Living (ADL) related to cognitive loss. The goal identified was that Resident #17 will perform ADL self-performance activities as possible. Interventions included but were not limited to the following:-10/6/25 Dycem to wheelchair to assist with slipping-10/16/25 Resident will spend majority of time in common area due to history of falls in room-10/1/25 Toilet hygiene moderate assist Review of the incident accident reports for falls, included the following reports with interventions:10/5/25- slip from wheelchair; Dycem added to wheelchair cushion10/11/25- educated safety needs12/12/25-toilet assist after meals12/12/25-appropriately sized pants that are cuffed at the bottom Further review of the fall care plan, (revised 10/23/25), did not provide documented evidence to toilet assist after meals. During an observation and interview on 3/31/26 at 10:30 A.M., the surveyor observed Resident #17 standing up from his/her bed and self-transfer to a straight back chair at his/her bedside. The Resident said he/she does not use a wheelchair. The surveyor did not see a wheelchair in the resident's room and the whiteboard on the wall across from resident's bed was blank. During an observation and interview on 3/31/26 at 1:05 P.M., the surveyor observed Resident #17 stand from the bed and ambulate to the bathroom without his/her walker. Resident #17 said he/she goes to the bathroom on his/her own. During an observation and interview on 4/1/26 at 9:49 A.M., the surveyor observed Resident #17 sitting in a straight back chair at his/her bedside. Resident #17 said he/she does not like to leave his/her room. Resident #17 said he/she did not like to go to activities or the day room. During an interview on 4/1/26 at 11:58 A.M., Certified Nursing Assistant (CNA) #2 said she was aware Resident #17 was a fall risk. She said Resident #17 did not use a wheelchair. CNA #2 said Resident #17 does not like to come out of his/her room. CNA #2 said Resident #17 does not need assistance to use the bathroom. During an interview on 4/1/26 at 2:06 P.M., Nurse #2 said nurses do not update Resident's care plans. Nurse #2 said she believed that the MDS nurse updated care plans. Nurse #2 said Resident #17 very seldom comes out of his/her room. Nurse #2 said Resident #17 is independent in his/her room and requires no supervision. During an interview on 4/2/26 at 2:21 P.M., the Regional Nurse Consultant (RNC) said the expectation was the nurse who was documenting the falls incident report would put the intervention into the care plan. The RNC said all falls are reviewed in the morning meeting and updated/revised as needed. Staff would be educated to new interventions. During an interview on 4/2/26 at 3:14 P.M., the Director of Nurses (DON) reviewed Resident #17's current falls care plan. The DON said he was not aware Resident #17 was no longer using a wheelchair or Resident preferred to stay in his/her room. The DON said Resident #17 did have a fall on 12/12/25 and interventions were not revised to prevent further falls. The DON said the current care plan needed to be revised. Although the plan of care, revised 10/23/25, for the risk of falls included approaches to prevent falls, there was no documented evidence that the interdisciplinary team reviewed the effectiveness of the interventions being put in place to prevent the falls.

Based on observation, record review, and interview, the facility failed to ensure staff provided care and services consistent with accepted standards of clinical practice for one Resident (#1), out of a total sample of 13 residents. Specifically, the facility failed to ensure a physician's order for Lidocaine 5% patch (topical anesthetic) was complete and included the duration/time of removal.Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.Resident #1 was admitted to the facility in January 2026 and had diagnoses including arthritis and one stage 2 pressure ulcer (partial-thickness skin loss involving the epidermis and dermis).Review of the Minimum Data Set (MDS) assessment, dated 2/12/26, indicated Resident #1 cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, and received pain medication daily.Review of the medical record indicated the following Physician's Order:-Lidoderm Patch 5% (Lidocaine), Apply to low back topically in the morning for low back pain (2/10/26)During an interview on 4/1/26 at 11:39 A.M., Nurse #3 reviewed Resident #1's medical record and said the order for the Lidocaine pain patch indicates it is to be applied in the morning but does not include a duration or a time when it is to be removed. She said Lidocaine 5% patches can be applied for up to 12 hours but can be ordered for different durations. She said the physician's order should be complete and include a duration/time of removal and it does not.

Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#1), out of a total sample of 13 residents, received care and treatment to prevent and to promote healing of a pressure injury consistent with professional standards of practice. Specifically, the facility failed to ensure an air mattress was set according to the physician's order.Findings include:Review of the facility's policy titled Support Surfaces-Air Mattresses, last revised 10/2022, indicated but was not limited to:Low air loss mattress use is indicated as follows:-To assist in the treatment and/or prevention of pressure ulcers as part of a holistic program of pressure ulcer management.-As part of a pain management program when indicated for resident comfortSettings:-The patient weight indication is a close proximation of the correct setting.Resident #1 was admitted to the facility in January 2026 and had diagnoses including one stage 2 pressure ulcer (partial-thickness skin loss involving the epidermis and dermis) to his/her left buttock and one unstageable deep tissue injury to his/her right heel.Review of the Minimum Data Set (MDS) assessment, dated 2/12/26, indicated Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, had one stage 2 pressure ulcer and one unstageable deep tissue injury and had a pressure reducing device for his/her bed.On 3/31/26 at 10:05 A.M., the surveyor observed Resident #1 lying in bed resting. An air mattress was in place, and the compressor was on and set to 280 pounds (lbs.). Review of the medical record indicated the following Physician's Order:- Air mattress to bed for pressure relief. Set per Resident's weight. Check functionality every shift for pressure relief (3/23/26)Review of the medical record indicated Resident #1's weight was last measured on 2/18/26 and was 193.0 lbs.On 4/1/26 at 9:17 A.M., the surveyor observed Resident #1 sitting upright in bed awake. An air mattress was in place, and the compressor was on and set to 280 lbs. Review of comprehensive care plans indicated, but was not limited to:-Focus: Impaired skin integrity related to pressure, decreased mobility, incontinence as evidenced by a stage 2 pressure injury to left buttock (3/13/26)-Interventions: Utilize air mattress set per Resident's weight (3/13/26)-Goal: Resident's stage 2 pressure injury to left buttock will show signs of healing within review period; Resident will remain free from additional pressure injuries during review period (target date: 6/10/26)During an interview with observation on 4/1/26 at 11:39 A.M., Nurse #3 and the surveyor went to Resident #1's room to inspect the air mattress in place on the Resident's bed. She said the air mattress was set to 280 lbs. and should be set to his/her weight as indicated in the physician's orders. She reviewed the Resident's medical record and said the Resident's last weight was taken on 2/18/26 and it was 193.0 lbs. She said the air mattress was set too high and should be set close to 193 lbs.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly date, label, and store food and drink items in one of two kitchenettes.Findings include:Review of the facility's policy titled Unit Food Storage, last revised January 2023, indicated but was not limited to:-Food items stored for nourishment or brought in by residents shall be stored in designated areas only. The unit area designated for food storage will remain clean and safe for food handling.-Food items will be identified with name of the owner and date placed in designated refrigerator.-All resident food items will be dated with use by date.-Dietary and nursing staff will be responsible to ensure food items stored in pantry, refrigerators, and freezers are not expired or past perish dates.Review of the facility's policy titled Food from Outside-Safety, last revised January 2023, indicated but was not limited to:-It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors.-Education on safe food handling will be provided to all staff, family, residents, resident council, visitors.-Education will include at a minimum: -Proper labeling and dating of each item. -Leftover foods be used within 3 days or discard. -Foods requiring refrigeration will be received by the facility designee (activity department, food and nutrition department, and charge nurse) for proper and immediate storage including labeling and dating.-Staff will examine food for quality (smell, packaging, appearance) to identify potential concerns. If concerns are identified, staff will notify the resident or resident representative of findings and necessary actions per proper food and beverage safe handling.On 3/31/26 at 12:26 P.M., in the Living Room refrigerator, the surveyor made the following observations:- A sign on refrigerator indicated but not limited to: -Attention Everyone, All food put into the refrigerator must be labeled with name and date. Any Item that is not dated will be thrown out.-One paper bag with a plastic container inside with fried chicken pieces, labeled as packed on 3/24/26, sell by 3/25/26. Both the bag and plastic container failed to indicate a Resident's name and date brought in.-Plastic container with a clear cover, covered with condensation and food inside, labeled with a Resident's name and dated 3/24/26- A gray insulated cup with soup inside, labeled with Resident's initials and undated- One opened container of sliced cheese with a black, fuzzy looking substance on a few of the cheese slices, labeled with a Resident's name and use by date of 5/8/26, but failed to indicate the date opened- One jar of tomato sauce, manufacturer's recommendations to use within 3 days after opening, failed to indicate a resident's name and date opened- One plastic container of ricotta cheese, manufacturer's recommendations to use within 3 to 5 days after opening, failed to indicate a resident's name or date opened- Half of an egg salad sandwich, dated 3/26/26- One open jar of olives, failed to indicate resident's name or date openedOn 3/31/26 at 4:17 P.M., in the Living Room refrigerator, the surveyor made the following observations:- One plastic container of ricotta cheese, manufacturer's recommendations to use within 3 to 5 days after opening, failed to indicate a resident's name or date opened- One jar of tomato sauce, manufacturer's recommendations to use within 3 days after opening, failed to indicate a resident's name and date opened- One opened container of sliced cheese with a black, fuzzy looking substance on a few of the cheese slices, labeled with a Resident's name and use by date of 5/8/26, failed to indicate date opened- One open jar of olives, failed to indicate resident's name or date opened- A gray insulated cup with soup inside, labeled with Resident's initials and undatedDuring an interview with observation on 3/31/26 at 4:46 P.M., Nurse #5 said the kitchen staff was responsible for cleaning the refrigerator, but sometimes she cleaned it on the overnight shift. She said foods brought in for a resident must be labeled with the resident's name and dated, then discarded after 72 hours. She said if food is unlabeled with a resident's name and undated then it should be thrown out. She opened the gray insulated cup and said, Oh, that soup doesn't look good and she was unsure when it was brought in. She said the sliced cheese looked moldy. She said the ricotta, tomato sauce, and olives should not be in the refrigerator and needed to be discarded.During an interview on 4/1/26 at 11:14 A.M., Dietary Aide #1 said the unit refrigerators were cleaned four times a day by the kitchen staff. He said resident items needed to be labeled with a resident's name and date brought in. He said foods that are not labeled with a with a resident's name and/or dated must be discarded. He said the nursing staff know that nothing should go in the refrigerator without being labeled and dated. During an interview on 4/1/26 at 12:04 P.M, the Food Service Manager said nursing was responsible for discarding food items which were not labeled and dated appropriately. He said the dietary department only cleans up spills. He said the dietary department was told not to discard any food in the refrigerator as not to upset residents or their families.During an interview on 4/2/26 at 3:25 P.M., the Director of Nursing said residents' food items needed to be labeled with a resident's name and date brought in and then discarded after 72 hours. He said if food is not labeled and dated then it should be discarded. He said the dietary department was responsible for cleaning the refrigerator and discarding foods not labeled and dated appropriately.

Based on observation, interview, and record review, the facility failed to ensure three Residents (#4, #27, and #12), out of a total sample of 12 residents, had their call bell devices accessible and within reach to utilize them to call for staff assistance while in their beds. Findings include: Review of the facility's policy titled Call Bell Policy, revised January 2023, indicated but was not limited to the following: Procedure: -As soon as a call bell is activated a staff member observing the light activation should answer promptly. c. Turn off the call light, make sure it is still within reach of the resident. f. Ensure the resident is safe and the call bell is within reach. -If a resident is unable to manipulate a call bell effectively provide the resident will be provided (sic) with an alternative device. a. Resident #4 was admitted to the facility in December 2020 and had diagnoses including unspecified dementia and overactive bladder. Review of the Minimum Data Set (MDS) assessment, dated 12/18/24, indicated Resident #4 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of the Falls care plan, initiated 1/22/24, indicated but was not limited to the following: Focus: Resident is at risk for falls characterized by history of falls/injury, multiple risk factors related to impaired balance, unsteady gait, and new unwitnessed falls. Intervention: Call bell pinned to gown when in bed, 3/17/24, Reinforce need to call for assistance, 1/22/24 On 3/3/25 at 10:59 A.M., the surveyor observed Resident #4 sitting up in bed. An overbed tray table was observed with two empty plastic cups, an empty yogurt container, and half of a peanut butter and jelly sandwich wrapped in saran wrap. Resident #4 said he/she was waiting for staff to come in and take it all, but they never come. The surveyor observed the Resident's call bell device wrapped around the Resident's left upper side rail, which was in the upright position, and hanging down toward the floor, not within reach or accessible to the Resident. The Resident said he/she didn't know where his/her call bell was. On 3/4/25 at 3:54 P.M., the surveyor observed Resident #4 sitting up in bed. The Resident's call bell device was wrapped around the Resident's left upper side rail, which was in the upright position, and hanging down toward the floor, not within reach or accessible to the Resident. The Resident was unable to demonstrate locating the call bell device for use and said he/she didn't know where it was. b. Resident #27 was admitted to the facility in January 2021 with diagnoses including frontotemporal neurocognitive disorder, polymyalgia rheumatica (inflammatory disorder causing muscle pain and stiffness around the shoulders and hips), and urinary tract infections. Review of the MDS assessment, dated 1/1/25, indicated Resident #27 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15 and had had two falls without injury since admission or prior assessment. Review of the Falls care plan, initiated 1/22/24, indicated but was not limited to the following: Focus: Resident is at risk for injuries related to decreased mobility and impaired balance Intervention: Call light within reach On 3/3/25 at 10:59 A.M., the surveyor observed Resident #27 lying in bed. The Resident said he/she didn't have a call bell. The surveyor observed the Resident's call bell device wrapped around the Resident's right upper side rail, which was in the upright position, with the end of the cord including the push button device no longer visible as it was underneath the mattress. The call bell was not within reach and was inaccessible to the Resident. Resident #27 was unable to demonstrate locating the call bell device and when asked how he/she would call for help he/she said, I can't. On 3/4/25 at 3:54 P.M., the surveyor observed Resident #27 lying in bed. The Resident said he/she didn't have a call bell. The surveyor observed the Resident's call bell device wrapped around the Resident's right upper side rail, which was in the upright position, with the end of the cord including the push button device no longer visible as it was underneath the mattress. The call bell was not within reach and was inaccessible to the Resident. Resident #27 was unable to demonstrate locating the call bell device and when asked how he/she would call for help he/she said, I don't know. During an observation with interview on 3/6/25 at 7:40 A.M., Nurse #2 entered Resident #4 and #27's (roommates) room and observed Resident #27's call bell device wrapped around the Resident's right upper side rail and disappearing underneath the mattress and Resident #4's call bell device wrapped around the Resident's left upper side rail which was in the down position and hanging down towards the floor. Nurse #2 said the call bells should have been accessible and within the Residents' reach. She said usually the two Residents call out if they need something. c. Resident #12 was admitted to the facility in March 2016 and had diagnoses including Parkinson's disease (a progressive brain disorder that causes movement problems, stiffness, and balance issues) and dementia. Review of the MDS assessment, dated 1/17/25, indicated that Resident #12 had severe cognitive impairment as evidenced by the BIMS unable to be completed due to the Resident being rarely/never understood. On 3/3/25 at 11:02 A.M. and 3/4/25 at 7:54 A.M., the surveyor observed Resident #12 reclined in bed asleep. The Resident's call light cord was observed wrapped around the upper side rail, which was in the upright position, and hanging down towards the floor and out of the Resident's reach. On 3/4/25 at 8:30 A.M., the surveyor observed Resident #12 sitting upright in bed being fed his/her breakfast meal by CNA #6. CNA #6 had a beeper fastened to her shirt and said when the Resident pulls the call light, the beeper sounds. The call light cord was observed wrapped around the upper left side rail, which was in the upright position, hanging down nearly touching the floor and out of the Resident's reach. During an interview on 3/6/25 at 10:42 A.M., the Director of Nursing said all residents should have call bell devices that are easily accessible and within reach of the residents.

Based on review of Resident Council Minutes, and interviews, the facility failed to ensure that staff addressed and promptly resolved grievances brought forward during Resident Council Meetings held from 3/4/24 through 1/6/25. Findings include: Review of the facility's policy titled Resident Council, last revised January 2023, included but was not limited to: -The Recreation Department should be responsible for assisting residents in organizing and facilitating a monthly resident council meeting in which residents bring their concerns to Department Heads respectively. -Concerns that are raised at the meeting must be recorded in minutes and followed with a concern/response form filled out by the designated staff representative and addressed to the corresponding Department Head to provide a resolution. All supporting documentation (i.e. in-services, staff education, clinical notes) must be attached. Concern/response forms must be completed within seven days of being issued. -Should a resident raise a concern that may need to be investigated, the concern must be escalated to Social Services as a grievance. Designated staff members must notify residents that concern has been forwarded to Social Services. -Residents who express a concern will be provided with a resident notification summary form, providing a summary of the concern stated and resolution given by the Department Head. Residents will be asked to sign a notification summary if the resident acknowledges and agrees with the resolution. Review of the facility's policy titled Grievances, last revised October 2022, included but was not limited to: -The Facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form when concerns are expressed. The facility will investigate and resolve resident grievances timely to ensure residents' safety and protect residents' rights. -Grievances/complaints may be submitted orally or in writing. -Upon receipt of a complaint/grievance, the corresponding department will investigate the allegation(s) and submit a written report of such findings within seven business days. -The resident and/or resident representative filing the grievance/complaint will be informed verbally and in writing of the findings of the investigation and the action(s) taken to correct any identified problems. During an interview on 3/4/25 at 9:17 A.M., the Administrator provided the survey team with the Grievance book for review. She said the book included only one grievance from 2024 and 2025. The grievance was filed on 1/6/25, for two missing nightshirts for one resident. The grievance was resolved on 1/9/25. The Administrator confirmed that there were no other grievances to review. On 3/4/25 at 1:30 P.M., the surveyor held a resident group meeting with 12 residents in attendance. All residents said long call bell wait times have been an ongoing issue for a long time; mostly on the evening and night shift and some weekends and have not been resolved. One resident said he/she waits 15 minutes or longer and there are times when he/she soils him/herself because it takes so long for staff to respond. They said that they do not receive any type of follow-up or discussion about the issues they raise during Resident Council meetings until the next monthly meeting. On 3/6/25 at 9:11 A.M., the Activity Director (AD) and surveyor reviewed Resident Council Minutes as follows: Review of the Resident Council Minutes, dated 3/4/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Three residents expressed concerns that call bells were not being answered in a timely manner, including on the overnight shift. -Residents wanted to know who could help with ordering things online. Review of the grievance book failed to indicate the concerns documented during the 3/4/24 Resident Council meeting were documented on a grievance/complaint/concern form. Review of the Resident Council Minutes, dated 4/8/24, indicated 10 residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Concerns with call bells. Residents recommended that all call bells should be answered by any staff member to make sure all is ok and then direct resident requests to the proper department. -White boards (dry erase boards) are not always updated with the correct date or staff members. Residents recommend that boards be updated daily with the correct date and staff members that will be assisting them for the day. There was no follow up or resolution to the issues brought forward during the previous meeting and they continued to be a concern. Review of the grievance book failed to indicate the concerns documented during the 4/8/24 Resident Council meeting were documented on a grievance/complaint/concern form. Review of the Resident Council Minutes, dated 5/6/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Residents stated that they need a full-time Social Worker that is available when needed. -Some residents feel there should be sensitivity training. -Curfews after dinner? -Nursing: Call bell, whiteboards, name tags. Need improvement. Staff patience needs improvement. Review of the grievance book failed to indicate the concerns documented during the 5/6/24 Resident Council meeting were documented on a grievance/complaint/concern form and continue to be a concern. Review of the Resident Council Minutes, dated 6/3/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Call bells are being checked more often but are then turned off and the person answering the bell will tell the assigned CNA what is needed, and no one comes back. -Residents recommend that call bells not be turned off until their needs are met. -White boards and call bells continue to need improvement. Name tags flip over and can't see the name. Review of the grievance book failed to indicate the concerns documented during the 6/3/24 Resident Council meeting were documented on a grievance/complaint/concern form and continue to be a concern. Review of the Resident Council Minutes, dated 7/1/24, indicated 11 residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Call bells; if nobody answers, we start to yell help. -One resident complained that he/she was missing an article of clothing and provided a description. The resident indicated he/she has asked several times, but it is not resolved. -Concerns about routine care when getting residents up: i.e. washing before dressing and brushing teeth. Review of the grievance book failed to indicate the concerns documented during the 7/1/24 Resident Council meeting were documented on a grievance/complaint/concern form and continue to be a concern. Review of the Resident Council Minutes, dated 8/3/24, indicated seven residents, one family member and the Ombudsman participated in the meeting, and brought forward the following grievances/complaints/concerns: -One resident is getting a replacement for clothing items. -Call bells about the same, maybe a little quicker. -One resident and one family member concerned about call bells not being answered in a timely manner to prevent any falls if trying to help him/herself. Review of the grievance book failed to indicate the concerns documented during the 8/3/24 Resident Council meeting were documented on a grievance/complaint/concern form and continue to be a concern. Review of the Resident Council Minutes, dated 9/2/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Call bells Review of the grievance book failed to indicate the concerns documented during the 9/2/24 Resident Council meeting were documented on a grievance/complaint/concern form and continue to be a concern. Review of the Resident Council Minutes, dated 10/14/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Staff extremely loud while directing mealtimes. -New Nurses, are they licensed? Review of the grievance book failed to indicate the concerns documented during the 10/14/24 Resident Council meeting were documented on a grievance/complaint/concern form. Review of the Resident Council Minutes, dated 11/4/24, indicated six residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Often searching for more linens-run out often. Review of the grievance book failed to indicate the concerns documented during the 11/4/24 Resident Council meeting were documented on a grievance/complaint/concern form. Review of the Resident Council Minutes, dated 12/2/24, indicated nine residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -One resident indicated he/she is missing an article of clothing. -Some bathrooms need attention. -One resident said white boards and call bells are still a problem. Review of the grievance book failed to indicate the concerns documented during the 12/2/24 Resident Council meeting were documented on a grievance/complaint/concern form and continue to be a concern. Review of the Resident Council Minutes, dated 1/6/25, indicated 11 residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -One resident indicated he/she has some concerns and will speak to the Director of Nursing about them. Review of the grievance book failed to indicate the concerns documented during the 1/6/25 Resident Council meeting were documented on a grievance/complaint/concern form. During an interview on 3/6/25 at 9:11 A.M., the AD said she sets up the monthly Resident Council meetings. The residents invite her to attend, she gets the meeting going and then she leaves. She said after the meeting, the Resident Council President gives her the handwritten minutes of the meetings and she types them up. When she is done, she has the Resident Council President proofread and approve them. She said if an issue comes up during the meetings, she highlights the meeting minutes with a pen and gives them to the appropriate Department Head. The AD said she did not think the issues brought forward during the Resident Council meetings were grievances, and did not complete a grievance/complaint/concern form. She said she was out on leave for three months in 2024 (September, October and November) and no one reviewed the Resident Council minutes. She said the handwritten minutes were just filed in the Resident Council book. She said if the residents had an issue that was brought up during the Resident Council meetings during that time, no one would have reviewed the minutes to know about it. She said she did not start doing education or audits of call bell response times or white board use by staff until January 2025, 10 months and nine months respectively, after the grievances were brought forward through Resident Council. During an interview on 3/6/25 at 10:30 A.M., the Administrator identified herself as the Grievance Official. She confirmed that the only grievance filed was the 1/6/25 grievance in the Grievance book. The Administrator and surveyor reviewed Resident Council Minutes from 3/4/24 through 1/6/25. She said she does not feel that the residents' complaints rise to the level of a grievance. She said it is her understanding that if an issue has an outcome associated with it, it is considered a grievance. The Administrator explained that an example of a grievance is if a resident soils themselves from waiting too long for their call light to be answered.

Based on observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on one of one nursing unit. Findings include: According to the National Institute of Health, November 24, 2024: The US Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, was established to safeguard patient privacy and secure health information. HIPAA sets strict standards for managing, transmitting, and storing protected health information. HIPAA applies to healthcare providers, insurers, and other organizations handling patient data, mandating safeguards to prevent unauthorized access or misuse of sensitive information. HIPAA regulations uphold patients' rights to confidentiality and empower them to control the disclosure of their health information, fostering trust in healthcare systems. On 3/4/25 at 11:27 A.M., the surveyor observed an unattended medication cart positioned outside the main dining room, where seven residents were seated and waiting for food to be served. The computer on top of the cart was open, displaying various residents' names, photos, and identifying information. The computer screen was visible to others in the vicinity including one resident, one visitor, and one dietary aide. During an interview on 3/4/25 at 10:32 A.M., Nurse #3 said she should have closed the screen to the computer before leaving it unattended to keep residents' health information private. On 3/5/25 at 11:06 A.M., the surveyor observed an unattended medication cart positioned against the wall in the unit hallway. The computer on top of the cart was open, displaying a resident's name and a list of his/her medications and was visible to others in the vicinity including a consultant mobile imaging provider and a non-clinical staff person. During an interview on 3/5/25 at 11:11 A.M., Nurse #5 said she was responsible for the medication cart and should have closed the computer screen before she left the medication cart unattended so no one could see the resident's private health information. During an interview on 3/6/25 at 3:05 P.M., the Director of Nursing said that nursing staff should either log out of the computer or close the computer screen when the carts are unattended to protect residents' private health information.

Based on observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed to develop and consistently implement effective interventions to prevent six unwitnessed falls for one Resident (#15), out of a total sample of 12 residents. Findings include: Review of the facility's policies titled Fall Prevention and Management, last revised January 2023 and Accidents and Incidents, last revised October 2022, indicated but was not limited to: Fall Assessment and Prevention: -Fall risk assessments will be completed for all residents; initially on admission/readmission, quarterly, significant change and after an identified fall. -As part of the assessment, the nurse will help identify individuals with a history of falls and risk factors for subsequent falling. Root causes for fall history will be identified. Post Fall: -The nurse will complete an incident report. -Resident will be referred to therapy for a screen-for indication of need for therapy interventions. Cause Identification: -For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall-causes refer to factors that are associated with or that directly result in fall. Monitoring and Follow Up: -Interdisciplinary team should monitor and document on the resident's response/success with fall reduction interventions -Residents who continue to fall with interventions in place will be assessed for changes in or additions to interventions -If continuous falls occur, Physician may assess for incorrectable risk factors, that may include reasons why additional interventions may not prevent falls. Resident #15 was admitted to the facility in October 2024 and had diagnoses including Parkinson's disease and drug induced dyskinesia (involuntary, repetitive, and often abnormal movements). Review of the Minimum Data Set (MDS) assessment, dated 10/26/24, indicated Resident #15 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 7 out of 15, was dependent on staff for transfers and toileting and had sustained one fall since admission to the facility. Review of a Physician's Progress Note, dated 10/25/24, indicated Resident #15 had a history of falls and is considered a major fall risk. Review of the initial Fall Risk Evaluation, dated 10/21/24, provided by the Director of Nursing was incomplete, unsigned and failed to indicate a fall risk score to guide care plan development. Review of comprehensive care plans indicated but was not limited to: -Focus: Falls-Resident is at risk for injuries related to fall history (10/22/24) -Interventions: Invite, encourage, remind, escort to activity program consistent with resident's interests to enhance physical strengthening needs; observe for side effects of any drugs; provide low bed, call light, glare free lighting, area free of clutter; remind resident and reinforce safety awareness; report falls to physician and responsible party; use fall screen to identify risk factors (10/22/24) -Goal: Resident will not sustain a fall related injury by utilizing fall precautions through next review (10/22/24; target date: 4/18/25) Review of the medical record indicated Resident #15 had six unwitnessed falls from October 2024 to February 2025. During an interview on 3/5/25 at 10:03 A.M., the Director of Nursing (DON) said the Resident has had five falls since admission to the facility. He provided the surveyor with copies of five fall incident reports and investigations for Resident #15 (a sixth unwitnessed fall was identified by the surveyor incidentally during record review). Review of the falls indicated: -10/24/24 at 4:30 P.M., Resident had an unwitnessed fall and was found lying on his/her back on the side of the left side of the bed in his/her room. The Resident reported he/she slid out of bed. Precipitating and/or contributing factors identified included confusion, behaviors, limitation with range of motion (ROM), involuntary movements, and unable to transfer on/off toilet. The investigation failed to include a root cause analysis of the fall and had no staff statements. Interventions to prevent further falls: fall mat provided. This fall intervention was added to the care plan on 10/30/24. -11/9/24 at 3:51 P.M., Resident #15 had an unwitnessed fall and was found on the floor next to his/her bed. Interventions in place at the time of the fall were a safety mat at the side of the bed and the bed was in the lowest position. The root cause analysis indicated the Resident has Parkinson's disease and is constantly moving. Interventions to prevent further falls: offer toileting more frequently. The Resident's care plan for incontinence already indicated to check and change the Resident every 2 to 3 hours and as needed (10/31/24). The incident report and investigation did not include any staff statements. No new interventions were added to the care plan to prevent future falls. -11/15/24 at 7:01 A.M., Resident #15 had an unwitnessed fall and was found on the floor mat next to his/her bed. The Resident sustained an abrasion to his/her head, a bruise to the right elbow and complained of pain to his/her forehead. Interventions in place at the time of the fall included a safety mat at the side of the bed, the bed was in the lowest position, and a canoe mattress (creates a raised rail, defined perimeter for enhanced fall prevention). The investigation failed to include a root cause analysis of the fall and had no staff statements. New interventions to prevent further falls: floor mat (already in place), bed placed in low position (already in place), Resident placed closer to nurses' station and diversional activity provided. No new interventions were added to the care plan to prevent further falls. -11/18/24 at 8:30 P.M., Resident #15 had an unwitnessed fall and was found lying on the floor beside his/her Broda (positioning) chair in front of the nurses' station. New interventions to prevent further falls: bed placed in low position (already in place and not relevant to the fall as the Resident fell out of a Broda chair at the nurses' station). -2/18/25 at 7:00 A.M., Resident #15 had an unwitnessed fall and was found by housekeeping staff lying on the floor mat beside his/her bed. The Resident was assisted into a Broda chair and brought out in front of the nurses' station for supervision. New interventions to prevent further falls: toileting scheduled. The Resident's care plan for incontinence already indicated to check and change the Resident every 2 to 3 hours and as needed (10/31/24). No new intervention was added to the care plan to prevent further falls. Review of the medical record indicated an Occupational Therapy (OT) Screening Form, dated 1/8/25, indicated Resident #15 fell off the toilet on 1/7/25. A Risk Meeting Note, dated 1/9/25, indicated the Resident had a fall in the bathroom. A new intervention was added for close supervision with all ADLs because the Resident flails and is very unsteady at baseline. This intervention was added to the care plan two days after the fall. During interviews on 3/5/25 at 3:32 P.M. and 3/6/25 at 3:05 P.M., the DON reviewed Resident #15's medical record and investigations for five unwitnessed falls. He said they should have identified new interventions after each fall that occurred and if they were not effective, tried something else. He reviewed the 1/9/25 Risk Meeting Note and could not explain why the fall that occurred on 1/7/25 was not documented in the medical record. There was no incident/accident report to review and no other documentation in the medical record for this unwitnessed fall on 1/7/25. Review of the staff schedule for 1/7/25 indicated Nurse #6 was assigned to Resident #15's care on that day. During a telephone interview on 3/6/25 at 3:58 P.M., Nurse #6 said she heard about Resident #15's fall in the bathroom during report when she came on duty on 1/7/25 at 11:00 P.M. She said she was told that Certified Nursing Assistant (CNA) #4 placed the Resident on the toilet and at that time, another resident across the hall started screaming out for help. She said the nurse on duty did not respond to the resident screaming for help, so the CNA left the bathroom and ran across the hall to check on the screaming resident. When the CNA returned to Resident #15 in the bathroom, he/she was on the floor. During an interview on 3/6/25 at 4:15 P.M., CNA #4 said he was working on the 3:00 P.M. to 11:00 P.M. shift on 1/7/25 when Resident #15 had a fall. He said he had placed the Resident on the toilet in the bathroom in his/her room when a resident across the hall started screaming his name over and over again. He said the resident's voice sounded panicked. CNA #4 said no other staff was responding to the screaming resident so he left Resident #15 on toilet to go help the other resident. He said when he returned to Resident #15, he/she had fallen off the toilet. He said he then called for Nurse #2, and she came to help the Resident. During an interview on 3/6/25 at 4:20 P.M., Nurse #2 said Resident #15 was on her assignment on 1/7/25 on the 3:00 P.M. to 11:00 P.M. when he/she fell off the toilet. She said CNA #4 was in the bathroom with the Resident, and a resident in a room across the hallway started screaming. She said the CNA left the Resident on the toilet to go to the screaming resident. She said she heard the resident screaming, but didn't go to assist the resident because he/she can be behavioral and scream. Nurse #2 said CNA #4 called her to let her know the resident had fallen and she assessed Resident #15. She said she didn't document anything about the fall in a note or anywhere in the medical record. She said she did not document the fall because she wanted to wait to speak to the DON to see how they (the facility) wanted it to be written so it didn't sound as bad.

Based on observation, document review, and interview, the facility failed to ensure sufficient staffing to ensure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed: 1. To have sufficient staffing on the weekends as indicated on the payroll-based journal (PBJ) report submitted to Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 4, 2024 when no nurse staffing waivers were in place; and 2. To ensure call bell devices were responded to timely to address the residents' needs per Resident Group voiced concerns and review of Resident Council minutes. Findings include: 1a. Review of the PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 4, 2024 (7/1/24-9/30/24) indicated the following: This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). Excessively Low Weekend Staffing - Triggered = Submitted Weekend Staffing data is excessively low Review of the facility's healthcare Facility Assessment (FA), revised December 2024, indicated but was not limited to the following: Part 1: Resident Profile 1.1 Number of residents facility is licensed to provide care for - 41 -We offer 41 beds for both long-stay, short-stay, respite and hospice residents and patients. The nursing home is a licensed SNF and is located on one floor with a single nursing station. 1.2 Average daily census: 38 residents 1.5 Acuity: The average acuity level of our residents ranges from low to complex acuity. While many long-stay patients tend to have lower acuity levels, short-stay patients tend to have higher acuity levels. Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies: Staffing Plan 3.2: Based on our resident population and their needs for care and support, our general approach to ensure we have sufficient staff is to meet the needs of the residents at any given time is outlined below. Nursing and clinical staffing is continuously (often by shift) adjusted for acuity and census fluctuations. Staffing Plan B: Below is a description of our general staffing plan to ensure we have sufficient staff to meet the needs of our facility residents at any given time. Staff: (Licensed Nurses (LN): Registered Nurse (RN), Licensed Practical Nurse (LPN), providing direct care, leadership and supervision of unit activities): Plan: -Director of Nursing (DON) - 1 RN full-time -Days - 2 Nurses, RN or LPN -Evenings - 2 Nurses, RN or LPN -Nights - 1 Nurse, RN or LPN Staff: (Direct Care Staff) Plan: -Days - 4 to 5 Certified Nursing Assistants (CNAs) -Evenings - 4 CNAs -Nights - 2 CNAs The Facility Assessment (FA) did not include a minimum standard of staffing for hours per patient day (HPPD- staffing hours per resident per day, which is the total number of hours worked by each type of staff divided by the total number of residents) of direct nursing care provided to ensure the residents' health and safety. During the entrance conference on 3/03/25 at 9:27 A.M., with the Administrator and Director of Nursing (DON), the Administrator said there was no scheduling coordinator, so the DON was assuming the role for the nursing schedules for now. They said there were no nurse staffing waivers in place. During an interview on 3/4/25 at 2:35 P.M., the Administrator and DON provided the requested weekend as worked licensed and direct care staff schedules for FY Quarter 4 (7/1/24 - 9/30/24) and corresponding daily staffing reports. The DON said staff names with a circle around them mean that they called out and staff names that are grayed out means that they picked up a shift. They said staffing is based on the census and they couldn't run a PPD (nursing hours per patient day) report because they don't submit staffing per PPD, rather by the number of licensed and unlicensed staff. The Administrator said it was a small facility with small staff, and they have trouble with the geographical area and travel. They said they only use one agency for agency staff and were currently only using agency staff for about one shift a week for licensed and unlicensed staff. They said they didn't use the agency much during the FY Quarter 4 and maybe not at all for about a month during that time but would confirm. They said during the quarter they had three CNAs that were out for a period of time and said the average daily staffing for day shift (7a-3p) is 2 Nurses and 4-5 CNAs depending on the census; evening shift (3p-11p) is 2 Nurses and 4 CNAs; and the night shift (11p-7a) is 1 Nurse and 2 CNAs. The Administrator and DON said if the census was 37, there are always 4 to 5 CNAs, and the goal is 1 CNA for every 8-10 residents. For example, they said, if the census is 30-31 residents, then they would need 3 CNAs but try to have a fourth. They further said there's a lot of CNAs that call out and said CNAs will pick up shifts then call out, so they think they're all set, but then they're not. The DON said there was no pattern, however, for call outs. During an interview on 3/5/25 at 3:00 P.M., the Administrator said corporate submits the PBJ staffing data. Review of the as worked weekend staffing schedules and daily staffing reports provided by the Administrator for licensed nurses and nurse aides during FY Quarter 4, 2024, (7/1/24-9/30/24) indicated the following: 7/5/24: Total census 35 3p-11p shift: -1 Licensed Nurse from 3p-7p (this is 1 less than the minimum required) -3 CNAs (this is 1 less than the minimum required), 2 call outs 7/6/24: Total census 37 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) -3 CNAs (this is 1 less than the minimum required) 7/7/24: Total census 37 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) -3 CNAs (this is 1 less than the minimum required), 1 call out 7/12/24: Total census 38 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) -3 CNAs (this is 1 less than the minimum required) 7/13/24: Total census 38 7a-3p shift: -2 CNAs (this is 2 less than the minimum required), 2 call outs 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) -2 CNAs (this is 2 less than the minimum required), 3 call outs 7/14/24: Total census 37 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) -3 CNAs (this is 1 less than the minimum required), 1 call out 7/19/24: Total census 36 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) 7/20/24: Total census 37 7a-3p shift: -3 CNAs (this is 1 less than the minimum required) 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) -census 37 7/21/24: Census 36 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) 7/26/24: Census 37 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) -3 CNAs (this is 1 less than the minimum required), 1 call out 7/27/24: Census 37 -census 37 7a-3p shift: -3 CNAs, (this is 1 less than the minimum requirement) 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) -3 CNAs (this is 1 less than the minimum requirement) 7/28/24: Census 36 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) -3 CNAs (this is 1 less than the minimum requirement) 8/3/24: Census 32 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) 8/4/24: Census 31 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) 8/9/24: Census 32 7p-3p shift: -3 CNAs (this is 1 less than the minimum requirement) 3p-11p shift: -3 CNAs (this is 1 less than the minimum requirement), 2 call outs 8/10/24: Census 33 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement), 1 call out 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) 8/11/24: Census 34 7a-3p shift: -3 CNAs (this is 1 less than the minimum required), 1 call out 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) 8/17/24: Census 34 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum required) 8/23/24: Census 31 7a-3p shift: -2 CNAs (this is 1 less than the minimum required), 2 call outs 8/24/24: Census 32 7a-3p shift: -2 CNAs (this is 2 less than the minimum required), 2 call outs 3p-11p shift: -3 CNAs (this is 1 less than the minimum requirement), 1 call out 8/25/24: Census 33 7a-3p shift: -2 CNAs (this is 2 less than the minimum requirement), 1 call out 3p-11p shift: -1 Licensed Nurse 7p-11p (this is 1 less than the minimum requirement) -2 CNAs (this is 2 less than the minimum requirement), 1 call out 8/30/24: Census 34 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) -3 CNAs (this is 1 less than the minimum requirement) 8/31/24: Census 34 7a-3p shift: -2 CNAs (this is 2 less than the minimum requirement) 3p-11p shift: -3 CNAs (this is 1 less than the minimum requirement) 9/1/24: Census 35 7a-3p shift: -2 CNAs (this is 2 less than the minimum requirement) 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) -2 CNAs (this is 2 less than the minimum requirement) 9/6/24: Census 33 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement) 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) -3 CNAs (this is 1 less than the minimum requirement) 9/7/24: Census 32 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement) 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) 9/13/24: Census 33 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement) 9/14/24: Census 33 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement) 3p-11p shift: -3 CNAs (this is 1 less than the minimum requirement), 1 call out 9/15/24: Census 33 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement) 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) 9/20/24: Census 33 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement), 2 call outs 3p-11p shift: -3 CNAs (this is 1 less than the minimum requirement), 2 call outs 9/21/24: Census 35 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement), 1 call out 3p-11p shift: -3 CNAs (this is 1 less than the minimum requirement), 2 call outs 9/22/24: Census 34 7a-3p shift: -2 CNAs (this is 2 less than the minimum requirement), 3 call outs 3p-11p shift: -3 CNAs (this is 1 less than the minimum requirement), 1 call out 9/27/24: Census 33 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement), 1 call out 9/28/24: Census 33 3p-11p shift: -1 Licensed Nurse from 7p-11p (this is 1 less than the minimum requirement) -3 CNAs (this is 1 less than the minimum requirement), 1 call out 9/29/24: Census 33 7a-3p shift: -3 CNAs (this is 1 less than the minimum requirement) 3p-11p shift: -1 Licensed Nurse 7p-11p (this is 1 less than the minimum requirement) -3 CNAs (this is 1 less than the minimum requirement), 1 call out Further review of the weekend staffing schedules and daily staffing reports indicated the facility was below the needed or average staffing requirement for 35 out of 39 days for Licensed Nurses and/or CNAs to assure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being. On 3/5/25 at 1:37 P.M., the surveyor reviewed a total sample of seven employee timecards for accuracy of as worked schedules. Minor discrepancies were noted and clarified with the Administrator and Director of Nursing (DON). During an interview on 3/5/25 at 2:44 P.M., the surveyor reviewed the Facility Assessment staffing requirement with the Administrator and DON who said it is consistent with what they try to schedule. They said they go by body, not hours worked. During an interview on 3/5/25 03:28 P.M., the surveyor reviewed the as worked schedules and daily staffing reports dated 7/5/24, 7/6/24, 7/7/24, 7/12/24, 7/13/24, 7/14/24, 7/19/24, 7/20/24, 7/21/24, 7/26/24, 7/27/24, 7/28/24, 8/3/24, 8/4/24, 8/9/24, 8/10/24, 8/11/24, 8/17/24, 8/23/24, 8/24/24, 8/25/24, 8/20/4, 8/31/24, 9/1/24, 9/6/24, 9/7/24, 9/13/24, 9/14/24, 9/15/24, 9/20/24, 9/21/24, 9/22/24, 9/27/24, 9/28/24, and 9/29/24 for FY Quarter 4 2024 with the Administrator and DON. The Administrator said they had more of an issue with CNA coverage than Licensed Nursing coverage. She said they did not meet their minimum staffing totals for all the dates reviewed. She said they want to make sure they're meeting all the residents' needs with staffing, activities of daily living (ADLs), toileting, and mobility. The Administrator said short-term residents may not need more help for ADLs, but skilled care residents do. She said staffing is based on making sure they can take care of everyone's needs. b. During an interview on 3/3/25 at 8:18 A.M., Resident #35 said he/she had a complaint about long call wait times but there was no particular day or shift that was worse. The Resident said one time he/she had pain in his/her right side and had to wait three hours for someone to come in. During an interview on 3/3/25 at 8:29 A.M., CNA #2 said sometimes the facility is short staffed and it's hard to do her tasks. She said it can be all shifts, all days, but felt the day shift was the worst. She said housing has a lot to do with it and while she does work double shifts, she offers to do it if needed sometimes and has never been mandated. She said if there's a call out, they will call agency staff and try to fill it if needed, but housing is an issue and distance driving late at night. She said a resident fell out of bed two nights ago, but it's not always related to staffing. She said they could have 5 CNAs and there could still be falls. She said due to staffing, sometimes she won't take a lunch break to instead complete her tasks. During an interview on 3/4/25 at 11:00 A.M., Resident #2 said there is low staff at the facility, especially on the weekends. She said there are long call bell wait times, especially on the 2nd and 3rd shifts and on weekends. The Resident could not be specific as to when the last time he/she experienced this. During an interview on 3/4/25 at 11:22 A.M., Nurse #3 said the registered nurse (RN) coverage has improved lately but it was tough last summer. She said the facility uses an agency and uses a RN for approximately 4-5 shifts/week. She said last summer they got rid of agency, but didn't know why, so they were short, but then they got agency again. She said about a month ago they weren't paying agency staff but now they are. Nurse #3 said she offers to work doubles sometimes and on occasion the day shift nurse will call out, so she has to stay a little longer until the DON or someone arrives to hand off her keys. She said despite the shortage; she is still able to complete her tasks. She said the staffing shortage was mostly Fridays and Saturdays. During an interview on 3/4/25 at 11:28 A.M., Nurse #4 said she has worked at the facility for about eight years now and staffing has improved. She said the facility uses agency staff and currently there hasn't been an issue with CNA staffing. Nurse #4 said about a month and a half ago though corporate said they couldn't use agency staff, and that some agency staff weren't getting paid, but now they are using agency again. During an interview on 3/5/25 at 10:23 A.M., CNA #3 said there has been low CNA staffing, mostly in the summer. He said the facility has agency, but they aren't using them. He said they need to. He said it's expensive to live there with the rent so many have to travel. He said this past summer there were a lot of call outs and in the winter people get sick. He said call outs are the worst during the summer and on the weekends. CNA #3 said there aren't enough CNA staff for the census if they have a lot of call outs. He said when they're short staffed it makes his job harder, especially during day shift, but said there hasn't been a bad outcome or higher incident of falls because of it that he knew of. He said if the house is full there should be 5 CNAs. During an interview on 3/5/25 at 12:43 P.M., CNA #3 said about six months ago, there were only 2 CNAs for 37-38 residents, and it was terrifying. During an interview on 3/6/25 at 3:15 P.M., CNA #4 and CNA #1 said they always need more people. CNA #4 said staffing was a problem from July to September last year because in the summer people don't pick up shifts and said other places offer more money. He said without enough staff everyone is in trouble. CNA #4 said when they are short staffed, it's harder to do their job. CNA #4 and CNA #1 said they choose sometimes to work through their breaks to get their work done but were never asked to do this and do a lot of doubles. They said they've never been mandated to work. They further said there's a lot of call outs and the facility can't always fill the spots. They said it's a safety concern if there isn't enough staff, but said it's gotten much better. 2. On 3/4/25 at 1:30 P.M., the surveyor held a Resident Group Meeting with 12 residents in attendance. All residents said long call bell wait times have been an ongoing issue for a long time; mostly on the evening and night shift and some weekends and have not been resolved. One resident said he/she waits 15 minutes or longer and there are times when he/she soils him/herself because it takes so long for staff to respond. They said that they do not receive any type of follow-up or discussion about the issues they raise during Resident Council meetings until the next monthly meeting. On 3/6/25 at 9:11 A.M., the Activity Director (AD) and surveyor reviewed Resident Council Minutes as follows: Review of the Resident Council Minutes, dated 3/4/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Three residents expressed concerns that call bells were not being answered in a timely manner. Overnight call bells also. Review of the Resident Council Minutes, dated 4/8/24, indicated 10 residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Concerns with call bells. Residents recommended that all call bells should be answered by any staff member to make sure all is ok and then direct resident requests to the proper department. Review of the Resident Council Minutes, dated 5/6/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Nursing: Call bell, whiteboards, name tags. Need improvement. Staff patience needs improvement. Review of the Resident Council Minutes, dated 6/3/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Call bells are being checked more often but are then turned off and the person answering the bell will tell the assigned CNA what is needed, and no one comes back. -Residents recommend that call bells not be turned off until their needs are met. Review of the Resident Council Minutes, dated 7/1/24, indicated 11 residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Call bells; if nobody answers, we start to yell help. -Concerns about routine care when getting residents up: i.e. washing before dressing and brushing teeth. Review of the Resident Council Minutes, dated 8/3/24, indicated seven residents, one family member and the Ombudsman participated in the meeting, and brought forward the following grievances/complaints/concerns: -Call bells about the same, maybe a little quicker. -One resident and one family member concerned about call bells not being answered in a timely manner to prevent any falls if trying to help him/herself. Review of the Resident Council Minutes, dated 9/2/24, indicated eight residents participated in the meeting, and brought forward the following grievances/complaints/concerns: -Call bells During an interview on 3/6/25 at 9:11 A.M., the AD said she did not start doing education or audits of call bell response times or white board use by staff until January 2025, 10 months and 9 months respectively after the grievances were brought forward through Resident Council.

Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Properly monitor medication refrigeration temperatures in one of one medication storage rooms reviewed to ensure the safety and integrity of medications and vaccines stored; and 2. Ensure medication carts were locked when not in direct supervision of the licensed nurse for two of two medication carts. Findings include: 1. Review of the facility's policy titled Medication Storage, revised October 2022, indicated but was not limited to the following: -This center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with Department of Health guidelines. -Medication will be stored at the appropriate temperatures in accordance with the pharmacy and/or manufacturer labeling. Appropriate temperature will be determined as per the following: c. Cold place -Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit (F)). -Refrigerators used for medication storage will contain a thermometer to indicate the temperature within. Review of Centers for Disease Control and Prevention (CDC) guidance titled Epidemiology and Prevention of Vaccine-Preventable Diseases: Chapter 5: Vaccine Storage and Handling, dated 4/3/24, indicated but was not limited to the following: Monitoring Vaccine Temperatures: -To ensure the safety of vaccines, the storage unit minimum and maximum temperatures should be checked and recorded at the start of each workday. If using a TMD (temperature monitoring device) that does not display minimum and maximum temperatures, then the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday). -A temperature monitoring log sheet should be placed on each storage unit door (or nearby), and the following information should be recorded: -Minimum/maximum temperature (or current temperature if using a device that does not record minimum/maximum temperatures) -Date -Time -Name of person who checked and recorded the temperature -Any actions taken if a temperature excursion occurred On 3/5/25 at 11:39 A.M., the surveyor reviewed the facility's medication storage room with Nurse #1 and observed the following: -Medication refrigerator dial analog thermometer on top shelf observed at 55 degrees F -Internal temperature monitoring device observed though surveyor did not locate the unit and current temperature -Insulin (regulates blood sugar levels) emergency kit, tobramycin (antibiotic), insulin pens, and four boxes of pre-filled syringes of Afluria quadrivalent influenza vaccine (18 syringes remaining) stored inside the refrigerator Review of the Seqirus package insert, undated, indicated but was not limited to the following: -AFLURIA QUADRIVALENT is an inactivated influenza vaccine indicated for active immunization against influenza disease caused by influenza A subtype viruses and type B viruses contained in the vaccine. -Storage and Handling: Store refrigerated at 2-8 C (36-46 F) Review of the medication refrigerator Temperature Log dated December 2024 through March 2025 indicated temperatures were being monitored and recorded only once daily. The normal range was 36-45 degrees F. Further review of the Temperature Log indicated the following out of range temperatures and/or missing documentation: December 2024: -4 out of 31 days no temperatures recorded January 2025: -10 out of 31 days no temperatures recorded -1/21/25 - 48 degrees F -1/28/25 - 48 degrees F February 2025: -2/4/25 - 48 degrees F -2/7/25 - 48 degrees F -2/8/25 - 50 degrees F During an interview on 3/5/25 at 11:39 A.M., Nurse #1 said she wasn't sure who monitors and records the temperatures, but the log looked like it was the 11:00 P.M.-7:00 A.M. shift. During an interview on 3/5/25 at 12:18 P.M., the surveyor and Infection Preventionist (IP) reviewed the medication storage room refrigerator. The IP said a new medication refrigerator is on order and she had asked to separate the vaccines from the other refrigerated medications, but they weren't yet. She said the facility was using a state vaccine temperature monitoring device and reached underneath the counter showing the surveyor a small yellow box on the upper right side of the refrigerator. A current temperature of 38.3 degrees F was observed. The surveyor did not observe a minimum and maximum temperature displayed. She said the unit will alarm if the temperature gets too high or too low. She said it continuously records temperatures but said the temperatures are still expected to be documented twice daily to ensure proper function of the unit because vaccines are stored in there. She said if the medications and vaccines stored inside the refrigerator are not stored at the proper temperatures then they could lose their potency and no longer be good. The surveyor requested to review previous temperature recordings. The IP said she thought the Maintenance Director could do that. During an interview on 3/5/25 at 12:49 P.M., the Maintenance Director said while the temperature monitoring device records continuously, he didn't know how to print a report. He said it goes to the state and asked the surveyor if it could be reviewed. He said he installed the unit two years ago and said it will alarm if the temperature is too high or too low. When asked how it's monitored by staff for proper function, he said it goes to the state, and it alarms. The surveyor requested the manufacturer's instructions for use. It was unclear by staff if the unit had alarmed due to out-of-range temperatures. During an interview on 3/6/25 at 7:05 A.M., the Maintenance Director said he could not locate the box the unit came in or the instructions, so he wasn't sure how to print out a temperature recording report to review with the surveyor but said the temperatures are only stored for 30 days. During an interview on 3/6/25 at 10:05 A.M., the Director of Nursing (DON) said medication refrigerator temperatures should be checked twice a day by the 11:00 P.M.-7:00 A.M. shift and day shift when vaccines are stored. He said he thought he could pull temperature logs from the past 30 days from the unit but didn't know maintenance said he couldn't do it. The DON said he didn't know how to do it either. He said vaccines have been stored in the refrigerator since December 2024 and said the normal temperature range is supposed to be between 36-45 degrees F. The DON said the potential harm of not monitoring twice daily is you could lose the efficacy of the vaccines stored. 34145 2a. On 3/4/25 at 11:27 A.M., the surveyor observed an unlocked medication cart positioned outside the main dining room. Seven residents were seated and waiting for food to be served in the room. One resident, one visitor and one dietary aide were observed walking in the vicinity of the unlocked medication cart. No staff were in the vicinity or within a line of sight of the unlocked medication cart. On 3/4/25 at 10:32 A.M., the surveyor observed Nurse #3 walk around the corner from the unit hallway, approach the medication cart and begin to prepare medications. She said she was responsible for the medication cart and should have locked it before she left it unattended. b. On 3/5/25 at 11:05 A.M., the surveyor observed Nurse #5 standing behind the nursing desk. On 3/5/25 at 11:06 A.M., the surveyor observed an unlocked medication cart positioned against the wall in the unit hallway around the corner and out of the line of sight of the nursing desk. Certified Nursing Assistant (CNA) #4 was seated at a kiosk at the end of the hallway using a computer tablet mounted to the wall. On 3/5/25 at 11:09 A.M., a consultant imaging provider walked down the hallway to a resident's room next to the unlocked medication cart. The consultant asked CNA #4 where the resident was. CNA #4 walked down the hallway and around the corner leaving the consultant alone standing next to the unlocked medication cart. On 3/5/25 at 11:11 A.M., the surveyor observed Nurse #5 walk around the corner and down the hallway and approach the unlocked medication cart. Nurse #5 said she was responsible for the medication cart and should have locked it before she left the hallway and went to the nursing desk. During an interview on 3/6/25 at 3:05 P.M., the DON said that medication carts must be locked at all times when they are unattended.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label, date and discard food products when past their use by date stored in the free-standing refrigerator and walk-in freezer in the main kitchen. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: - 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A)Except when PACKAGING FOOD using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 Celsius (41 Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B)Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. - 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3- 501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). On 3/3/25 at 8:14 A.M. and 8:54 A.M., the surveyor reviewed the cook's refrigerator and the walk-in freezer in the main kitchen with the Food Service Manager (FSM) and observed the following inside: Cook's refrigerator: -One clear plastic storage container with a lid and contained eight peeled, hard-boiled eggs. The storage container was undated and unlabeled with its contents. -One large resealable plastic storage bag contained five muffins. The bag was undated and unlabeled with its contents. -One metal pan contained several raw hamburger patties in a resealable plastic bag. The bag was dated 2/24/25 and unlabeled with its contents. -One metal pan contained: -one resealable plastic storage bag contained sliced deli meat, dated 3/1/25 and was unlabeled. The bag was unsecured and its contents was open to air. -one resealable plastic bag contained sliced deli meat, dated 3/1/25 and was labeled turkey. The bag was unsecured its contents was open to air. -sliced deli meat wrapped in plastic wrap, undated and unlabeled with its contents. -One resealable plastic bag contained cooked elbow pasta. The bag was dated 2/28/25 and was unlabeled. The bag was unsecured and its contents were open to air. Walk-in freezer: -One large cardboard box contained a plastic bag of corn kernels that was unsecured and open to air potentially exposing the corn and carrots to environmental contaminants. -One large cardboard box contained a plastic bag of carrots slices with a plastic cup inside. The plastic bag was unsecured and open to air potentially exposing the corn and carrots to environmental contaminants. During an interview on 3/3/25 at 8:54 A.M., the FSM said all food stored in the refrigerator and freezer should be labeled, dated and properly stored and not open to air for food safety. She said that food not in it's original packaging should be purged after 48 hours and any food item that is not labeled, dated or stored properly should be discarded.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated that he/she required the use of a hoyer lift (mechanical floor lift system used to transfer a medically dependent person from point A to point B), physical assistance of two staff members for transfers and was assessed by nursing at high risk for falls, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her Plan of Care while meeting his/her transfer needs. On 01/13/24, Certified Nurse Aide (CNA) #1 transferred Resident #1 with a hoyer lift out of bed into a reclining wheelchair without another staff member present to assist him and then stepped out of Resident #1's room to get another staff member to assist him with positioning Resident #1 appropriately in the reclining wheelchair. Upon returning to Resident #1's room, staff found Resident #1, who was still on the hoyer lift pad in his/her wheelchair which had tipped over backwards, and his/her head had hit the floor resulting in a laceration to the back of his/her head. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required seven staples to close the wound to the back of his/her head. Findings include: Review of the Facility's Policy, titled Care Plans, dated as revised January 2023, indicated the following: -each resident shall be involved in the development and review of his/her care plan along with his/her family member; -the interdisciplinary team shall evaluate the resident's progress toward meeting the goals outlined in the plan of care, revise the plan of care, treatment, and services, collaborate with the resident and the family in revising the plan of care; - the interdisciplinary team shall document the goals and interventions; -documentation of resident response and progress toward the goals shall be designated by the interdisciplinary team; -care plans shall be updated and documented in the resident's medical record. Review of the Facility's Policy, titled Lift - Mechanical, dated as revised January 2023, indicated the following: -this procedure is to establish the general principles of safe lifting using a mechanical lifting device; -at least two nursing assistants are needed to safely move a resident with a mechanical lift; - mechanical lifts may be used for tasks that require transferring a resident from bed to chair; -staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Resident #1 was admitted to the Facility in April 2017, diagnoses included normal pressure hydrocephalus, benign neoplasm of cerebral meninges, dementia with behavioral disturbance, anxiety disorder, muscle weakness, and atherosclerotic heart disease. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and was totally dependent on staff with transfers. Review of Resident #1's Care Plan related to Functional Performance, dated 11/08/23, indicated that he/she required the physical assistance of two staff members with transfers and bed mobility. Review of Resident #1's Care Plan related to Risk for Falls, dated 11/09/23, indicated that he/she required a hoyer lift with two staff members for all transfers. Review of the Facility's Internal Investigation Report, dated 01/22/24, indicated that on 01/13/24 at 6:30 A.M., Resident #1 was being transferred from bed to wheelchair via a mechanical lift (hoyer) and sustained a fall. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation of his/her injury and returned with seven staples to his/her head. Review of a Nurse Progress Note, dated 01/13/24 at 8:41 A.M., (written by Nurse #2) indicated that a CNA (later identified as CNA #1) alerted the nurse that Resident #1 had fallen and that he needed help to get Resident #1 up. The Note indicated that Resident #1 was observed on the floor still positioned in the wheelchair with the hoyer pad underneath him/her with his/her feet up in the air. The Note indicated that Resident #1 was bleeding from a deep gash to the back of his/her head. The Note indicated that 911 (Emergency Medical Services) was called and Resident #1 was transferred to the Hospital Emergency Department. During a telephone interview on 02/13/24 at 10:03 A.M., (which included review of her written witness statement), Nurse #2 said that she was sitting at the nurse's station when Nurse #1 asked her for assistance with Resident #1. Nurse #2 said that when she entered Resident #1's room, he/she was lying on the floor with his/her head lifted off the floor and there was a lot of blood on the floor. Nurse #2 said she, Nurse #1 and CNA #1 safely transferred Resident #1 back into bed. Nurse #2 said that Resident #1 required a hoyer lift for transfers and that he/she required the assistance of two staff members to transfer with a hoyer lift. Review of Nurse #1's Written Witness Statement, undated, indicated that a CNA (later identified as CNA #1) notified her that Resident #1 had fallen, and he needed help getting Resident #1 back up. The Statement indicated that Resident #1 was observed lying on the floor still physically in his/her wheelchair with hoyer pad underneath him/her. The Statement indicated that Resident #1 had a deep laceration to the back of his/her head, 911 was called and Resident #1 was transferred to the Hospital ED. During a telephone interview on 02/08/24 at 7:03 A.M., Nurse #1 said that CNA #1 had informed her that Resident #1 had fallen. Nurse #1 said that she found Resident #1 sitting on the hoyer pad in the reclining wheelchair which was tipped backwards with the leg rest up in the air. Nurse #1 said that Resident #1's head was on the floor and there was a lot of blood on the floor. Nurse #1 said that she assessed Resident #1 for injury and noted that the back of his/her head had a deep laceration. Nurse #1 said that 911 was called and Resident #1 was transferred to the Hospital ED. Nurse #1 said that Resident #1 required a hoyer lift for transfers and that he/she required the assistance of two staff members to transfer with a hoyer lift. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 1/13/24, indicated that he transferred Resident #1 from bed to wheelchair and when he tried to lift the head (back rest) of the wheelchair, the left side would not go up. The Statement indicated that he brought the wheelchair (back rest) to what he thought was a stable position and left the room to get help. The Statement indicated that he heard a thud, rushed back in and saw that the wheelchair had tipped over and Resident #1 had hit his/her head on the floor. During a telephone interview on 2/08/24 at 9:16 A.M., CNA #1 said that Resident #1 required the use of a hoyer lift and the assistance of two staff members for all transfers. CNA #1 said that on 1/13/24, he transferred Resident #1 by himself from the bed into his/her reclining wheelchair using the hoyer lift, because he thought he could transfer Resident #1 with the hoyer lift by himself without the assistance of another staff member. CNA #1 said that he should not have transferred Resident #1 with the hoyer lift without another staff member and said he did not follow the facility's hoyer transfer rules (policy) of always having another staff member present when you use the hoyer for transfers. CNA #1 said that the head (back) of Resident #1's reclining wheelchair was down in a reclining position and he was having difficulty getting the head (back rest) of the reclining wheelchair adjust into a sitting position. CNA #1 said that he lowered the reclining wheelchair to where he thought it was stable and said that he left Resident #1 in a lying position in the reclining wheelchair while he went to get someone to help him. CNA #1 said that he walked out of Resident #1's room and then heard a thud. CNA #1 said he went back into Resident #1's room and found the reclining wheelchair had tipped backwards, the leg rests were up in the air and Resident #1's head was on the floor. CNA #1 said that Resident #1 slid backwards out of the reclining wheelchair and the back his/her head hit the floor. Review of a Hospital Emergency Department Discharge Summary, dated 01/13/24, indicated that Resident #1 was in a wheelchair and the wheelchair went backwards striking the back of his/her head on the floor. The Summary indicated that Resident #1 sustained a scalp laceration to the back of his/her head which bled fairly copiously and required seven staples to close the wound. During an interview on 02/07/24 at 2:30 P.M., the Director of Nurses (DON) said that Resident #1 requires a hoyer lift and the assistance of two staff members with all transfers. The DON said that CNA #1 transferred Resident #1 from bed to his/her reclining wheelchair without the assistance of another staff member. The DON said that CNA #1 did not follow Resident #1's plan of care and said that it was her expectation that staff follow the plan of care. On 02/07/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction that addressed the area(s) of concern as evidenced by: A) On 01/13/24, Resident #1 was immediately assessed by Nursing for any injuries, first aid was administered, and he/she was transferred to the Hospital Emergency Department for evaluation. B) On 01/13/24, CNA #1 wrote a written witness statement and was sent home during the Facility's internal investigation. C) On 01/14/24, an audit of all residents requiring a mechanical lift for transfers was completed by the Director of Nurses. D) On 01/15/24, CNA #1 was educated on the Facility's mechanical lift (hoyer) policy, on reviewing and following the resident's plan of care prior to providing care and a mechanical lift (hoyer) competency was completed with him prior to working his next shift. E) On 01/15/24 through 01/19/24, all licensed nurses and CNA's were educated by the DON on the Facility's mechanical lift (hoyer) policy, as well as the need to review and follow the resident's plan of care prior to providing care. F) On 01/15/24 through 01/19/24, the DON completed mechanical lift competencies with all licensed nurses and CNA's. G) On 01/22/24, Resident #1's Care Plan was updated by the Director of Nurses to indicate that he/she required two staff for all hoyer transfers. H) On 01/24/24, Resident #1's reclining wheelchair and the mechanical lift (hoyer) was inspected by the Director of Maintenance to ensure they were both in good working order. I) On 01/24/24, Audits were initiated of Resident transfers with the mechanical lift to ensure that the mechanical lift policy was followed, and will be completed by unit nurses three times a week. The DON is responsible for ensuring that the audits are being completed weekly. J) Results of the Audits will be discussed and reviewed monthly at the Quality Assurance and Performance Improvement (QAPI) Committee meeting for three months and then quarterly until the team determines compliance is met. K) The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at high risk for falls, and required the use of a hoyer lift (mechanical floor lift system used to transfer a medically dependent person from point A to point B) and physical assistance of two staff members for transfers, the Facility failed to ensure he/she was provided with the required level of staff assistance in an effort to prevent an accident resulting in an injury. On 01/13/24, Certified Nurse Aide (CNA) #1 transferred Resident #1 with a hoyer lift out of bed into a reclining wheelchair, by himself, without another staff member present to assist him. CNA #1 was unable to secure the positioning of the head (back rest) of the wheelchair, and left Resident #1's room to get another staff member to help him. While left unattended, Resident #1's reclining wheelchair tipped over backwards, and his/her head hit the floor resulting in a laceration to the back of his/her head. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required seven staples to close the wound to the back of his/her head. Findings include: Review of the Facility's Policy, titled Lift - Mechanical, dated as revised January 2023, indicated the following: -this procedure is to establish the general principles of safe lifting using a mechanical lifting device; -at least two nursing assistants are needed to safely move a resident with a mechanical lift; - mechanical lifts may be used for tasks that require transferring a resident from bed to chair; -staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Review of the Facility's Policy, titled Fall Prevention and Management, dated as revised January 2023, indicated the following: -a fall risk evaluation will be completed for all residents, upon admission, re-admission, quarterly, significant change and after an identified fall; -the fall risk evaluation will determine fall risk factors; -the nurse will help identify individuals with a history of falls and risk factors for subsequent falling; -the staff will document risk factors for falling in the resident's record and discuss the resident's fall risk; -the staff will implement goals and interventions for inclusion in the interdisciplinary care plan based on the resident's individual needs; -if interventions have been successful in preventing falls, the staff will continue with current approaches; -all staff shall receive education on the fall prevention program at orientation and annually. Resident #1 was admitted to the Facility in April 2017, diagnoses included normal pressure hydrocephalus, benign neoplasm of cerebral meninges, dementia with behavioral disturbance, anxiety disorder, muscle weakness, and atherosclerotic heart disease. Review of Resident #1's Fall Risk Evaluation, dated 11/08/23, indicated that he/she was at high risk for falls. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and was totally dependent on staff with transfers. Review of Resident #1's Care Plan related to Functional Performance, dated 11/08/23, indicated that he/she required the physical assistance of two staff members with transfers and bed mobility. Review of Resident #1's Care Plan related to Risk for Falls, dated 11/09/23, indicated that he/she required a hoyer lift with two staff members for all transfers. Review of the Facility's Internal Investigation Report, dated 01/22/24, indicated that on 01/13/24 at 6:30 A.M., Resident #1 was being transferred from bed to chair via a mechanical lift (hoyer) and sustained a fall. The Report indicated that Resident #1 was sent to the Hospital Emergency Department (ED) for evaluation of his/her injury and returned with seven staples to his/her head. Review of a Nurse Progress Note, dated 01/13/24 at 8:41 A.M., (written by Nurse #2) indicated that a CNA (later identified as CNA #1) alerted the nurse that Resident #1 had fallen and that he needed help to get Resident #1 up. The Note indicated that Resident #1 was observed on the floor still positioned in the wheelchair with the hoyer pad underneath him/her with his/her feet up in the air. The Note indicated that Resident #1 was bleeding from a deep gash to the back of his/her head. The Note indicated that 911 (Emergency Medical Services) was called and Resident #1 was transferred to the Hospital Emergency Department. During a telephone interview on 02/13/24 at 10:03 A.M., (which included review of her written witness statement), Nurse #2 said that she was sitting at the nurse's station when Nurse #1 asked her for assistance with Resident #1. Nurse #2 said that when she entered Resident #1's room, he/she was lying on the floor with his/her head lifted off the floor and there was a lot of blood on the floor. Nurse #2 said that she and Nurse #1 assessed Resident #1 for any further injuries and then she, Nurse #1 and CNA #1 safely transferred Resident #1 back into bed. Nurse #2 said that she further assessed Resident #1 to see exactly where the bleeding was coming from and noted a deep laceration with a flap to the back of his/her head. Nurse #2 said that 911 was called and Resident #1 was transferred to the Hospital ED. Review of Nurse #1's Written Witness Statement, undated, indicated that a CNA (later identified as CNA #1)notified her that Resident #1 had fallen, and he needed help getting Resident #1 back up. The Statement indicated that Resident #1 was observed lying on the floor still physically in his/her wheelchair with hoyer pad underneath him/her. The Statement indicated that Resident #1 had a deep laceration to the back of his/her head, 911 was called and Resident #1 was transferred to the Hospital ED. During a telephone interview on 02/08/24 at 7:03 A.M., Nurse #1 said that CNA #1 had informed her that Resident #1 had fallen. Nurse #1 said that she found Resident #1 sitting on the hoyer pad in the reclining wheelchair which was tipped over backwards with the leg rests up in the air. Nurse #1 said that Resident #1's head was on the floor and there was a lot of blood on the floor. Nurse #1 said that she assessed Resident #1 for injury and noted that the back of his/her head had a deep laceration. Nurse #1 said that 911 was called and Resident #1 was transferred to the Hospital ED. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 1/13/24, indicated that he transferred Resident #1 from bed to wheelchair and when he tried to lift the head (back rest) of the wheelchair, the left side would not go up. The Statement indicated that he brought the wheelchairs (head, back rest) to what he thought was a stable position and left the room to get help. The Statement indicated that he heard a thud, rushed back in, saw that the wheelchair had tipped over and that Resident #1 had hit his/her head on the floor. During a telephone interview on 2/08/24 at 9:16 A.M., CNA #1 said that Resident #1 required the use of the hoyer and the assistance of two staff members for all transfers. CNA #1 said that on 1/13/23, he transferred Resident #1 by himself from the bed into his/her reclining wheelchair using the hoyer lift because he thought he could transfer Resident #1 with the hoyer lift by himself. CNA #1 said that he should not have transferred Resident #1 with the hoyer lift without another staff member present to assist with the transfers and to help position him/her in the reclining wheelchair. CNA #1 said that the head (back rest) of the reclining wheelchair was down in a reclining position and he was having difficulty getting the head (back rest) of the reclining wheelchair up and into a sitting position. CNA #1 said that he lowered the head (back rest) of reclining wheelchair to where he thought was a stable position and said that he left Resident #1 in a lying position in the reclining wheelchair while he went to get someone to help him. CNA #1 said that he walked out of Resident #1's room and then heard a thud. CNA #1 said he went back into Resident #1's room and found that the reclining wheelchair had tipped over backwards, the leg rests were up in the air and Resident #1's head was on the floor. CNA #1 said that Resident #1 had slid backwards out of the reclining wheelchair and the back his/her head hit the floor. Review of a Hospital Emergency Department Discharge Summary, dated 01/13/24, indicated that Resident #1 was in a wheelchair and the wheelchair went backwards striking the back of his/her head on the floor. The Summary indicated that Resident #1 sustained a scalp laceration to the back of his/her head which bled fairly copiously and required seven staples to close the wound. During an interview on 02/07/24 at 2:30 P.M., the Director of Nurses (DON) said that Resident #1 requires a hoyer lift and the assistance of two staff members with all transfers. The DON said that CNA #1 transferred Resident #1 from bed to his/her reclining wheelchair without the assistance of another staff member. The DON said that CNA #1 had not followed facility policy related to the use of mechanical lift for transfers and the need for two staff members to assist, as well as not having followed Resident #1's plan of care. On 02/07/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction that addressed the area(s) of concern as evidenced by: A) On 01/13/24, Resident #1 was immediately assessed by Nursing for any injuries, first aid was administered, and he/she was transferred to the Hospital Emergency Department for evaluation. B) On 01/13/24, CNA #1 wrote a witness statement and was sent home during the Facility's internal investigation. C) On 01/14/24, an audit of all residents requiring a mechanical lift for transfers was completed by the Director of Nurses. D) On 01/15/24, CNA #1 was educated on the Facility's mechanical lift (hoyer) policy, on reviewing and following the resident's plan of care prior to providing care and a mechanical lift (hoyer) competency was completed with him prior to working his next shift. E) On 01/15/24 through 01/19/24, all licensed nurses and CNA's were educated by the DON on the Facility's mechanical lift (hoyer) policy and the need to review and follow the resident's plan of care prior to to providing care to resident's. F) On 01/15/24 through 01/19/24, the DON completed mechanical lift competencies with all licensed nurses and CNA's. G) On 01/22/24, Resident #1's Care Plan was updated by the Director of Nurses to indicate that he/she requires two staff for all hoyer transfers. H) On 01/24/24, Resident #1's reclining wheelchair and the mechanical lift (hoyer) were checked by the Director of Maintenance to ensure they were both in good working order. I) On 01/24/24, Audits were initiated of Resident transfers with the mechanical lifts to ensure that the mechanical lift policy was followed and will be completed by unit nurses three times a week. The DON is responsible for ensuring that the audits are being completed weekly. J) Results of the Audits will be discussed and reviewed monthly at the Quality Assurance and Performance Improvement (QAPI) Committee meeting for three months and then quarterly until the team determines compliance is met. K) The Director of Nurses and/or designee are responsible for overall compliance.

Based on record review, observation, and staff interview, the facility failed to ensure that staff provided care consistent with professional standards of practice to prevent pressure ulcers from developing for one Resident (#23), out of a total sample of 13 residents. Findings include: Resident #23 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 3/21/21, indicated that Resident #23 was totally dependent for bed mobility, transfers, and personal hygiene, was always incontinent of bowel and bladder, and was at risk for developing pressure ulcers. Further review of the MDS indicated the Resident did not have any unhealed pressure ulcers/injuries upon admission to the facility and had occasional moderate pain requiring pain medication as needed. Review of the Nursing Assessment, dated 3/14/21, indicated that except for bruising at the right elbow, left elbow, and right shoulder, the Resident's skin was intact. Review of the Interim Care Plan, dated 3/14/21, indicated that Resident #23 scored an 11 (high risk) on the Norton Plus Score (assesses the risk for pressure injuries). The interim care plan indicated that the Resident will have intact skin or show evidence of wound healing x 20 days. Interventions listed on the Interim Care Plan were: -Encourage nutrition and hydration -Assist with mobility/positioning No additional interventions to provide off-loading (distributing the load to other areas which are not susceptible to pressure) of the coccyx and/or heels were listed on the Interim Care Plan. During an interview on 12/15/21 at 12:36 P.M., the surveyor and the Director of Nurses (DON) reviewed the Resident's development of the Stage IV (full-thickness loss of skin and tissue) coccyx pressure ulcer and the unstageable left heel wound that developed shortly after admission on March 14, 2021. The DON said that upon admission, the Resident was assessed to be at high risk for the development of pressure ulcers, as determined by the Norton Plus Score Skin Assessment, conducted on 3/15/21, which the Resident scored an 11 (Between 14-10 High Risk). The DON also said that upon admission, the Resident's skin was intact and the facility was unaware that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the facility would have provided the Resident with additional interventions to prevent skin breakdown if they had known about the Resident's history for pressure ulcer development. The DON remarked, We own it, in reference to the Resident's Stage IV coccyx pressure ulcer being treated at the wound clinic at present. The DON said that the Resident did not have a specialty, pressure off-loading mattress, upon admission, but instead a regular mattress that did not provide any added pressure relieving properties. The DON said that it was a challenge repositioning the Resident due to his/her fractured humerus. Review of the Comprehensive Care Plan for Pressure Ulcer Prevention, dated 3/18/21, indicated the following: Problem Start Date: 3/18/21 Resident is at risk for pressure ulcer due to moisture/decreased mobility/incontinence, Norton Plus Score of 8 (Norton Score previously listed as 11 on 3/14/21). Short Term Goal Target Date: 1/21/2022 Approach Start Date: 3/26/21 -Air overlay applied to bed Approach Start Date: 3/26/21 -Off-load heels at all times in bed Approach Start Date: 3/18/21 - Assess for other moisture problem areas such as under breasts Approach Start Date: 3/18/21 -Avoid hot water, use mild soap and soft cloths, or packaged cleanser wipes Approach Start Date: 3/18/21 -Check incontinence pads frequently (every 2-3 hours) and change as needed, turn and reposition every 2 hours and PRN (as needed) Approach Start Date: 3/18/21 -Moisturize dry unbroken skin Approach Start Date: 3/18/21 -Position/reposition every 2 hours Approach Start Date: 3/18/21 -Skin assessment and inspection every shift with close attention to heels Review of the facility's policy titled Pressure Ulcer (Injury) Prevention Program, reviewed by the Governing Body on 2/7/21, indicated: Based upon the assessment and resident's clinical condition, choices, and identified needs, the resident's plan of care shall include interventions to: -Redistribute pressure -Minimize the resident's skin exposure to moisture -Keep the skin clean -Provide appropriate pressure-redistributing support surfaces -Provide non-irritating surfaces -Maintain or improve nutrition and hydration status when feasible -Monitor any adverse drug reactions related to the resident drug regimen (i.e. those drugs that cause anorexia or cause lethargy. Interventions shall be incorporated into the resident's plan of care, evaluated, and revised as the condition of the resident indicates. The facility failed to provide an appropriate level of pressure-redistribution for the Resident, assessed to be at high risk for pressure ulcer development (8 on Norton Scale) , who presented with compromised bed mobility, due to the fractured humerus, pain, and at added risk for pressure ulcer development due to bowel and bladder incontinence and exposure of skin to urine and feces. Review of a Nursing Progress Note, dated 3/30/21, indicated the Resident was observed by nursing to have developed an open, 1 centimeter (cm) x 1 cm x 0.1 cm, wound on the coccyx. The note further indicated that there was no s/s (signs or symptoms) of infection, NP (nurse practitioner) notified, awaiting tx (treatment) orders. OT (occupational therapy) in to eval w/c (wheelchair) cushion air mattress in place. Review of a Nursing Progress Note, dated 3/30/21 at 3:33 P.M., indicated the Resident was A & O (alert and oriented) x 2, sling in place to right arm as ordered. OOB (out of bed) to w/c cont. (continue) with PT/OT/SLP (physical therapy/occupational therapy/speech language pathology) in to see pt (patient), see rehab note. Bi-lat (bilateral heels) off-loaded, area to right heel unchanged, left heel red, boggy, and skin prepped, new area to coccyx. Record review on 12/15/21 and 12/16/21, indicated the facility-acquired left heel pressure ulcer resolved sometime in June 2021, with the interventions of a wound care clinic. However, the coccyx pressure ulcer continued to decline from March 30, 2021, when first observed, until the Resident began receiving treatment at the wound clinic on May 25, 2021. On 12/15/21, the DON provided the surveyor with the Resident's Care Plan for Pressure Ulcers, dated 4/13/21. The Care Plan indicated the following: Problem Start Date: 04/13/21 Category: Pressure ulcer Resident has a pressure ulcer on her coccyx measured 4 cm x 2 cm x 1.8 cm (1.0 cm long x 1.0 cm wide x 0.1 cm deep on 3/30/21) Goal: Short Term Goal Target Date: 01/21/22 -Resident will not develop additional pressure ulcers Approach Start Date: 7/1/2021 -Alternating air mattress for pressure relief while in bed. Approach Start Date: 4/13/2021 -Apply dressings per MD order daily. Approach Start Date: 04/13/2021 -Assess the pressure ulcer for stage, size, (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin. Approach Start Date: 04/13/2021 -Conduct a systematic skin inspection weekly and as needed, Report any signs of any further skin breakdown (sore, tender, red, or broken areas). Approach Start Date: 04/13/21 -Keep clean and dry as possible. Minimize skin exposure to moisture. Approach Start Date: 04/13/21 -Provide incontinence care after each incontinent episode. Approach Start Date: 04/13/21 -Turn and reposition every 2 hours. Approach Start Date: 04/13/21 -Use a Roho cushion for pressure reduction when resident is in chair. Approach Start Date: 04/13/21 -Use moisture barrier product to perineal area. On 5/25/21, the Resident was seen at the wound clinic as a new patient. The Stage IV coccyx wound was treated at that time. Record Review indicated that the wound had increased in size from 3/30/21, to 3.5 cm length x 5 cm width x 1.9 cm depth. Undermining was listed as 2.5 cm at 4 o'clock and 5 o'clock position. According to the wound clinic report, the coccyx wound was debrided of nonviable tissue and cellular debris. Tissue exposed pre-procedure was listed as fat/subcutaneous and bone. The wound clinic report indicated: Patient with history of pressure ulcers primarily coccyx typically occurring after injuries. Initial coccyx ulcer approximately 2003. She/He also developed recurrent coccyx ulcers while recovering from left arm fracture 2017, left hip replacement, right knee replacement, and most recently right arm fracture February 2020. The report indicated that the patient's [family member] stated that patient was recovering in rehab (facility), not able to off-load, and developed coccyx breakdown. This is being treated with VAC (wound vacuum). Prior treatments listed as Dakin's solution (Dakin's solution is made from bleach that has been diluted. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic) and gauze and other topical agents. Patient's [family member] remains concerned regarding off-loading. On 12/15/21 at 1:31 P.M., the surveyor observed Resident #23 sitting up in bed positioned at a 90 degree angle, placing direct pressure on the Resident's coccyx wound. The surveyor requested the DON come to the Resident's room to observe the position of the Resident in bed. The DON and Staff Development Coordinator (SDC) who were both present, acknowledged the risk and added pressure to the Resident's coccyx wound sitting in bed at a 90 degree angle. The SDC said that the Resident needed to remain upright after meals. It was unclear how long it had been since the Resident finished her/his meal. On 12/15/21 at 1:45 PM., the Resident's Treatment to his/her Stage IV coccyx wound by the SDC was observed by the surveyor. The DON provided assistance with holding the Resident in position while the SDC conducted the treatment. The gauze packing removed from the coccyx wound was observed to contain a large amount of dark, greenish-brown-colored drainage. The wound presented as an irregularly-shaped, deep, (approximate 2 cm depth), half-dollar sized pressure wound. The inner aspect of the wound and the wound periphery presented as pink, granulation tissue. (On 11/19/21, the wound clinic assessed the wound at Stage IV, 2.8 cm length x 2 cm width x 1.9 cm depth. The wound was debrided at the wound clinic with the recommendation to continue topical wound care with Dakin's solution and off-load). The Resident was observed to be alert and oriented and tolerated the treatment without incident. However, the Resident was observed to be totally dependent with turning and repositioning, and required complete assistance from the DON to maintain a side-lying position. On 12/15/21 at 2:30 PM, the surveyor observed Resident #23 lying flat in bed, positioned on his/her back with the head of the bed elevated at approximately 45 degrees, placing pressure on the coccyx wound. A sign was observed over the Resident's bed that indicated, (Resident's name) is to be placed on his/her side at all times while in bed. No exceptions. Turn every 2 hours. During an interview on 12/16/21 at 8:36 A.M., regarding the Resident's development of the Stage IV, coccyx pressure ulcer, the DON reiterated that the facility would have implemented additional interventions to off-load pressure sooner, had they known of the Resident's past history of pressure ulcer development following injury, i.e. provide an alternating air/low air loss mattress, and other off-loading measures sooner.